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Background: The implementation science literature acknowledges a need for engagement of key stakeholders when designing, delivering and evaluating implementation work. To date, the literature reports minimal or focused stakeholder engagement, where stakeholders are engaged in either barrier identification and/or barrier prioritisation. This paper begins to answer calls from the literature for the development of tools and guidance to support comprehensive stakeholder engagement in implementation research and practice. The paper describes the systematic development of the Implementation‐STakeholder Engagement Model (I‐STEM) in the context of an international, large‐scale empirical implementation study (ImpleMentAll) aimed at evaluating the effectiveness of a tailored implementation toolkit. The I‐STEM is a sensitising tool that defines key considerations and activities for undertaking stakeholder engagement activities across an implementation process. Methods: In‐depth, semistructured interviews and observations were conducted with implementers who were tailoring implementation strategies to integrate and embed internet‐based cognitive behavioural therapy (iCBT) services in 12 routine mental health care organisations in nine countries in Europe and Australia. The analytical process was informed by principles of first‐ and third‐generation Grounded Theory, including constant comparative method. Results: We conducted 55 interviews and observed 19 implementation‐related activities (e.g., team meetings and technical support calls). The final outcome of our analysis is expressed in an initial version of the I‐STEM, consisting of five interrelated concepts: engagement objectives, stakeholder mapping, engagement approaches, engagement qualities and engagement outcomes. Engagement objectives are goals that implementers plan to achieve by working with stakeholders in the implementation process. Stakeholder mapping involves identifying a range of organisations, groups or people who may be instrumental in achieving the engagement objectives. Engagement approaches define the type of work that is undertaken with stakeholders to achieve the engagement objectives. Engagement qualities define the logistics of the engagement approach. Lastly, every engagement activity may result in a range of engagement outcomes. Conclusion: The I‐STEM represents potential avenues for substantial stakeholder engagement activity across key phases of an implementation process. It provides a conceptual model for the planning, delivery, evaluation and reporting of stakeholder engagement activities. The I‐STEM is nonprescriptive and highlights the importance of a flexible, iterative approach to stakeholder engagement. It is developmental and will require application and validation across a range of implementation activities. Patient or Public Contribution: Patient contribution to ImpleMentAll trial was facilitated by GAMIAN‐Europe at all stages—from grant development to dissemination. GAMIAN‐Europe brings together a wide variety of patient representation organisations (local, regional and national) from almost all European countries. GAMIAN‐Europe was involved in pilot testing the ItFits‐toolkit and provided their views on the various aspects, including stakeholder engagement. Patients were also represented in the external advisory board providing support and advice on the design, conduct and interpretation of the wider project, including the development of the ItFits‐toolkit. Trial registration: ClinicalTrials.gov NCT03652883. Retrospectively registered on 29 August 2018. [ABSTRACT FROM AUTHOR]

Background: The aim of the study is to analyse the association between job stress and interpersonal relationships on and outside of the job in Europe. The main assumption of the paper is that since social relations at various levels enhance individual well-being, they may counteract stress created by an unfavourable work environment.Methods: The econometric analysis, based on a standard ordered probit model, employs data taken from the Sixth European Working Conditions Survey carried out in 2015 and released in 2017.Results: The results show significant correlations between interpersonal contacts on and outside of the job and job stress. Help and support provided by one's manager decreases the probability of being stressed at work, while receiving help and support from co-workers is likely to increase the probability of job stress occurrence. However, maintaining cooperation and getting on well with colleagues decrease the probability of experiencing stress, confirming the positive and gratifying features of contact with co-workers reported by the literature.Conclusions: While we were not able to establish the direction of causality between job stress and interpersonal relationships (a limitation of this paper), the present work contributes new evidence to the literature on occupational stress. Our results show that interpersonal relationships on and outside of the job can be considered valuable resources that, when available to an individual, are useful for managing stress created by workplace stressors. [ABSTRACT FROM AUTHOR]

Amidst the widespread stigma and exclusion attached to dementia in dominant narratives of successful ageing, this article addresses a gap in the scientific literature concerning our understanding of the medicalization of cognitive decline as a natural phenomenon. To this end, it explores how a dementia diagnosis acquires its symbolic power of exclusion in later life through an ethnography of cognitive rehabilitation therapy in two memory clinics in a southern European nation. It argues that this symbolic power of exclusion is locally produced through the meaning making practices of therapists and researchers administering regular cognitive training therapy and exercises to support autonomy. It shows how the different steps involved in rehabilitation play a role in dividing later life by defining and reifying a category of abnormal ageing during the cognitive assessment, and by applying a confrontational approach exposing decline. It shows how this approach generates the position of older adults who can be rehabilitated against those who cannot; the latter representing a "failed" ageing in the narrative of successful ageing. This article proposes the adoption of the concept of "technologies of ascription" to characterize this process of exclusion through reification and confrontation of "abnormal cognitive decline." The paper argues that such practices are central to the local production of the symbolic power attached to a dementia diagnosis as well as its capacity to fragment later life. Finally, it argues for the utility of this concept in offering new opportunities for anthropology to characterize exclusion in later life through medicalization. [ABSTRACT FROM AUTHOR]

Background: People with dementia are often marginalized and excluded from influence, also in relation to dementia research. There is, however, a growing requirement for inclusion through Patient and Public Involvement (PPI), but there is still limited knowledge on how researchers can fully benefit from the involvement of people with dementia in the development and testing of psychosocial interventions. This paper describes the results of a pan‐European consultation with people with dementia, synthesizing their views on outcomes of psychosocial interventions. Objective: To involve people with dementia in establishing what are meaningful outcomes when participating in psychosocial interventions. Setting and participants: Consultations took place at four divergent sites across Europe, involving twenty‐five people with dementia from nine European countries. Methods: The methods used for the consultation were developed through an iterative process involving people with dementia. Data from the consultation were analysed from a thematic analysis approach. Results: The results suggested that people with dementia wish to participate in interventions that enhance their well‐being, confidence, health, social participation and human rights. This highlights a need for improvements in psychosocial research to capture these outcomes. Discussion and conclusions: Involving people with dementia in discussions of psychosocial interventions has enhanced our understanding about meaningful outcome measures in research and methods of data collection. This study suggests that new outcome measures in psychosocial research are needed where concepts of positive psychology and social health can guide innovation and outcome measurement. [ABSTRACT FROM AUTHOR]

The paper aims at exploring how the university understands, manages and improves the quality culture related to the national and European/international principles of quality assurance, based on interviews having as subject academic staff, students and partners/employers. After a brief introduction and the presentation of the scope and methodology of the research the paper relates some issues of quality culture in the higher education to the literature, followed by a briefing presentation of the results. The main findings are discussed in correlation with the questions used with the interviews: the presence of the university in the social-economical life, the continuing improvement of the quality of teaching-learning process, the satisfaction of participation/collaboration on research projects, the students' involvement in the university governance and life and the role of quality culture system in assuring the university beneficiaries expectations. Finally, a quality culture system and some reflective views are proposed. [ABSTRACT FROM AUTHOR]

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Background: The COVID-19 pandemic has necessitated changes in European healthcare systems, with a significant proportion of COVID-19 cases being managed on an outpatient basis in primary healthcare (PHC). To alleviate the burden on healthcare facilities, many European countries developed contact-tracing apps and symptom checkers to identify potential cases. As the pandemic evolved, the European Union introduced the Digital COVID-19 Certificate for travel, which relies on vaccination, recent recovery, or negative test results. However, the integration between these apps and PHC has not been thoroughly explored in Europe. Objective: To describe if governmental COVID-19 apps allowed COVID-19 patients to connect with PHC through their apps in Europe and to examine how the Digital COVID-19 Certificate was obtained. Methodology: Design and setting: Retrospective descriptive study in PHC in 30 European countries. An ad hoc, semi-structured questionnaire was developed to collect country-specific data on primary healthcare activity during the COVID-19 pandemic and the use of information technology tools to support medical care from 15 March 2020 to 31 August 2021. Key informants belong to the WONCA Europe network (World Organization of Family Doctors). The data were collected from relevant and reliable official sources, such as governmental websites and guidelines. Main outcome measures: Patient's first contact with health system, governmental COVID-19 app (name and function), Digital COVID-19 Certification, COVID-19 app connection with PHC. Results: Primary care was the first point of care for suspected COVID-19 patients in 28 countries, and 24 countries developed apps to complement classical medical care. The most frequently developed app was for tracing COVID-19 cases (24 countries), followed by the Digital COVID-19 Certificate app (17 countries). Bulgaria, Italy, Serbia, North Macedonia, and Romania had interoperability between PHC and COVID-19 apps, and Poland and Romania's apps considered social needs. Conclusions: COVID-19 apps were widely created during the first pandemic year. Contact tracing was the most frequent function found in the registered apps. Connection with PHC was scarcely developed. In future pandemics, connections between health system levels should be guaranteed to develop and implement effective strategies for managing diseases. [ABSTRACT FROM AUTHOR]

Aim: To investigate nursing/midwifery students, Clinical Mentors, Link Teachers and Head Nurses experiences within "Dedicated Education Unit" model in 6 European clinical placements and analyse the necessary elements for a powerful clinical learning environment. Design: A multi‐country, phenomenological, qualitative study. Methods: Focus group interviews were performed to identify the personal and organizational factors of importance for students and nurses/midwives. Results: Data analysis produced 4 main themes (1) Clinical placement organization, (2) students' clinical knowledge and skill acquisition, (3) students, and nurses/midwives' experiences within the DEU model and (4) factors for creating an effective learning environment. Conclusions: A close educational‐service collaboration, a realistic clinical placement planning, a focus on student learning process and an investment in professionals' education and development among others, are elements to set up a powerful clinical learning environment. Implications for the profession: It is considered advisable and urgent to improve the working conditions of nurses/midwives and the learning environments of students as a strategy to alleviate the global shortage of nurses and respond to the increasingly demanding health needs of the population. Impact: Due to the close relationship between students' learning and features of the clinical environment nurse educators seek innovative models which allow students to manage patient care and their transition to professional practice. To implement new learning strategies, identifying students, nurses and midwives perceptions and suggestions is a powerful information to evaluate implementation process and outcomes. Public Contribution: Our findings could help academic and clinical managers to meet the human and organizational requirements to create a successful learning environment in every student placement. [ABSTRACT FROM AUTHOR]

Background: The paper presents the first ethnobotanical application of Ellenberg indicator values, which are widely used in European plant ecology. The aim of the study was to find out if Ellenberg values (indicating habitat preferences) differ for wild food and medicinal plants used in north-eastern Istria (Croatia). We used Ellenberg-Pignatti values (the version of Ellenberg values used in this part of Europe). Methods: Fifty semi-structured interviews were carried out among local key informants, asking which wild food and medicinal plants they used. Results: The mean number of food and medicinal plants mentioned per interview was 30. Altogether, 121 species were recorded as food or medicine used or previously used in the study area. Thirty-one species are used exclusively as food or everyday drink, 50 species are used exclusively as medicine and 40 species are used for both food and medicine. There were no significant differences between Ellenberg values for food and medicinal plants, apart from the Nitrogen indicator value - the plants used exclusively as food had a significantly higher index than those used in medicine. This probably stems from the fact that plants with soft fleshy shoots are attractive as food and they are more likely to come from nitrogen-rich ruderal habitats. Conclusions: Food plants and medicinal plants are collected from a variety of habitats and no clear difference between the two categories of plants was detected, however further testing of Ellenberg values in ethnobotanical studies could be interesting. [ABSTRACT FROM AUTHOR]

Background and objective The spread of self-care holds the promise of containing chronic illness burden. Falling within the framework of a FP7 collaborative research project, this paper reports the views of key informants from six countries regarding who the main stakeholders are at different levels in the support system for self-care for patients with chronic illness ( SSSC) and how they accomplish their role and collaborate. Methods 90 Interviews with purposefully selected key informants from Bulgaria, Greece, the Netherlands, Norway, Spain and United Kingdom were conducted. Interviews involved government and local authorities, politicians, academics, health professionals and private sector representatives. Interviewers followed an expert opinion-based guide. Analysis involved a cross-country examination with thematic analysis and framework method techniques. Results Key informants described the ideal SSSC as inclusive, interdependent and patient-centred. The following main stakeholders in SSSC were identified: patients, governments, health-care professionals, associations, private companies and the media. In the current SSSCs, collaboration among stakeholders within and across different levels was said to be lacking. Patients were seen as playing a passive subordinate role based on the following: their own attitudes; the paternalistic and medicalized attitudes of the health-care professionals; their misrepresentation by patient associations; and their exposure to the damaging influences of media and industries. Conclusions Making SSSC patient-centred constitutes the greatest challenge for European authorities. Strategies must be revised for promoting patient participation. They should undergo changes so as to promote industry and media social responsibility and patient association advocacy capacity. [ABSTRACT FROM AUTHOR]

The aim of this paper is to discuss some of the underlying concepts and unique features of a major European study of industrial marketing and purchasing, being carried out by the IMP group of academic researchers. The paper is partly based on theory and cases which are more fully reported by the IMP in Industrial Marketing and Purchasing in Europe: An Interaction Approach, John Wiley (forthcoming). The focus of the research is upon the relationships between buying and selling companies in and between five European countries. One of the objectives of the research has been to make a comparative analysis of the operations, strategies and organisation structures of companies involved in export marketing to, and international purchasing from, France, Germany, Italy, Sweden and the United Kingdom. The importance of analysing both sides of the buyer-seller relationship has been recognised and met by adopting an interaction approach to industrial marketing and purchasing. Instead of investigating general approaches to organisational buying behaviour and industrial marketing, over 800 specific inter-company relationships have been examined as a result of carrying out personal interviews in companies throughout Europe. The assumption that industrial markets are strongly influenced by technological factors has influenced our decision to obtain a systematic variation in the product and manufacturing technologies of supplier and customer companies respectively and permits an examination of the interaction processes between individuals and organisations concerned. [ABSTRACT FROM AUTHOR]

Background: During the COVID-19 pandemic, effective contact tracing was recognized as a crucial public health response to mitigate the spread of SARS-CoV-2 and reduce COVID-19-related morbidity and mortality, particularly before widespread vaccination. The World Health Organization (WHO) recommended implementing active surveillance strategies to trace and quarantine contacts of confirmed or suspected COVID-19 cases. Methods: A detailed review and analysis of the COVID-19 contact tracing responses was conducted in five European countries and territories, between March 2021 and August 2022. The countries and territories were selected to ensure geographical representation across the WHO European Region and applied a mixed-methods approach of in-depth interviews with various stakeholders across different administrative levels to identify good practices in COVID-19 contact tracing. The interviews covered 12 themes, including methods and procedures for COVID-19 contact tracing, information technology, quality assurance and key performance indicators. Results: The findings demonstrate that the policy approach, digitalization capabilities and implementation approach varied in the countries and territories and were dynamic throughout the pandemic. The analysis revealed that some practices were applicable across all countries and territories, while others were context-specific, catering to each country's and territory's unique needs. The study highlighted a need for all countries to institutionalize contact tracing as an essential function of existing health systems, to digitalize contact tracing practices and processes, and to build and retain contact tracing capacities for better pandemic preparedness. Conclusion: The lessons related to COVID-19 contact tracing should be utilized to strengthen future outbreak response operations as part of epidemic and pandemic preparedness. [ABSTRACT FROM AUTHOR]

Background: Although there is evidence that tailored implementation strategies can be effective, there is little evidence on which methods of tailoring improve the effect. We designed and evaluated five tailored programs (TPs) each consisting of various strategies. The aim of this study was to examine (a) how determinants of practice prioritized in the design phase of the TPs were perceived by health care professionals who had been exposed to the TPs and whether they suggested other important determinants of practice and (b) how professionals used the offered strategies and whether they suggested other strategies that might have been more effective.Methods: We conducted a mixed-method process evaluation linked to five cluster-randomized trials carried out in five European countries to implement recommendations for five chronic conditions in primary care settings. The five TPs used a total of 28 strategies which aimed to address 38 determinants of practice. Interviews of professionals in the intervention groups and a survey of professionals in the intervention and control groups were performed. Data collection was conducted by each research team in the respective national language. The interview data were first analyzed inductively by each research team, and subsequently, a meta-synthesis was conducted. The survey was analyzed descriptively.Results: We conducted 71 interviews; 125 professionals completed the survey. The survey showed that 76 % (n = 29) of targeted determinants of practice were perceived as relevant and 95 % (n = 36) as being modified by the implementation interventions by 66 to 100 % of professionals. On average, 47 % of professionals reported using the strategies and 51 % considered them helpful, albeit with substantial variance between countries and strategies. In the interviews, 89 determinants of practice were identified, of which 70 % (n = 62) had been identified and 45 % (n = 40) had been prioritized in the design phase. The interviewees suggested 65 additional strategies, of which 54 % (n = 35) had been identified and 20 % (n = 13) had been prioritized, but not selected in the final programs.Conclusions: This study largely confirmed the perceived relevance of the targeted determinants of practice. This contrasts with the fact that no impact of the trials on the implementation of the recommendations could be observed. The findings suggest that better methods for prioritization of determinants and strategies are needed.Trial Registration: Each of the five trials was registered separately in recognized trial registries. Details are given in the respective trial outcome papers. [ABSTRACT FROM AUTHOR]

Background: The Medical Research Council (MRC) Framework for complex interventions highlights the need to explore interactions between components of complex interventions, but this has not yet been fully explored within complex, non-pharmacological interventions. This paper draws on the process evaluation data of a suicide prevention programme implemented in four European countries to illustrate the synergistic interactions between intervention levels in a complex programme, and to present our method for exploring these.Methods: A realist evaluation approach informed the process evaluation, which drew on mixed methods, longitudinal case studies. Data collection consisted of 47 semi-structured interviews, 12 focus groups, one workshop, fieldnoted observations of six programme meetings and 20 questionnaires (delivered at six month intervals to each of the four intervention sites). Analysis drew on the framework approach, facilitated by the use of QSR NVivo (v10). Our qualitative approach to exploring synergistic interactions (QuaSIC) also developed a matrix of hypothesised synergies that were explored within one workshop and two waves of data collection.Results: All four implementation countries provided examples of synergistic interactions that added value beyond the sum of individual intervention levels or components in isolation. For instance, the launch ceremony of the public health campaign (a level 3 intervention) in Ireland had an impact on the community-based professional training, increasing uptake and visibility of training for journalists in particular. In turn, this led to increased media reporting of OSPI activities (monitored as part of the public health campaign) and also led to wider dissemination of editorial guidelines for responsible reporting of suicidal acts. Analysis of the total process evaluation dataset also revealed the new phenomenon of the OSPI programme acting as a catalyst for externally generated (and funded) activity that shared the goals of suicide prevention.Conclusions: The QuaSIC approach enabled us to develop and refine our definition of synergistic interactions and add the innovative concept of catalytic effects. This represents a novel approach to the evaluation of complex interventions. By exploring synergies and catalytic interactions related to a complex intervention or programme, we reveal the added value to planned activities and how they might be maximised. [ABSTRACT FROM AUTHOR]

Background: Growing demand for Global Health (GH) training and the internationalisation of education requires innovative approaches to training. Blended learning (BL, a form of e-learning combining face-to-face or real-time interaction with computer-assisted learning) is a promising approach for increasing GH research capacity in low- to middle-income countries. Implementing BL, however, requires additional skills and efforts from lecturers. This paper explores lecturers' views and experiences of delivering BL courses within the context of two north-south collaborative research capacity building projects, ARCADE HSSR and ARCADE RSDH. Design: We used a qualitative approach to explore the experiences and perceptions of 11 lecturers involved in designing and delivering BL courses collaboratively across university campuses in four countries (South Africa, Uganda, India and Sweden). Data were collected using interviews in person or via Skype. Inductive qualitative content analysis was used. Results: Participants reported that they felt BL increased access to learning opportunities and made training more flexible and convenient for adult learners, which were major motivations to engage in BL. However, despite eagerness to implement and experiment with BL courses, they lacked capacity and support, and found the task time consuming. They needed to make compromises between course objectives and available technological tools, in the context of poor Internet infrastructure. Conclusions: BL courses have the potential to build bridges between low- and middle-income contexts and between lecturers and students to meet the demand for GH training. Lecturers were very motivated to try these approaches but encountered obstacles in implementing BL courses. Considerable investments are needed to implement BL and support lecturers in delivering courses. [ABSTRACT FROM AUTHOR]

Background A pre-existing, well-established European influenza surveillance network known as I-MOVE enabled the rapid implementation of a European multi-country COVID-19 hospital surveillance network for surveillance of hospitalized COVID-19 cases in early 2020. This network included 257 hospitals in 11 surveillance sites across nine countries. We aimed to identify whether the surveillance objectives were relevant to public health actions, whether the surveillance system met its objectives, where and how shortcomings could be improved, and whether the system was sustainable. Methods We identified six key attributes (meeting objectives, usefulness, timeliness, data quality, simplicity and sustainability) to assess, using Centers for Disease Control and Prevention's evaluation framework. We analyzed pooled datasets, held interviews and group discussions with 10 participating and coordinating sites and gathered feedback through web surveys. Results There was overall agreement that the surveillance objectives had been met and being involved in a network of European partners had additional important benefits for stakeholders. While the publication of the outputs was not always sufficiently timely, data submission processes were considered straightforward and the key surveillance variables (age, sex, hospital admission and mortality data) were complete. The main challenges were identified as the collection of the large number of variables, limited available human resources and information governance and data protection laws. Conclusions I-MOVE-COVID-19 delivered relevant and accurate data supporting the development and implementation of COVID-19 surveillance. Recommendations presented here identify learning opportunities to support preparedness and surveillance response for future pandemics. The applied evaluation framework in this study can be adapted for other European surveillance system evaluations. [ABSTRACT FROM AUTHOR]

Background: The integration of stakeholders is crucial in developing smart living technologies to support the autonomy of elderly populations. Despite the clear benefits of these technologies, there remains a significant gap in comprehensive research. Methods: This study presents the viewpoints of 19 stakeholders from Europe and Japan, focusing on the sustainability of smart living solutions for Active and Healthy Ageing (AHA). Data were gathered through qualitative semi-structured interviews and analysed using a Framework Analysis approach. Results: Analysis of the interviews revealed six key sustainability categories: addressing the unmet needs of older adults, functionalities of the smart living coach, integration within organizations, identified barriers, financial considerations, and the social role of the smart living coach. Conclusions: This research underscores the importance of evaluating user needs through the involvement of various stakeholders, including the elderly, their caregivers, professionals, technicians, service providers, and government bodies. Collaborative efforts are essential to generate new evidence demonstrating the value of smart living solutions in facilitating Active and Healthy Ageing. [ABSTRACT FROM AUTHOR]

Purpose: Achieving greater health and social care integration is a policy priority in many countries, but challenges remain. We focused on governance and accountability for integrated care and explored arrangements that shape more integrated delivery models or systems in Italy, the Netherlands and Scotland. We also examined how the COVID-19 pandemic affected existing governance arrangements. Design/methodology/approach: A case study approach involving document review and semi-structured interviews with 35 stakeholders in 10 study sites between February 2021 and April 2022. We used the Transparency, Accountability, Participation, Integrity and Capability (TAPIC) framework to guide our analytical enquiry. Findings: Study sites ranged from bottom-up voluntary agreements in the Netherlands to top-down mandated integration in Scotland. Interviews identified seven themes that were seen to have helped or hindered integration efforts locally. Participants described a disconnect between what national or regional governments aspire to achieve and their own efforts to implement this vision. This resulted in blurred, and sometimes contradictory, lines of accountability between the centre and local sites. Flexibility and time to allow for national policies to be adapted to local contexts, and engaged local leaders, were seen to be key to delivering the integration agenda. Health care, and in particular acute hospital care, was reported to dominate social care in terms of policies, resource allocation and national monitoring systems, thereby undermining better collaboration locally. The pandemic highlighted and exacerbated existing strengths and weaknesses but was not seen as a major disruptor to the overall vision for the health and social care system. Research limitations: We included a relatively small number of interviews per study site, limiting our ability to explore complexities within sites. Originality: This study highlights that governance is relatively neglected as a focus of attention in this context but addressing governance challenges is key for successful collaboration. [ABSTRACT FROM AUTHOR]

The progressive population ageing observed in Western countries determines a growing need for long-term care for older people. At the same time, migrants and refugees often have integration difficulties in regards to the hosting country society and labour market, with one reason being the lack of EU recognition of the educational degrees obtained in their native country. Creating educational opportunities in elderly care for migrants may facilitate their social inclusion, increase their employability, and constitute a response to the growing labor demand. The HERO project moved in this direction by planning, designing, and carrying out an original training curriculum targeted to migrants and refugees from African and Middle Eastern countries, piloted in four Mediterranean countries (Cyprus, Greece, Italy, and Portugal). The impact of the training on migrants and refugees' quality of life was assessed through the WHOQOL-BREF questionnaire, while social inclusion was assessed through semistructured interviews and participant observation carried out during the internship in elderly care facilities. Eighty-two migrants (70.7 percent women) were involved in the study. The results showed that despite the fact that the training did not have an impact on the trainees' quality of life, it was associated with social inclusion. Four ideal types of migrant learners were drawn: "ex-professional trainees," "fall-back trainees," "care-oriented trainees," and "nonprofessional care workers," based on which as many possible educational pathways were drawn to optimise the trainees' learning process. The study results shaped the formulation of suggestions on migrants' education in elderly care. [ABSTRACT FROM AUTHOR]

Building integrated photovoltaics, a special form of photovoltaics, is still a niche market with a relatively low number of installations worldwide. Although it is considered a promising technology, especially in Europe where land for large-scale photovoltaic plants is rare, several factors continue to constrain its widespread adoption. This paper investigates the prospects for, and barriers to, building integrated photovoltaics adoption in the European context, building on a series of interviews with experts in the field. The results indicate that the main problems relate to cost calculations, to the existing gap between the photovoltaic and the building industry, and to the lack of expertise and knowledge concerning the potential of the technology among important stakeholders. However, with the implementation of the new European Building Directive 2010/31/EU that demands "nearly zero-energy buildings" by 2020, building integrated photovoltaics is likely to gain considerable momentum. [ABSTRACT FROM AUTHOR]

INTRODUCTION Having a chronic disease either caused or worsened by tobacco smoking does not always translate into quitting smoking. Although smoking cessation is one of the most cost-effective medical interventions, it remains poorly implemented in healthcare settings. The aim was to examine whether smokers with chronic and respiratory diseases were more likely to receive support to quit smoking by a healthcare provider or make a quit attempt than smokers without these diseases. METHODS This population-based study included a sample of 6011 adult smokers in six European countries. The participants were interviewed face-to-face and asked questions on sociodemographic characteristics, current diagnoses for chronic diseases, healthcare visits in the last 12 months and, if so, whether they had received any support to quit smoking. Questions on smoking behavior included nicotine dependence, motivation to quit smoking and quit attempts in the last 12 months. The results are presented as weighted percentages with 95% confidence intervals (CI) and as adjusted odds ratios with 95% CI based on logistic regression analyses. RESULTS Smokers with chronic respiratory disease, those aged 55 years and older, as well as those with one or more chronic diseases were more likely to receive smoking cessation advice from a healthcare professional. Making a quit attempt in the last year was related to younger age, high educational level, higher motivation to quit, lower nicotine dependence and having received advice to quit from a healthcare professional but not with having chronic diseases. There were significant differences between countries with smokers in Romania consistently reporting more support to quit as well as quit attempts. CONCLUSIONS Although smokers with respiratory disease did indeed receive smoking cessation support more often than smokers without disease, many smokers did not receive any advice or support to quit during a healthcare visit. [ABSTRACT FROM AUTHOR]

Background: People experiencing homelessness (PEH) are known to be at higher risk of adverse health outcomes and premature mortality when compared to the housed population and often face significant barriers when attempting to access health services. This study aimed to better understand the specific health care needs of PEH and the barriers and facilitators associated with their timely and equitable access to health services in the European context. Methods: We conducted an exploratory cross-national qualitative study involving people with lived experience of homelessness and health and social care professionals in Austria, Greece, Spain, and the UK. A total of 69 semi-structured interviews comprising 15 social care professionals, 19 health care professionals, and 35 PEH were completed, transcribed, and analysed thematically. Results: Findings were organised into three overarching themes relating to the research question: (a) Health care needs of PEH, (b) Barriers to health care access, and (c) Facilitators to health care access. Overall, the general health of PEH was depicted as extremely poor, and mainstream health services were portrayed as ill-equipped to respond to the needs of this population. Adopting tailored approaches to care, especially involving trusted professionals in the delivery of care, was identified as a key strategy for overcoming existing barriers. Conclusions: The results of this study indicate there to be a high degree of consistency in the health care needs of PEH and the barriers and facilitators associated with their access to health care across the various European settings. Homelessness in itself is recognized to represent an essential social determinant of health, with PEH at risk of unequal access to health services. Changes are thus required to facilitate PEH's access to mainstream primary care. This can also be further complemented by investment in 'in-reach' services and other tailored and person-centred forms of health care. Trial registration: This study was registered retrospectively on June 6, 2022, in the registry of ClinicalTrials.gov under the number NCT05406687. [ABSTRACT FROM AUTHOR]

Background The material practices which researchers use in research partnerships may enable or constrain the nature of engagement with stakeholder groups. Participatory learning and action ( PLA) research approaches show promise, but there has been no detailed analysis of stakeholders' and researchers' experiences of PLA techniques for data generation and co-analysis. Objectives To explore stakeholders' and researchers' experiences of PLA techniques for data generation and co-analysis. Design The EU RESTORE implementation science project employed a participatory approach to investigate and support the implementation of guidelines and training initiatives ( GTIs) to enhance communication in cross-cultural primary care consultations. We developed a purposeful sample of 78 stakeholders (migrants, general practice staff, community interpreters, service providers, service planners) from primary care settings in Austria, England, Greece, Ireland and The Netherlands. We used speed evaluations and participatory evaluations to explore their experiences of two PLA techniques-Commentary Charts and Direct Ranking-which were intended to generate data for co-analysis by stakeholders about the GTIs under analysis. We evaluated 16 RESTORE researchers' experiences using interviews. We conducted thematic and content analysis of all evaluation data. Results PLA Commentary Charts and Direct Ranking techniques, with their visual, verbal and tangible nature and inherent analytical capabilities, were found to be powerful tools for involving stakeholders in a collaborative analysis of GTIs. Stakeholders had few negative experiences and numerous multifaceted positive experiences of meaningful engagement, which resonated with researchers' accounts. Conclusion PLA techniques and approaches are valuable as material practices in health research partnerships. [ABSTRACT FROM AUTHOR]

Background In Europe, more than 15 million people live with heart failure (HF). It imposes an enormous social, organizational and economic burden. As a reaction to impending impact on healthcare provision, different country-specific structures for HF-care have been established. The aim of this report is to provide an overview and compare the HF-care approaches of Germany, Ireland, the Netherlands and the UK, and to open the possibility of learning from each other's experience. Methods A mixed methods approach was implemented that included a literature analysis, interviews and questionnaires with HF-patients and caregivers, and expert interviews with representatives from healthcare, health service research and medical informatics. Results The models of HF-care in all countries analyzed are based on the European Society of Cardiology guidelines for diagnosis and treatment of HF. Even though the HF-models differed in design and implementation in practice, key challenges were similar: (i) unequal distribution of care between urban and rural areas, (ii) long waiting times, (iii) unequal access to and provision of healthcare services, (iv) information and communication gaps and (v) inadequate implementation and financing of digital applications. Conclusion Although promising approaches exist to structure and improve HF-care, across the four countries, implementation was reluctant to embrace novel methods. A lack of financial resources and insufficient digitalization making it difficult to adopt new concepts. Integration of HF-nurses seems to be an effective way of improving current models of HF-care. Digital solutions offer further opportunities to overcome communication and coordination gaps and to strengthen self-management skills. [ABSTRACT FROM AUTHOR]

Introduction: Data and digital infrastructure drive collaboration and help develop integrated healthcare systems and services. COVID-19 induced changes to collaboration between healthcare organisations, which previously often happened in fragmented and competitive ways. New collaborative practices relied on data and were crucial in managing coordinated responses to the pandemic. In this study, we explored datadriven collaboration between European hospitals and other healthcare organisations in 2021 by identifying common themes, lessons learned and implications going forward. Methods: Study participants were recruited from an existing Europe-wide community of mid-level hospital managers. For data collection, we ran an online survey, conducted multi-case study interviews and organised webinars. Data were analysed using descriptive statistics, thematic analysis and cross-case synthesis. Results: Mid-level hospital managers from 18 European countries reported an increase in data exchange between healthcare organisations during the COVID-19 pandemic. Data-driven collaborative practices were goal-oriented and focused on the optimisation of hospitals’ governance functions, innovation in organisational models and improvements to data infrastructure. This was often made possible by temporarily overcoming system complexities, which would otherwise hinder collaboration and innovation. Sustainability of these developments remains a challenge. Discussion: Mid-level hospital managers form a huge potential of reacting and collaborating when needed, including rapidly setting up novel partnerships and redefining established processes. Major post-COVID unmet medical needs are linked to hospital care provision, including diagnostic and therapeutic backlogs. Tackling these will require rethinking of the position of hospitals within healthcare systems, including their role in care integration. Conclusion: Learning from COVID-19-induced developments in data-driven collaboration between hospitals and other healthcare organisations is important to address systemic barriers, sustain resilience and further build transformative capacity to help build better integrated healthcare systems. [ABSTRACT FROM AUTHOR]

Background: Health and social care systems face difficulties in managing multimorbidity, disease burden and complex needs in long‐term conditions such as Parkinson's disease. Objective: This study aimed to develop a European understanding of how health and social care professionals can collaborate with stakeholders from different organizations and sectors to enhance the management of Parkinson's disease in a community setting by identifying the existing gaps in this process and how people with Parkinson's disease and their family carers could benefit from these partnerships. Methods: A mixed‐methods sequential study was conducted in Denmark, Norway, Spain and the United Kingdom. The findings from the qualitative phase are presented. Individual semistructured interviews were analysed using Braun's and Clarke's thematic analysis. A meta‐ethnography approach was used to analyse and synthesize cross‐national findings. Results: A total of 41 healthcare professionals and 39 stakeholders from different disciplines and sectors were interviewed in the four countries. The participants acknowledged a lack of awareness of available resources and poor communication between the different support systems in the management of Parkinson's disease. To promote multiagency collaborations, the participants highlighted the need to organize services along the Parkinson's disease journey, patient involvement and strategic involvement of carers in organizing resources and Parkinson's disease care pathways. According to the participants, the benefits from multiagency partnerships could lead to an enhanced continuity of care and specialized knowledge, mobilization of resources in the community, personalized support and improved access to services. Conclusions: Policymakers are called upon to create formal structures that facilitate multisectoral collaborations to promote an integrated system of care for the management of Parkinson's disease in the community. To address this challenge, we propose five strategies showing how organizations can work together to optimize the use of resources and enhance the management of Parkinson's disease throughout the illness trajectory. Patient or Public Contribution: Patient and Public Involvement groups made up of stakeholders, healthcare professionals, patients with Parkinson's disease and family carers participated in the design of the study, the development of the interview guides and the validation of the findings. [ABSTRACT FROM AUTHOR]

Background: Catalonia (in the north east of the Iberian Peninsula) is among the most prospected territories in Europe, from the ethnobotanical point of view. The aim of the present paper is to undertake a global analysis in the area considered, including plants, plant life forms, and ethnobotanical data within a physiographic and geographic framework. Methods: Data from 21 ethnobotanical prospection areas in Catalonia were collected, analyzed, and compared, with the focus on plant life forms and geographic divisions. Results: A total of 824 taxa constitute the Catalan ethnoflora, and 316 of them are shared by the six physiographic zones recognized in Catalonia. When three major geographic areas are considered (Pyrenean, inland, and littoral), 394 taxa have been reported in only one out of the three areas. Concerning life forms, phanerophytes and chamaephytes together, i.e., those taxa present all through the year, are the most cited (37.12%). Conclusions: This first study constitutes a new approach to ethnobotanical data analysis. The results show the particular importance of plants with a large distribution area and plants with available biomass throughout the year. Apart from this, other kind of plants, e.g., those present in only one territory, are of interest for its originality and sometimes for the local significance. [ABSTRACT FROM AUTHOR]

Aim: Nurse leaders influence workplace culture; however, little is known about ethnic cultural influences on nurse leader development. This research aims to identify personal strategies promoting effective leadership by nurse leaders from European small island countries. Design: Descriptive qualitative study. Methods: In 2017, nineteen semi‐structured interviews with nurse leaders from England, Greece, Republic of Ireland and Malta explored leadership journeys, strategies employed to support their growth and development, and how cultural identity played a role. Transcripts were analysed using reflexive thematic analysis. Results: Four main themes and 12 subthemes captured the strategies and approaches of the nurse leaders: (1) Influences, (2) Communication, (3) Process and (4) Relationships. These findings reflect and validate the five transformational leadership practices of the Exemplary Leadership Model. While cultural island identity was discussed, there was a shared cultural identity within the role of "nurse leader" that spanned all islands. Patient or Public Contributions: Nineteen nurse leaders contributed to this study. [ABSTRACT FROM AUTHOR]

Background Active mobility and public transport increase physical activity (PA) levels. With varying intensity and effectiveness, European cities implement Sustainable Urban Mobility Plans (SUMPs) to spur transport-related PA. Therefore, we aim to examine drivers and barriers to SUMP implementation and assess its influence on PA across European cities. Methods We screened policy reports to gain insights into SUMP implementation in one Danish, two German and two Polish cities. Further, we conducted semi-structured interviews with SUMP stakeholders in these cities to explore their experiences with SUMP implementation. Thematic analysis of interview transcripts was applied to identify similarities and differences across cities. To assess the effect of SUMP implementation on PA, we searched for data on indicators of transport-related PA. Results All investigated cities are committed to sustainable mobility. Nonetheless, complex institutional structures, the dominant role of motorized traffic as well as complex regional and local policy integration hamper SUMP implementation. Danish, German and Polish cities face different contexts in terms of financing, national guidelines and the prominence of sustainability as a policy objective. Each city adopts unique indicators for monitoring the effects of SUMPs on transport-related PA. The variety of indicators and limited data availability impede a comparative evaluation across cities. Constrained by this restriction, we identified motorization rate, modal split and public transport ridership as suitable indicators. Conclusions Local idiosyncrasies need to be accounted for when assessing the implementation of SUMPs. Nonetheless, consistent indicators and data transparency are essential for comparing the effectiveness of SUMPs and their impact on PA. [ABSTRACT FROM AUTHOR]

Aim To examine whether in Europe perceptions of 'alcoholism' differ in a discrete manner according to geographical area. Method Secondary analysis of a data set from a European project carried out in 2013–2014 among 1767 patients treated in alcohol addiction units of nine countries/regions across Europe. The experience of all 11 DSM-4 criteria used for diagnosing 'alcohol dependence' and 'alcohol abuse' were assessed in patient interviews. The analysis was performed through Multiple Correspondence Analysis. Results The symptoms of 'alcohol dependence' and 'alcohol abuse', posited by DSM-IV, were distributed according to three discrete geographical patterns: a macro-area mainly centered on drinking beer and spirit, a culture traditionally oriented toward wine and a mixed intermediate alcoholic beverage situation. Conclusion These patterns of perception seem to parallel the diverse drinking cultures of Europe. [ABSTRACT FROM AUTHOR]

The objectives of this study were to: (1) determine the impact of COVID-19 on the operations within the 9 sections of the European Council on Chiropractic Education (ECCE) 'Standards'; (2) identify specific rapid changes to the programs; and (3) identify positive changes that will continue post-pandemic. This was a mixed methods audit and thematic analysis of data from interviews conducted via a cloud-based video conferencing tool with program leaders of the ECCE accredited institutions. A validated questionnaire designed around ECCE's "Standards" was used, consisting of 3 sections: (1) Severity of the COVID-19 impact on each ECCE Standard section; (2) Description of program changes made for each section; (3) Identification of positive changes continuing post-pandemic. Descriptive statistics were calculated for Part 1 and compared for significant differences via the Kruskal-Wallis test. Verbal responses to Parts 2 and 3 were evaluated independently by 3 researchers using a modified "thematic analysis" approach. Final thematic categories and themes were agreed upon by the researchers. There was a 100% response rate. Outpatient teaching clinics were most severely affected, followed by teaching chiropractic technique courses. Curricular structure and duration and program management were least affected (p =.033). Four thematic categories were identified: Extreme Stress, Courses Most Severely Affected, Integrity of Examinations and Assessments, and Positive Changes That Will Continue. Final-year students were most negatively impacted due to restricted opportunities in outpatient clinics. Integrity of examinations was also a problem. Positive, innovative teaching materials and methods were quickly developed and should continue. [ABSTRACT FROM AUTHOR]

Data about the regulatory approaches to donor human milk (DHM) in European countries are lacking. The aim of this study is to describe the various regulations of DHM within European countries, to assess its legislative context and its impact in relation to donor milk banking. We performed a cross‐sectional survey using a semistructured online questionnaire addressing 29 national European milk‐banking representatives from June 2020 to February 2021. Representatives of 26 national DHM services participated in this study. The legal classification and regulatory status of DHM were defined in 9 out of 26 areas of jurisdiction (35%) as either food product (n = 6), product of human origin according to a blood, tissue, cell regulation (n = 2), or medicinal product (n = 1). In the remainder, DHM remains unclassified. Most legislations did not provide a comprehensive framework concerning DHM and costs to cover milk bank operations were rarely reimbursed. In general, the lack of national legislative governance and the actual legislative regulations in place do not support the use of DHM in European countries. National medical guidelines for the use of DHM have been issued in only 11 countries. The current number and distribution of milk banks (n = 239) within participating countries may not provide an equitable access to DHM for eligible infants. These findings could guide stakeholders aiming to establish a regulatory framework for DHM. Key messages: There is a lack of a legislative framework concerning the use of donor human milk in the majority of European countries.Available national legislative frameworks differed widely with gaps in the regulation of safety and quality of donor human milk, protection of donors and recipients, and cost recovery.Despite clearly demonstrated benefits and unequivocal recommendations for the use of donor human milk there is a lack of national guidance in many European countries. [ABSTRACT FROM AUTHOR]

Migrants comprise a growing proportion of European populations. Although many are healthy, those who do need healthcare often face barriers and the care they receive may be inappropriate to their needs. This paper summarises good practices identified in a review of health services for migrants in Europe. Governments should ensure that migrants are entitled to health services, that the services are appropriate to their needs and that data systems are in place to monitor utilisation and detect inequities. Health services should adopt a 'whole organisation approach', in which cultural competence is viewed as much as a task for organisations as for individuals. Health workers should take steps to overcome language, social and cultural barriers to care. In each case, existing examples of good practice are provided. At a time when support is growing in some countries for political parties pursuing anti-immigrant agendas and governments in all countries are pursuing austerity policies, there is a greater need than ever for the public health community to ensure that migrants have access to services that are effective and responsive to their needs. [ABSTRACT FROM AUTHOR]

Abstract: The paper makes uses of cognitive mappings developed from personal interviews with a number of European airline executives to examine the differences in managerial attitudes of low-cost and transitional carriers. In particular it explores the extent to which there is a convergence of views regarding the ways various airline models will develop in the future. [Copyright &y& Elsevier]

Studies show that older migrants have poorer health than native populations in Western Europe. To date, little systematic research has explored the differences between men and women within older populations with migration backgrounds. This article examines gender-specific aspects and mediating mechanisms of self-reported health among older migrants from Turkey. Using a mixed method approach, data and results from a quantitative survey and a qualitative study conducted in Berlin, Germany, are analysed and integrated at the interpretive level. Standardised face-to-face interviews were carried out with the help of a network approach with 194 older migrants from Turkey (93 women, 101 men, mean age: 68). Potential mediators showing significant gender differences are included in a parallel multiple mediation analysis. The documentary method is used to analyse 11 semi-structured narrative interviews with first-generation labour migrants from Turkey. Women reported significantly worse subjective health than men (c = 0.443, bCI [0.165–0.736]), conveyed through greater functional limitations (ab = 0.183, bCI [0.056–0.321]) and emotional loneliness (ab = 0.057, bCI [0.008–0.128]). Respondents to the qualitative study perceived that women age earlier and have poorer health due to the burden of performing a greater variety of social roles. Higher levels of emotional loneliness among women could be caused by their experiences of negatively assessed partnerships. Our results show that as a group, older female migrants have an elevated health vulnerability. A broader scientific foundation regarding gender differences in the health of older migrants and their causes is needed to promote gender-sensitive prevention and care for this group. [ABSTRACT FROM AUTHOR]

To explore how cancer could be diagnosed in a more timely way. Grounded theory analysis of primary care physicians' free text survey responses to: 'How do you think the speed of diagnosis of cancer in primary care could be improved?'. Secondary analysis of primary care physician interviews, survey responses, literature. Primary care in 20 European Örenäs Research Group countries. Primary care physicians: 1352 survey respondents (2013-2016), 20 Spanish and 7 Swedish interviewees (2015–2019). Conceptual explanation of how to improve timeliness of cancer diagnosis. Pluralistic task shifting is a grounded theory of a composite strategy. It includes task sharing – among nurses, physicians, nurse assistants, secretaries, and patients – and changing tasks with cancer screening when appropriate or cancer fast-tracks to accelerate cancer case finding. A pluralistic dialogue culture of comprehensive collaboration and task redistribution is required for effective pluralistic task shifting. Pluralistic task shifting relies on cognitive task shifting, which includes learning more about slow analytic reasoning and fast automatic thinking initiated by pattern recognition; and digital task shifting, which by use of eHealth and telemedicine bridges time and place and improves power symmetry between patients, caregivers, and clinicians. Financial task shifting that involves cost tracking followed by reallocation of funds is necessary for the restructuring and retraining required for successful pluralistic task shifting. A timely diagnosis reduces expensive investigations and waiting times. Also, late-stage cancers are costlier to treat than early-stage cancers. Timing is central to cancer diagnosis: not too early to avoid overdiagnosis, and never too late. We present pluralistic task shifting as a conceptual summary of strategies needed to optimise the timeliness of cancer diagnosis. Cancer diagnosis is under-researched in primary care, especially theoretically. Thus, inspired by classic grounded theory, we analysed and conceptualised the field: Pluralistic task shifting is a conceptual explanation of how the timeliness of cancer diagnosis could be improved, with data derived mostly from primary care physicians. This includes task sharing and changing tasks including screening and cancer fast-tracks to accelerate cancer case finding, and requires cognitive task shifting emphasising learning, and digital task shifting involving the use of eHealth and telemedicine. Financial task shifting with cost tracking and reallocation of funds is eventually necessary for successful pluralistic task shifting to happen. [ABSTRACT FROM AUTHOR]

This article focuses on the book "Technology Management and Public Policy in the European Union," edited by William Cannell and Ben Dankbarr. This book contains seven papers based on a study conducting interviews with top managers in over 250 enterprises in nine European countries, explore firm-level competencies underlying technology management in European firms and consider the policy instruments that can be used to promote them. Ben Dankbarr provides an over-view of the patterns of technology management found in European firms.

Background: Recognized disparities in quality of end‐of‐life care exist. Our aim was to assess the quality of care for patients dying from cancer, as perceived by bereaved relatives, within hospitals in seven European and South American countries. Materials and Methods: A postbereavement survey was conducted by post, interview, or via tablet in Argentina, Brazil, Uruguay, U.K., Germany, Norway, and Poland. Next of kin to cancer patients were asked to complete the international version of the Care Of the Dying Evaluation (i‐CODE) questionnaire 6–8 weeks postbereavement. Primary outcomes were (a) how frequently the deceased patient was treated with dignity and respect, and (b) how well the family member was supported in the patient's last days of life. Results: Of 1,683 potential participants, 914 i‐CODE questionnaires were completed (response rate, 54%). Approximately 94% reported the doctors treated their family member with dignity and respect "always" or "most of the time"; similar responses were given about nursing staff (94%). Additionally, 89% of participants reported they were adequately supported; this was more likely if the patient died on a specialist palliative care unit (odds ratio, 6.3; 95% confidence interval, 2.3–17.8). Although 87% of participants were told their relative was likely to die, only 63% were informed about what to expect during the dying phase. Conclusion: This is the first study assessing quality of care for dying cancer patients from the bereaved relatives' perspective across several countries on two continents. Our findings suggest many elements of good care were practiced but improvement in communication with relatives of imminently dying patients is needed. (ClinicalTrials.gov Identifier: NCT03566732). Implications for Practice: Previous studies have shown that bereaved relatives' views represent a valid way to assess care for dying patients in the last days of their life. The Care Of the Dying Evaluation questionnaire is a suitable tool for quality improvement work to help determine areas where care is perceived well and areas where care is perceived as lacking. Health care professionals need to sustain high quality communication into the last phase of the cancer trajectory. In particular, discussions about what to expect when someone is dying and the provision of hydration in the last days of life represent key areas for improvement. Disparities exist in the quality of end‐of‐life care. This article assesses the quality of care for dying cancer patients, as perceived by bereaved relatives, within hospitals in seven European and South American countries. [ABSTRACT FROM AUTHOR]

The interplay between professionals and clients has been examined in a number of settings and the impact of laymen on professional behavior is well-known to the sociologists. In this research report these insights are applied to police-citizen interaction in an effort to explain the dynamics of discretionary decisions by police officers and the role such discretion plays in their quest to attain higher professional stature. Specific attention will be paid to variations in the willingness of policemen to develop and utilize informers or "stool pigeons." This article examines information secured in tape-recorded personal interviews conducted during the winter of 1971 by the author in two European police departments. Discretionary decisions to arrest or not, or to press serious or minor charges, become one part of the negotiation between policemen and citizens, making it possible for the police to carve out a work style balancing professional rules and codes while also making sufficient concessions to client controls necessary to operate in the streets.

Background: Lifting The Burden (LTB) and European Headache Federation (EHF) have developed a set of headache service quality indicators, successfully tested in specialist headache centres. Their intended application includes all levels of care. Here we assess their implementation in primary care. Methods: We included 28 primary-care clinics in Germany (4), Turkey (4), Latvia (5) and Portugal (15). To implement the indicators, we interviewed 111 doctors, 92 nurses and medical assistants, 70 secretaries, 27 service managers and 493 patients, using the questionnaires developed by LTB and EHF. In addition, we evaluated 675 patients' records. Enquiries were in nine domains: diagnosis, individualized management, referral pathways, patient education and reassurance, convenience and comfort, patient satisfaction, equity and efficiency of headache care, outcome assessment and safety. Results: The principal finding was that Implementation proved feasible and practical in primary care. In the process, we identified significant quality deficits. Almost everywhere, histories of headache, especially temporal profiles, were captured and/or assessed inaccurately. A substantial proportion (20%) of patients received non-specific ICD codes such as R51 ("headache") rather than specific headache diagnoses. Headache-related disability and quality of life were not part of routine clinical enquiry. Headache diaries and calendars were not in use. Waiting times were long (e.g., about 60 min in Germany). Nevertheless, most patients (> 85%) expressed satisfaction with their care. Almost all the participating clinics provided equitable and easy access to treatment, and follow-up for most headache patients, without unnecessary barriers. Conclusions: The study demonstrated that headache service quality indicators can be used in primary care, proving both practical and fit for purpose. It also uncovered quality deficits leading to suboptimal treatment, often due to a lack of knowledge among the general practitioners. There were failures of process also. These findings signal the need for additional training in headache diagnosis and management in primary care, where most headache patients are necessarily treated. More generally, they underline the importance of headache service quality evaluation in primary care, not only to identify-quality failings but also to guide improvements. This study also demonstrated that patients' satisfaction is not, on its own, a good indicator of service quality. [ABSTRACT FROM AUTHOR]

Background The study assessed awareness and use of heated tobacco products (HTPs) and factors that influenced these issues among cigarette smokers from six European countries in 2016 (Wave 1) and 2018 (Wave 2). Methods A survey was conducted among a nationally representative sample of cigarette smokers aged 18 years or older from Germany, Greece, Hungary, Poland, Romania and Spain in 2016 (N  = 6011) and 2018 (N  = 6027; 53% of smokers from the previous wave were retained, regardless of smoking status and dropouts were replaced by a replenishment sample of smokers). Data were collected through face-to-face interviews. Estimates were produced using weighted data. The study presents the cross-sectional results. Results Awareness of HTPs increased from 8% to 17% between the two waves. At Wave 1, 1.1% of the smokers declared having used HTPs at least once during their lifetime; and at Wave 2, this increased to 1.9% (around 1% or less in four countries, except for Greece and Romania where it was around 4%). Factors associated with HTPs use among those who had ever heard about these products at Wave 1 were country of residence, being a daily cigarette smoker and ever use of electronic cigarettes. At Wave 2, ever use of HTPs was significantly higher among those who had tried to quit smoking combustible cigarettes in the last 12 months, had tried electronic cigarettes during lifetime and perceived HTPs as less dangerous than combustible cigarettes; the country of residence was also associated with HTPs use. Conclusion This study offers insights into the behaviours and perceptions of European adult smokers regarding HTPs, an important emerging issue in the field of tobacco control. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to explore whether positive impacts were sustained and unanticipated ripple effects had occurred four years after the implementation of interventions to improve cross‐cultural communication in primary care. Background: Sustaining the implementation of change using complex interventions is challenging. The EU‐funded "RESTORE" study implemented guidelines and training on cross‐cultural communication in five Primary Care sites in Europe, combining implementation theory (Normalisation Process Theory) with participatory methodology (participatory learning and action—PLA). There were positive impacts on knowledge, skills and clinical routines. Design, setting and participants: Four of the five original sites (England, Ireland, Greece, The Netherlands) were available for this qualitative follow‐up study. The study population (N = 44) was primary healthcare staff and migrants, most of whom had participated in RESTORE. Intervention; main outcome measures: PLA‐style focus groups and interviews explored routine practice during consultations with migrants. Etic cards based on the effects of RESTORE stimulated the discussion. Deductive framework analysis was performed in each country followed by comparative data analysis and synthesis. Results: Changes in knowledge, attitudes and behaviour with regard to consultations with migrants were sustained and migrants felt empowered by their participation in RESTORE. There were ongoing concerns about macro level factors, like the political climate and financial policies, negatively affecting migrant healthcare. Conclusion: There were sustained effects in clinical settings, and additional unanticipated positive ripple effects, due in part, from the participatory approach employed. [ABSTRACT FROM AUTHOR]

Background: There has been an increase in children growing up in non-traditional families, such as single-parent and blended families. Children from such families have a higher prevalence of obesity and poorer health outcomes, but research on the relationship with obesogenic behaviours is limited. Objectives: Therefore, the aim of this study was to investigate whether there are associations between family structures and obesogenic behaviours and related family rules in European children and adolescents. Methods: The sample included 7664 children (mean age ± SD: 10.9 ± 2.9) from 4923 families who were participants of the multi-centre I.Family study (2013/2014) conducted in 8 European countries. Family structure was assessed by a detailed interview on kinship and household. Obesogenic behaviours (screen time, sleep duration, consumption of sugar-sweetened beverages (SSBs)) and family rules (rules for computer and television, bedtime routine, availability of SSBs during meals) were determined by standardized questionnaires. Multilevel mixed-effects linear and logistic regression models were used to model the associations of family structure with obesogenic behaviours and family rules. Sex, age, parental education level, number of children and adults in the household and BMI z-score were covariates in the models. Two-parent biological families were set as the reference category. Results: Children from single-parent families were less likely to have family rules regarding screen time (OR: 0.62, 95% CI: 0.40–0.94, p = 0.026) with higher reported hours of screen time per week (β = 2.70 h/week, 95% CI: 1.39–4.00, p < 0.001). The frequency of weekly SSB consumption differed by family structure in a sex-specific manner: girls from single-parent (β = 3.19 frequency/week, 95% CI: 0.91–5.47, p = 0.006) and boys from blended/adoptive families (β = 3.01 frequency/week, 95% CI: 0.99–5.03, p = 0.004) consumed more SSBs. Sleep duration, bedtime routines and availability of SSBs during meals did not differ between children from these family structures. Parental education did not modify any of these associations. Conclusions: Parents in non-traditional family structures appear to experience more difficulties in restricting screen time and the intake of SSBs in their children than parents in traditional two-parent family structures. Our findings therefore suggest that additional support and effective strategies for parents in non-traditional families may help to reduce obesogenic behaviours in children from such family types. [ABSTRACT FROM AUTHOR]

Background Forty-three out of 53 of the WHO European Member States have set up political and institutional mechanisms to implement the United Nations (UN) 2030 Agenda for Sustainable Development. This includes governance and institutional mechanisms, engaging stakeholders, identifying targets and indicators, setting governmental and sectoral priorities for action and reporting progress regularly. Still, growing evidence suggests that there is room for advancing implementation of some of the Sustainable Development Goals (SDGs) and targets at a higher pace in the WHO European Region. This article proposes the E4A approach to support WHO European Member States in their efforts to achieve the health-related SDG targets. Methods The E4A approach was developed through a 2-year, multi-stage process, starting with the endorsement of the SDG Roadmap by all WHO European Member States in 2017. This approach resulted from a mix of qualitative methods: a semi-structured desk review of existing committal documents and tools; in-country policy dialogs, interviews and reports; joint UN missions and discussion among multi-lateral organizations; consultation with an advisory group of academics and health policy experts across countries. Results The E—engage—functions as the driver and pace-maker; the 4 As—assess, align, accelerate and account—serve as building blocks composed of policies, processes, activities and interventions operating in continuous and synchronized action. Each of the building blocks is an essential part of the approach that can be applied across geographic and institutional levels. Conclusion While the E4A approach is being finalized, this article aims to generate debate and input to further refine and test this approach from a public health and user perspective. [ABSTRACT FROM AUTHOR]

Background: General Practice (GP) seems to be perceived as less attractive throughout Europe. Most of the policies on the subject focused on negative factors. An EGPRN research team from eight participating countries was created in order to clarify the positive factors involved in appeals and retention in GP throughout Europe. The objective was to explore the positive factors supporting the satisfaction of General Practitioners (GPs) in clinical practice throughout Europe. Method: Qualitative study, employing face-to-face interviews and focus groups using a phenomenological approach. The setting was primary care in eight European countries: France, Belgium, Germany, Slovenia, Bulgaria, Finland, Poland and Israel. A thematic qualitative analysis was performed following the process described by Braun and Clarke. Codebooks were generated in each country. After translation and back translation of these codebooks, the team clarified and compared the codes and constructed one international codebook used for further coding. Results: A purposive sample of 183 GPs, providing primary care to patients in their daily clinical practice, was interviewed across eight countries. The international codebook included 31 interpretative codes and six themes. Five positive themes were common among all the countries involved across Europe: the GP as a person, special skills needed in practice, doctor-patient relationship, freedom in the practice and supportive factors for work-life balance. One theme was not found in Poland or Slovenia: teaching and learning. Conclusion: This study identified positive factors which give GPs job satisfaction in their clinical practice. This description focused on the human needs of a GP. They need to have freedom to choose their working environment and to organize their practice to suit themselves. In addition, they need to have access to professional education so they can develop specific skills for General Practice, and also strengthen doctor-patient relationships. Stakeholders should consider these factors when seeking to increase the GP workforce. [ABSTRACT FROM AUTHOR]

The study aimed to investigate the role of social activities, social networks as well as socioeconomic status (SES) in influencing some aspects of cognitive functioning (immediate and delayed verbal recall tests and semantic verbal fluency) in elderly people over time. This analysis was conducted on a sample of 31,954 healthy elderly people (58% female, mean age 65.54 ± 9.74) interviewed in both the fourth and sixth waves of the Survey on Health, Aging and Retirement in Europe (SHARE), in 2011 and 2015. A structural equation model with measurement component was used to assess the relationship between cognitive function, social life and SES over time. Multilevel ordinal logistic regression was applied to explain satisfaction with social network in relation to different types of social network across countries. Being equipped with good cognitive skills did not seem to be predictive of their maintenance over time (latent coefficient = 0.24, p value = 0.34). On the contrary, the subject's social and participatory life, understood as satisfying one's social network and engaging in diversified non-professional social activities, seemed to play a crucial role in the maintenance of cognitive functions in the elderly (latent coefficient = 3.5, p value = 0.03). This research suggests that a socially active and participatory lifestyle mitigates the effects of the physiological process of brain aging. [ABSTRACT FROM AUTHOR]

Background: Whilst many health systems offer a range of urgent and emergency care services to deal with the need for unscheduled care, these can be problematic to navigate. Objective: To explore how lay people make sense of urgent care provision and processes. Design: Qualitative study, incorporating citizen panels and longitudinal semi‐structured qualitative interviews. Setting and Participants: Two citizens' panels, comprising purposively selected public populations—a group of regular users and a group of potentially marginalized users of urgent and emergency care. Semi‐structured interviews were conducted with 100 people, purposively sampled to include those over 75, aged 18‐26 years, and from East/Central Europe. A sub‐sample of 41 people received a second interview at +6‐12 months. Framework analysis was thematic and comparative, moving through coding to narrative and interpretive summaries. Findings and Discussion: Participants narratives illuminated considerable uncertainty and confusion regarding urgent and emergency care provision which in part could be traced to the contingent nature of urgent and emergency care need. Accounts of emergency care provision were underpinned by strong moral positioning of appropriate help‐seeking, demarcating legitimate service use that echoed policy rhetoric, but did not necessarily translate into individual behaviour. People struggled to make sense of urgent care provision making navigating "appropriate" use problematic. Conclusions: The focus on help‐seeking behaviour, rather than sense‐making, makes it difficult to move beyond the polarization of "appropriate" and "inappropriate" service use. A deeper analysis of sense‐making might shift the focus of attention and allow us to intervene to reshape understandings before this point. [ABSTRACT FROM AUTHOR]

Adapting and providing quality services for people as they age is a common challenge across Europe. The perspective of older people is fundamental in a person-centred care approach. Expanding research at the European level that explicitly includes their views can offer a relevant contribution to the development of evidence-based guidelines that can be shared in education and training across health and social care professions. This study aimed to identify common meaningful dimensions of professional competence in health and social care emphasised by older people from six countries in different regions of Europe according to their experiences. A qualitative approach was chosen with a total of 95 semi-structured interviews conducted in Austria, Finland, Lithuania, Portugal, Turkey and UK, following a common topic guide. Participants in this study were aged 60 and above, and recruitment considered age, gender, level of education and living arrangements. Results identified a set of universal skills and practices that according to older people, health and social care professionals should meet. Competences at the interpersonal level were central in older people's discourses, and its core dimensions are anchored in relational, communication and socio-emotional skills of professionals. These findings reinforce the aspiration of establishing best practices in care that relies on the harmonisation of a competence framework that can be shared in the training and education of health and social care professionals across Europe and that voices older people's preferences, expectations and needs. [ABSTRACT FROM AUTHOR]

Background Mental health problems are a risk factor for loss of paid employment. This study investigates (i) the relation between depressive symptoms and different involuntary pathways of labour force exit and (ii) explores gender and geographical differences in this relation. Methods The study population consisted of 5263 individuals in paid employment aged between 50 years and the country-specific retirement age from 11 European countries participating in the longitudinal Survey of Health, Ageing and Retirement in Europe (SHARE). Self-reported depressive symptoms at baseline were assessed using the EURO-D. Employment status was derived from interviews after 2 and 4 years. Cox proportional hazards regression analyses were used to investigate the association between depressive symptoms and labour force exit via disability benefit and unemployment. Population attributable fractions (PAFs) were calculated to estimate the contribution of depressive symptoms to these pathways of labour force exit. Results Both men and women with a EURO-D score ≥4 had a >2-fold increased risk of a disability benefit (HR: 2.46, 95%CI 1.68–3.60) after adjustment for demographics and work-related characteristics. Among men depressive symptoms elevated the risk of becoming unemployed at follow-up (HR 1.55; 95%CI: 0.94–2.57). The PAF was 0.18 for disability benefit and 0.04 for unemployment, and varied across European regions. Conclusions Individuals with depressive symptoms are at increased risk of losing paid employment, which in turn may aggravate their symptoms. Targeting depressive symptoms with public health and occupational policies should be considered to reduce the burden of mental diseases in Europe. [ABSTRACT FROM AUTHOR]

Background This study aimed to assess cross-sectional and prospective relationships between vigorous physical activity (VPA) and the risk of major chronic diseases among European older adults. Methods Participants were 37 524 older adults who responded to the fourth (in 2011) and fifth (in 2013) wave of the SHARE project, from 13 European countries. Participants answered interview questions about the presence of chronic conditions and VPA. The cross-sectional and prospective association between PA and the number of chronic diseases was assessed using logistic regression models. Results Among men and women, the prevalence of chronic diseases was significantly lower among those who reported VPA once a week or more than once a week. For men, VPA once a week was prospectively related with lower odds of heart attack, chronic lung disease, Parkinson's disease and Alzheimer's disease. VPA more than once a week was prospectively related with lower odds of having all chronic diseases. Women who engaged in VPA once a week presented lower odds of having chronic diseases, except for hypertension, high blood cholesterol and cancer. For VPA more than once a week, cancer was the only disease not associated with physical activity. Conclusion VPA is associated with reduced risk of chronic diseases in men and women. Even the practice of VPA once a week seems to be sufficient to reduce risks of chronic diseases. [ABSTRACT FROM AUTHOR]