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Background: Variation in hospital stroke care is problematic. The Quality in Acute Stroke (QASC) Australia trial demonstrated reductions in death and disability through supported implementation of nurse-led, evidence-based protocols to manage fever, hyperglycaemia (sugar) and swallowing (FeSS Protocols) following stroke. Subsequently, a pre-test/post-test study was conducted in acute stroke wards in 64 hospitals in 17 European countries to evaluate upscale of the FeSS Protocols. Implementation across countries was underpinned by a cascading facilitation framework of multi-stakeholder support involving academic partners and a not-for-profit health organisation, the Angels Initiative (the industry partner), that operates to promote evidence-based treatments in stroke centres..We report here an a priori qualitative process evaluation undertaken to identify factors that influenced international implementation of the FeSS Protocols using a cascading facilitation framework. Methods: The sampling frame for interviews was: (1) Executives/Steering Committee members, consisting of academics, the Angels Initiative and senior project team, (2) Angel Team leaders (managers of Angel Consultants), (3) Angel Consultants (responsible for assisting facilitation of FeSS Protocols into multiple hospitals) and (4) Country Co-ordinators (senior stroke nurses with country and hospital-level responsibilities for facilitating the introduction of the FeSS Protocols). A semi-structured interview elicited participant views on the factorsthat influenced engagement of stakeholders with the project and preparation for and implementation of the FeSS Protocol upscale. Interviews were recorded, transcribed verbatim and analysed inductively within NVivo. Results: Individual (n = 13) and three group interviews (3 participants in each group) were undertaken. Three main themes with sub-themes were identified that represented key factors influencing upscale: (1) readiness for change (sub-themes: negotiating expectations; intervention feasible and acceptable; shared goal of evidence-based stroke management); (2) roles and relationships (sub-themes: defining and establishing roles; harnessing nurse champions) and (3) managing multiple changes (sub-themes: accommodating and responding to variation; more than clinical change; multi-layered communication framework). Conclusion: A cascading facilitation model involving a partnership between evidence producers (academic partners), knowledge brokers (industry partner, Angels Initiative) and evidence adopters (stroke clinicians) overcame multiple challenges involved in international evidence translation. Capacity to manage, negotiate and adapt to multi-level changes and strategic engagement of different stakeholders supported adoption of nurse-initiated stroke protocols within Europe. This model has promise for other large-scale evidence translation programs. [ABSTRACT FROM AUTHOR]

Background: Variation in hospital stroke care is problematic. The Quality in Acute Stroke (QASC) Australia trial demonstrated reductions in death and disability through supported implementation of nurse-led, evidence-based protocols to manage fever, hyperglycaemia (sugar) and swallowing (FeSS Protocols) following stroke. Subsequently, a pre-test/post-test study was conducted in acute stroke wards in 64 hospitals in 17 European countries to evaluate upscale of the FeSS Protocols. Implementation across countries was underpinned by a cascading facilitation framework of multi-stakeholder support involving academic partners and a not-for-profit health organisation, the Angels Initiative (the industry partner), that operates to promote evidence-based treatments in stroke centres..We report here an a priori qualitative process evaluation undertaken to identify factors that influenced international implementation of the FeSS Protocols using a cascading facilitation framework. Methods: The sampling frame for interviews was: (1) Executives/Steering Committee members, consisting of academics, the Angels Initiative and senior project team, (2) Angel Team leaders (managers of Angel Consultants), (3) Angel Consultants (responsible for assisting facilitation of FeSS Protocols into multiple hospitals) and (4) Country Co-ordinators (senior stroke nurses with country and hospital-level responsibilities for facilitating the introduction of the FeSS Protocols). A semi-structured interview elicited participant views on the factorsthat influenced engagement of stakeholders with the project and preparation for and implementation of the FeSS Protocol upscale. Interviews were recorded, transcribed verbatim and analysed inductively within NVivo. Results: Individual (n = 13) and three group interviews (3 participants in each group) were undertaken. Three main themes with sub-themes were identified that represented key factors influencing upscale: (1) readiness for change (sub-themes: negotiating expectations; intervention feasible and acceptable; shared goal of evidence-based stroke management); (2) roles and relationships (sub-themes: defining and establishing roles; harnessing nurse champions) and (3) managing multiple changes (sub-themes: accommodating and responding to variation; more than clinical change; multi-layered communication framework). Conclusion: A cascading facilitation model involving a partnership between evidence producers (academic partners), knowledge brokers (industry partner, Angels Initiative) and evidence adopters (stroke clinicians) overcame multiple challenges involved in international evidence translation. Capacity to manage, negotiate and adapt to multi-level changes and strategic engagement of different stakeholders supported adoption of nurse-initiated stroke protocols within Europe. This model has promise for other large-scale evidence translation programs. [ABSTRACT FROM AUTHOR]

Background: There is little evidence on experiences in psychiatric care treatment among patients with immigrant or ethnic minority background. Knowledge about their experiences is crucial in the development of equal and high-quality services and is needed to validate instruments applied in national patient experience surveys in Norway. The aim of this scoping review is to assess and summarize current evidence on immigrant and ethnic minorities' experiences in psychiatric care treatment in Europe. Methods: Guidelines from the Joanna Briggs Institute were followed and the research process adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. The literature search was carried out in Medline, Cinahl, Web of Science, Cochrane database of systematic reviews, Embase, and APA PsychInfo, up to Dec 2022, for articles on immigrant patients' experiences in psychiatric care. Reference lists of included articles were screened for additional relevant articles. Titles and abstracts were screened, and potentially relevant articles read in full-text, by two researchers. Evidence was extracted using an a priori extraction form and summarized in tables and text. Any disagreement between the reviewers regarding inclusion of articles or extracted information details were resolved through discussion between authors. Results: We included eight studies in the scoping review. Immigrant and ethnic minority background patients did not differ from the general population in quantitative satisfaction questionnaires. However, qualitative studies showed that they experience a lack of understanding and respect of own culture and related needs, and difficulties in communication, which do not seem to be captured in questionnaire-based studies. Conclusion: Raising awareness about the importance of respect and understanding for patients' cultural background and communication needs for treatment satisfaction should be addressed in future quality improvement work. [ABSTRACT FROM AUTHOR]

Background: Women from ethnic minority backgrounds are at greater risk of adverse maternal outcomes. Antenatal care plays a crucial role in reducing risks of poor outcomes. The aim of this study was to identify, appraise, and synthesise the recent qualitative evidence on ethnic minority women's experiences of accessing antenatal care in high-income European countries, and to develop a novel conceptual framework for access based on women's perspectives. Methods: We conducted a comprehensive search of seven electronic databases in addition to manual searches to identify all qualitative studies published between January 2010 and May 2021. Identified articles were screened in two stages against the inclusion criteria with titles and abstracts screened first followed by full-text screening. Included studies were quality appraised using the Critical Appraisal Skills Programme checklist and extracted data were synthesised using a 'best fit' framework, based on an existing theoretical model of health care access. Results: A total of 30 studies were included in this review. Women's experiences covered two overarching themes: 'provision of antenatal care' and 'women's uptake of antenatal care'. The 'provision of antenatal care' theme included five sub-themes: promotion of antenatal care importance, making contact and getting to antenatal care, costs of antenatal care, interactions with antenatal care providers and models of antenatal care provision. The 'women's uptake of antenatal care' theme included seven sub-themes: delaying initiation of antenatal care, seeking antenatal care, help from others in accessing antenatal care, engaging with antenatal care, previous experiences of interacting with maternity services, ability to communicate, and immigration status. A novel conceptual model was developed from these themes. Conclusion: The findings demonstrated the multifaceted and cyclical nature of initial and ongoing access to antenatal care for ethnic minority women. Structural and organisational factors played a significant role in women's ability to access antenatal care. Participants in majority of the included studies were women newly arrived in the host country, highlighting the need for research to be conducted across different generations of ethnic minority women taking into account the duration of stay in the host country where they accessed antenatal care. Protocol and registration: The review protocol was registered on PROSPERO (reference number CRD42021238115). [ABSTRACT FROM AUTHOR]

Background: The immigrant population across Europe is ageing rapidly. Nurses will likely encounter an increasing number of patients who are older adult immigrants. Moreover, access to and equal provision of healthcare is a key issue for several European countries. The relationship between nurses and patients is asymmetrical with unequal power relations; however, the way nurses construct the patient through language and discourse can help maintain or change the balance of power. Unequal power relations can affect access and be a hindrance to equal healthcare delivery. Hence, the aim of this study is to explore how older adult immigrants are discursively constructed as patients by nurses. Methods: An exploratory qualitative design was used. Data were collected through in-depth interviews with a purposive sample of eight nurses from two hospitals. The nurses' narratives were analysed using critical discourse analysis (CDA) as described by Fairclough. Results: The analysis identified an overarching, stable, and dominant discursive practice; 'The discourse of the other', with three interdiscursive practices: (1) 'The discourse on the immigrant patient versus an ideal patient'; (2) 'The expert discourse'; and (3) 'The discourse of adaption'. Older immigrant adults were constructed as 'othered' patients, they were different, alienated, and 'they' were not like 'us'. Conclusion: The way nurses construct older adult immigrants as patients can be an obstacle to equitable health care. The discursive practice indicates a social practice in which paternalism overrides the patient's autonomy and generalization is more prevalent than a person-centred approach. Furthermore, the discursive practice points to a social practice wherein the nurses' norms form the basis for normal; normality is presumed and desirable. Older adult immigrants do not conform to these norms; hence, they are constructed as 'othered', have limited agency, and may be considered rather powerless as patients. However, there are some examples of negotiated power relations where more power is transferred to the patient. The discourse of adaptation refers to a social practice in which nurses challenge their own existing norms to best adapt a caring relationship to the patient's wishes. [ABSTRACT FROM AUTHOR]

Background: Pandemics such as the COVID-19 pandemic and other severe health care disruptions endanger individuals to miss essential care. Machine learning models that predict which patients are at greatest risk of missing care visits can help health administrators prioritize retentions efforts towards patients with the most need. Such approaches may be especially useful for efficiently targeting interventions for health systems overburdened during states of emergency. Methods: We use data on missed health care visits from over 55,500 respondents of the Survey of Health, Ageing and Retirement in Europe (SHARE) COVID-19 surveys (June – August 2020 and June – August 2021) with longitudinal data from waves 1–8 (April 2004 – March 2020). We compare the performance of four machine learning algorithms (stepwise selection, lasso, random forest, and neural networks) to predict missed health care visits during the first COVID-19 survey based on common patient characteristics available to most health care providers. We test the prediction accuracy, sensitivity, and specificity of the selected models for the first COVID-19 survey by employing 5-fold cross-validation, and test the out-of-sample performance of the models by applying them to the data from the second COVID-19 survey. Results: Within our sample, 15.5% of the respondents reported any missed essential health care visit due to the COVID-19 pandemic. All four machine learning methods perform similarly in their predictive power. All models have an area under the curve (AUC) of around 0.61, outperforming random prediction. This performance is sustained for data from the second COVID-19 wave one year later, with an AUC of 0.59 for men and 0.61 for women. When classifying all men (women) with a predicted risk of 0.135 (0.170) or higher as being at risk of missing care, the neural network model correctly identifies 59% (58%) of the individuals with missed care visits, and 57% (58%) of the individuals without missed care visits. As the sensitivity and specificity of the models are strongly related to the risk threshold used to classify individuals, the models can be calibrated depending on users' resource constraints and targeting approach. Conclusions: Pandemics such as COVID-19 require rapid and efficient responses to reduce disruptions in health care. Based on characteristics available to health administrators or insurance providers, simple machine learning algorithms can be used to efficiently target efforts to reduce missed essential care. [ABSTRACT FROM AUTHOR]

Background: The aim of this cross-sectional study was to evaluate the course of self-reported mental distress and quality of life (QoL) of physicians, working in the outpatient care (POC). Outcomes were compared with a control group of physicians working in the inpatient care (PIC), throughout the Corona Virus Disease (COVID)-19 pandemic. The impact of risk and protective factors in terms of emotional and supportive human relations on mental distress and perceived QoL of POC were of primary interest. Methods: Within the largest prospective, multi-center survey on mental health of health care workers (HCW), conducted during the first (T1) and second (T2) wave of the COVID-19 pandemic in Europe, we investigated the course of current burden (CB), depression (Patient Health Questionnaire-2), anxiety (Generalized Anxiety Disorder-2) and QoL, cross-sectionally, in n = 848 POC (T1: n = 536, T2: n = 312). The primary outcomes were compared with an age- and gender-matchted control group of n = 458 PIC (T1: n = 262, T2: n = 196). COVID-19-, work-related, social risk and protective factors were examined. Results: At T1, POC showed no significant differences with respect to CB, depression, anxiety, and QoL, after Bonferroni correction. Whereas at T2, POC exhibited higher scores of CB (Cohen´s d/ Cd =.934, p <.001), depression (Cd = 1.648, p < 001), anxiety (Cd = 1.745, p <.001), work-family conflict (Cd = 4.170, p <.001) and lower QoL (Cd =.891, p =.002) compared with PIC. Nearly all assessed parameters of burden increased from T1 to T2 within the cohort of POC (e.g. depression: CD = 1.580, p <.001). Risk factors for mental distress of POC throughout the pandemic were: increased work-family conflict (CB: ß =.254, p <.001, 95% CI:.23,.28; PHQ-2: ß =.139, p =.011, 95% CI:.09,.19; GAD-2: ß =.207, p <.001, 95% CI:.16,.26), worrying about the patients´ security (CB: ß =.144, p =.007, 95% CI:.07,.22; PHQ-2: ß =.150, p =.006, 95% CI:.00,.30), fear of triage situations (GAD-2: ß =.132, p =.010, 95% CI: -.04,.31) and burden through restricted social contact in spare time (CB: ß =.146, p =.003, 95% CI:.07,.22; PHQ-2: ß =.187, p <.001, 95% CI:.03,.34; GAD-2: ß =.156, p =.003, 95% CI: -.01,.32). Protective factors for mental distress and QoL were the perceived protection by local authorities (CB: ß = -.302, p <.001, 95% CI: -.39, -.22; PHQ-2: ß = -.190, p <. 001, 95% CI: -.36, -.02; GAD-2: ß = -.211, p <.001, 95% CI: -.40, -.03; QoL: ß =.273, p <.001, 95% CI:.18,.36), trust in colleagues (PHQ-2: ß = -.181, p <.001, 95% CI: -.34, -.02; GAD-2: ß = -.199, p <.001, 95% CI: -.37, -.02; QoL: ß =.124, p =.017, 95% CI:.04,.21) and social support (PHQ-2: ß = -.180, p <.001, 95% CI: -.22, -.14; GAD-2: ß = -.127, p =.014, 95% CI: -.17, -.08; QoL: ß =.211, p <.001, 95% CI:.19,.23). Conclusions: During the pandemic, the protective role of emotional and supportive human relations on the mental distress and quality of life of POC should be taken into account more thoroughly, both in practice and future research. [ABSTRACT FROM AUTHOR]

Background: Since 2017, PERFORM2Scale, a research consortium with partners from seven countries in Africa and Europe, has steered the implementation and scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda. This article presents PERFORM2Scale's theory of change (ToC) and reflections upon and adaptations of the ToC over time. The article aims to contribute to understanding the benefits and challenges of using a ToC-based approach for monitoring and evaluating the scale-up of health system strengthening interventions, because there is limited documentation of this in the literature.Methods: The consortium held annual ToC reflections that entailed multiple participatory methods, including individual scoring exercises, country and consortium-wide group discussions and visualizations. The reflections were captured in detailed annual reports, on which this article is based.Results: The PERFORM2Scale ToC describes how the management strengthening intervention, which targets district health management teams, was expected to improve health workforce performance and service delivery at scale, and which assumptions were instrumental to track over time. The annual ToC reflections proved valuable in gaining a nuanced understanding of how change did (and did not) happen. This helped in strategizing on actions to further steer the scale-up the intervention. It also led to adaptations of the ToC over time. Based on the annual reflections, these actions and adaptations related to: assessing the scalability of the intervention, documentation and dissemination of evidence about the effects of the intervention, understanding power relationships between key stakeholders, the importance of developing and monitoring a scale-up strategy and identification of opportunities to integrate (parts of) the intervention into existing structures and strategies.Conclusions: PERFORM2Scale's experience provides lessons for using ToCs to monitor and evaluate the scale-up of health system strengthening interventions. ToCs can help in establishing a common vision on intervention scale-up. ToC-based approaches should include a variety of stakeholders and require their continued commitment to reflection and learning on intervention implementation and scale-up. ToC-based approaches can help in adapting interventions as well as scale-up processes to be in tune with contextual changes and stakeholders involved, to potentially increase chances for successful scale-up. [ABSTRACT FROM AUTHOR]

Background: Drug shortages are a growing global problem, posing clinical and economic challenges. To understand them better, we conducted an inventory of national public drug shortage registers and their comparability in Europe and the USA.Methods: The study was based on openly accessible drug shortage notifications published by national drug authorities. These data were obtained from all national data sources mentioned on the European Medicines Agency's (EMA's) web page and FDA in the USA. After selection of the countries with comparable data, descriptive statistics were used to present characteristics of the shortages both across countries and within countries for 9 months (January-September) in 2020. We studied whether the shortages that occurred in these countries were the same, and how shortages were distributed by therapeutic uses and formulations. We also investigated price variation between the United States and Finland among drugs in shortage in one formulation category (creams and gels).Results: Finland, Sweden, Norway, Spain, and the United States had suitable registers and were included. Altogether 5132 shortage reports from Finland (n = 1522), Sweden (n = 890), Norway (n = 800), Spain (n = 814), and the United States (n = 1106) were published during the study period. Of active ingredient level shortages 54% occurred in only one country, and 1% occurred in all five. However, at the country level, where there was one or more shortage notifications in an ATC active ingredient category, 19-41% were in a single country. The distributions by ATC therapeutic class and drug formulation differed substantially between countries, particularly between the USA and European countries. Injectables had a high shortage risk in the USA (57% of all shortages versus 17-31% of all shortages in the European countries). By contrast, shortages in gels and creams occurred only in European data (4-6% of all shortages). In the price comparison, creams and gels in shortage in Finland were 160% more expensive in the USA where these shortages were not detected.Conclusions: Public drug shortage registers are vital data sources for proactively maintaining and managing a reliable drug supply. However, our study demonstrates that much work remains to standardize the contents and quality of public register data. Shortages may not be solely a consequence of manufacturing disruptions but may reflect other contributing factors in the international drug distribution and supply mechanisms, including price differences and profit margins between national pharmaceutical markets. Data to perform practical and useful international comparisons to understand these shortages are required. [ABSTRACT FROM AUTHOR]