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BACKGROUND Belongingness is an important factor in the social development of medical students, and the ability to quantify belongingness in medical students may provide additional metrics by which we can compare different learning environments to help explore differential attainment. Previous studies looking at the measurement of belongingness have demonstrated good internal and external validity for tools designed to measure this facet of student experience. This study aimed to explore the use of the Exeter Belongingness Assessment Tool (EBAT) as one potential source of evidence in the study of student learning experience on clinical placements, which could be used to support quality assurance of clinical learning. This study sought to validate the use of the EBAT and carry out an initial pilot study to compare levels of belongingness in medical students in Belgium and the United Kingdom. METHODS This study used a validated assessment tool self-administered via an online survey platform in undergraduate medical students in all years studying in Belgium and the United Kingdom. RESULTS The EBAT described here demonstrated good internal validity in undergraduate medical students in the United Kingdom and Belgium and identified statistically significant differences between these medical student populations . CONCLUSIONS These results suggest that belongingness in undergraduate medical students varies between different demographic groups and provides further evidence that the EBAT described here is a valid tool to study this. It also supports the proposal that this may be a useful tool to monitor teaching environments.

Background: Supporting self-management in healthcare practice is essential to improve chronic patients’ daily life experiences. Primary care professionals play an indispensable role in this. Nevertheless, supporting self-management in practice comes with many challenges. The aim of this study is to identify determinants of professionals’ supportive behaviour and develop an intervention that facilitates self-management support in primary care practice, using these determinants as building blocks. Methods: To develop the intervention, the Behaviour Change Wheel (BCW) was used which involves eight steps in three stages: (1) Understanding the behaviour using the COM-B model, (2) Identifying intervention options, and (3) Identifying content and implementation options. The theoretical underpinnings for stage 1 included data from interviews, focus groups and brainstorm sessions, incorporated beforehand in a self-management support model. Subsequently, literature analysis, empirical research and expertise from the research group guided stages 2 and 3. Results: We found that changes in “psychological capability”, “physical opportunity”, “reflective motivation” and “automatic motivation” are required to optimize professionals’ behaviour towards self-management support. The two key intervention functions identified were “enablement” and “education”. Therefore, a blended learning trajectory that incorporated these interventional building blocks was developed, integrating specific behaviour change techniques (BCTs) including: (1) Information about social and environmental consequences, (2) Information about health consequences, and (3) Social support (practical). The learning design was finalized by applying the Absorb-Do-Connect learning framework developed by Horton. Conclusions: Application of the BCW framework shaped a self-management support intervention to educate and enable healthcare professionals. Future research will pilot and refine the intervention.

Abstract Background Self-management of a chronic condition is a complex but increasingly important issue. However, a supportive attitude and behaviour among healthcare professionals is hampered by a lack of awareness, knowledge and motivation. In addition, the role of professionals in supporting self-management seems unclear. Methods A blended learning program for primary healthcare professionals was developed to strengthen self-management support in primary care. The program was piloted in community health centres and multidisciplinary medical practices in Flanders. Using the Kirkpatrick model, the impact on healthcare professionals’ reaction, learning and behaviour regarding self-management support was evaluated. Results A total of 60 healthcare professionals registered for the educational program. Post-learning questionnaires and verbal feedback showed a positive response, with professionals highly appreciating the innovative blended learning approach. In terms of learning, participants showed a good understanding of self-management support, although nuances were observed in the application of acquired knowledge to practice scenarios. Finally, preliminary insights into behavioural change were explored, revealing a positive impact of the intervention on participants’ supportive self-management behaviours in healthcare practice. Conclusions Our study provides preliminary insights into the outcomes of a blended learning program designed to increase awareness and knowledge of self-management support among professionals. The program needs to be refined for general implementation in primary care.

Abstract Objectives Workplace-based assessment (WBA) has been vigorously criticized for not fulfilling its educational purpose by medical educators. A comprehensive exploration of stakeholders’ needs regarding WBA is essential to optimize its implementation in clinical practice. Method Three homogeneous focus groups were conducted with three groups of stakeholders: General Practitioner (GP) trainees, GP trainers, and GP tutors. Due to COVID-19 measures, we opted for an online asynchronous form to enable participation. An constructivist grounded theory approach was used to employ this study and allow the identification of stakeholders’ needs for using WBA. Results Three core needs for WBA were identified in the analysis. Within GP Training, stakeholders found WBA essential, primarily, for establishing learning goals, secondarily, for assessment purposes, and, lastly, for providing or receiving feedback. Conclusion All stakeholders perceive WBA as valuable when it fosters learning. The identified needs were notably influenced by agency, trust, availability, and mutual understanding. These were facilitating factors influencing needs for WBA. Embracing these insights can significantly illuminate the landscape of workplace learning culture for clinical educators and guide a successful implementation of WBA.

INTRODUCTION The Joint United Nations Program on HIV/AIDS (UNAIDS) has set a goal to eliminate AIDS as a public health threat by 2030 and the World Health Organization emphasized pre-exposure prophylaxis (PrEP) as a crucial element. Despite the lack of a specific role for general practitioners (GPs) in PrEP care, GPs could play a crucial role in the follow-up but this is still uncommon. Above, GPs estimate their knowledge about PrEP as low. OBJECTIVES This study seeks to understand the knowledge of GPs regarding PrEP care. Through online e-learning, we aimed to enhance our knowledge of PrEP care. METHODS Firstly, we assessed general knowledge about the PrEP of GPs. Secondly, we investigated the impact of e-learning on knowledge of PrEP care among GPs. We developed a multiple-choice questionnaire to evaluate self-assessed knowledge and knowledge about PrEP. One group of participants completed an e-learning module and took a pre- and post-test to assess changes in knowledge. Another group completed the questionnaire without e-learning. RESULTS Seventy-two participants completed the survey. Finally, 18 participants successfully completed the e-learning module. Nineteen percent ( n = 14) of all GPs considered their general knowledge of PrEP to be “good,” while 68% ( n = 49) of the GPs felt confident in identifying patients at risk, rating their ability as “good.” Participants achieved an average score of 4.7 (test group) and 4.6 (e-learning group) out of 10 on the knowledge test. After completion of the e-learning, the overall average score of the e-learning group significantly increased by 33% ( p -value

INTRODUCTION Competency-based medical education (CBME) has transformed postgraduate medical training, prioritizing competency acquisition over traditional time-based curricula. Integral to CBME are Entrustable Professional Activities (EPAs), that aim to provide high-quality feedback for trainee development. Despite its importance, the quality of feedback within EPAs remains underexplored. METHODS We employed a cross-sectional study to explore feedback quality within EPAs, and to examine factors influencing length of written comments and their relationship to quality. We collected and analyzed 1163 written feedback comments using the Quality of Assessment for Learning (QuAL) score. The QuAL aims to evaluate written feedback from low-stakes workplace assessments, based on 3 quality criteria (evidence, suggestion, connection). Afterwards, we performed correlation and regression analyses to examine factors influencing feedback length and quality. RESULTS EPAs facilitated high-quality written feedback, with a significant proportion of comments meeting quality criteria. Task-oriented and actionable feedback was prevalent, enhancing value of low-stakes workplace assessments. From the statistical analyses, the type of assessment tool significantly influenced feedback length and quality, implicating that direct and video observations can yield superior feedback in comparison to case-based discussions. However, no correlation between entrustment scores and feedback quality was found, suggesting potential discrepancies between the feedback and the score on the entrustability scale. CONCLUSION This study indicates the role of the EPAs to foster high-quality feedback within CBME. It also highlights the multifaceted feedback dynamics, suggesting the influence of factors such as feedback length and assessment tool on feedback quality. Future research should further explore contextual factors for enhancing medical education practices.

Abstract Background In medical education, Entrustable Professional Activities (EPAs) have been gaining momentum for the last decade. Such novel educational interventions necessitate accommodating competing needs, those of curriculum designers, and those of users in practice, in order to be successfully implemented. Methods We employed a participatory research design, engaging diverse stakeholders in designing an EPA framework. This iterative approach allowed for continuous refinement, shaping a comprehensive blueprint comprising 60 EPAs. Our approach involved two iterative cycles. In the first cycle, we utilized a modified-Delphi methodology with clinical competence committee (CCC) members, asking them whether each EPA should be included. In the second cycle, we used semi-structured interviews with General Practitioner (GP) trainers and trainees to explore their perceptions about the framework and refine it accordingly. Results During the first cycle, 14 CCC members agreed that all the 60 EPAs should be included in the framework. Regarding the formulation of each EPAs, 20 comments were given and 16 adaptations were made to enhance clarity. In the second cycle, the semi-structured interviews with trainers and trainees echoed the same findings, emphasizing the need of the EPA framework for improving workplace-based assessment, and its relevance to real-world clinical scenarios. However, trainees and trainers expressed concerns regarding implementation challenges, such as the large number of EPAs to be assessed, and perception of EPAs as potentially high-stakes. Conclusion Accommodating competing stakeholders’ needs during the design process can significantly enhance the EPA implementation. Recognizing users as experts in their own experiences empowers them, enabling a priori identification of implementation barriers and potential pitfalls. By embracing a collaborative approach, wherein diverse stakeholders contribute their unique viewpoints, we can only create effective educational interventions to complex assessment challenges.

Abstract Background To support self-management of chronically ill persons, innovative approaches of care practice are being developed. Unfortunately, many self-management supporting interventions struggle to achieve reliable and consistent improvements at various levels (patient, provider and healthcare system level). One possible strategy to facilitate translating theory into practice, is to consider the healthcare professionals’ perspective prior to the development of new interventions. An exploration of their knowledge and opinion about barriers and facilitators is necessary before employing any self-management support (SMS) intervention. Therefore, our study aims to explore care professionals’ perspectives about SMS within the Flemish primary care setting. Methods This study used a qualitative study design to examine SMS in primary care setting. Five focus groups were conducted, grouped into three waves. Participants were healthcare professionals in Flanders representing different disciplines and settings. A maximum variation purposive sampling was used to recruit participants. For the data analysis, the framework of thematic networks by Attride-Stirling was applied. Results A total of 34 healthcare professionals participated. Three global themes related to SMS were derived from the thematic analysis: (1) Characteristics, (2) Support strategies, (3) Barriers and facilitators. SMS was characterised as a collaboration-based and person-centred approach. A variety of supporting strategies were mentioned by the focus group participants. Most strategies consisted of informing and educating patients. Complementary to individual strategies, collaborative strategies were deemed necessary to support self-management. Regarding barriers and facilitators, different patient-related factors were identified. Additionally, competencies of healthcare providers and external factors seem to hinder the implementation of SMS in practice. Conclusions This focus group study highlights the importance of a collaborative, person-centred approach to SMS in the context of chronic diseases. Our findings point to the need for interventions that raise awareness and address barriers associated with SMS. Since generic SMS does not exist, the road to success is a growth process in which support must be adapted to the individual patient.

Background: The DAWN antivirals trial was a multicentric, randomised placebo-controlled trial evaluating antiviral medication for COVID-19 in general practice. The trial was prematurely terminated because of insufficient recruitment. Aim: To explore which factors contributed to the premature termination. Design & setting: General practice in Belgium. Method: Patients were randomised to camostat or placebo (patients and physicians blinded) between June 2021 and July 2022; a third arm evaluating molnupiravir (open label) was opened in March 2022. The outcome assessor was blinded for all comparisons except for the patient reported outcomes in case of molnupiravir. The authors analysed available trial data and evaluated trial context, implementation, and mechanisms of impact based on semi-structured interviews with trial stakeholders. Results: The trial recruited 44 participants; 19 were allocated to camostat (median age 55 years), 8 to molnupiravir (median age 60 years), and 17 to placebo (median age 56 years). There were no serious adverse events in either group. Most difficulties were related to the pandemic context: disruption to routine clinical services; multiple changes to the service model for COVID-19 patients; overwhelmed clinical staff; delays of trial medication; and staff shortages in the sponsor and clinical team. In addition, regulatory approval processes were lengthy and led to additional study procedures. It was felt that the trial started too late, when vaccinations had already begun. Conclusion: The DAWN antivirals trial was stopped prematurely. Although many barriers were related to the pandemic itself, hurdles such as a small and inexperienced sponsor and clinical teams, delays in regulatory processes, and research capacity in routine settings could be overcome by established research infrastructure and standardisation of processes.

Physician-oriented online education could be a pathway to improve care for patients with heart failure, however, it is difficult to measure the impact of such education. Self-efficacy is a potential outcome measure. In this article, we develop a methodology for analyzing an educational intervention for general practitioners (GPs) using self-efficacy as a concept. This study was partly conducted within the setting of an observational study, IMPACT-B, where we developed online education for GPs. We designed and refined a 24-item questionnaire using item analysis, and exploratory and confirmatory factor analysis. Ninety-one GPs completed the questionnaire before and after the online education. Follow-up data after 6 months was available for 13 GPs. Item analysis revealed a high degree of internal consistency (coefficient alpha 0.95) and validity. Each additional year of experience was associated with an average baseline self-efficacy score of 0.50 points (95% CI [0.21-0.80]), and each additional patient in HF follow-up with an average score of 2.0 points (95% CI [0.48-3.5]). Items that differentiated most between GPs with high and low self-efficacy were the treatment of congestion as well as titrating medication and MRA in heart failure with reduced ejection fraction. Factor analysis reduced the number of questions to 14, mapping to three factors (diagnosis, treatment, and follow-up), and improved the model fit as measured by the goodness-of-fit indicator comparative-fit-index (from 0.83 to 0.91). We demonstrated a method to assess the impact of online education on general practitioners. This led to a questionnaire that was reliable, valid, and convenient to use in an implementation context.

Abstract Aims To increase our understanding of which factors contribute to long‐term benzodiazepine receptor agonist (BZRA) use for insomnia in primary care, from a patients', general practitioners' (GP) and pharmacists' perspective. Design Qualitative research following a grounded theory approach. Setting Primary care in Belgium. Participants Twenty‐four participants were interviewed, including nine patients, six GPs and nine pharmacists. Measurements In‐depth, semistructured interviews with iterative cycles of data collection and analysis. Transcripts were analysed using the framework method. Thematic findings were interpreted in the context of the Theoretical Domains Framework. Findings A reflexive relation was identified between views about hypnotic use at the level of society, healthcare and patients. Behaviour change appeared to depend strongly on context and social influence, including a need for supporting relationships by all stakeholders. Six key messages captured factors that contribute to long‐term BZRA use for insomnia in primary care: societal beliefs as a game changer, the opportunity of nonpharmacological treatment, collaborative primary care, patient‐centred goals, informed consent and self‐management. Conclusions Long‐term BZRA use for insomnia is a complex and multifaceted public health problem that is not adequately addressed in primary care at this time. Although primary care professionals in this study found discontinuation of long‐term BZRA use relevant to the patient's health, many organisational and personal barriers were reported. Moreover, the current social and healthcare context is not empowering patients and professionals to reduce long‐term BZRA use for insomnia. Specifically, for primary care, all stakeholders reported the need for a nonmedicalised relationship between the patient and GP to lower prescribing rates. Patient or Public Contribution The Flemish Patient Platform, a patient representative organisation, assisted with recruitment by launching a call for participants in their newsletter and volunteered to disseminate the results. The call for recruitment was also published online in social media groups regarding insomnia and via posters in public pharmacies. Patients or public were not involved in designing or conducting the interview study.

Abstract Background In view of the exponential use of the CanMEDS framework along with the lack of rigorous evidence about its applicability in workplace-based medical trainings, further exploring is necessary before accepting the framework as accurate and reliable competency outcomes for postgraduate medical trainings. Therefore, this study investigated whether the CanMEDS key competencies could be used, first, as outcome measures for assessing trainees’ competence in the workplace, and second, as consistent outcome measures across different training settings and phases in a postgraduate General Practitioner’s (GP) Training. Methods In a three-round web-based Delphi study, a panel of experts (n = 25–43) was asked to rate on a 5-point Likert scale whether the CanMEDS key competencies were feasible for workplace-based assessment, and whether they could be consistently assessed across different training settings and phases. Comments on each CanMEDS key competency were encouraged. Descriptive statistics of the ratings were calculated, while content analysis was used to analyse panellists’ comments. Results Out of twenty-seven CanMEDS key competencies, consensus was not reached on six competencies for feasibility of assessment in the workplace, and on eleven for consistency of assessment across training settings and phases. Regarding feasibility, three out of four key competencies under the role “Leader”, one out of two competencies under the role “Health Advocate”, one out of four competencies under the role “Scholar”, and one out of four competencies under the role “Professional” were deemed as not feasible for assessment in a workplace setting. Regarding consistency, consensus was not achieved for one out of five competencies under “Medical Expert”, two out of five competencies under “Communicator”,one out of three competencies under “Collaborator”, one out of two under “Health Advocate”, one out of four competencies under “Scholar”, one out of four competencies under “Professional”. No competency under the role “Leader” was deemed to be consistently assessed across training settings and phases. Conclusions The findings indicate a mismatch between the initial intent of the CanMEDS framework and its applicability in the context of workplace-based assessment. Although the CanMEDS framework could offer starting points, further contextualization of the framework is required before implementing in workplace-based postgraduate medical trainings.

Abstract Background Experience and research show that screening for malnutrition in primary care mainly takes place by monitoring the weight parameter and that validated screening instruments are hardly used. In this study we examined the effectiveness and predictive value of weight evolution in screening for (risk of) malnutrition in older people living at home, in comparison with a validated screening tool, namely the Mini Nutritional Assessment Short Form (MNA-SF). Methods This project was a prospective, longitudinal study with quantitative data that took place in the province of Antwerp (Belgium) from December 2020 until June 2021. The target group of this study consisted of people over 70 living at home who were visited by a home nurse on a regular basis (at least once a month). The outcome measure was the weight evolution over six months compared with the score on the MNA-SF at month six. Weight was measured and recorded once a month during 6 months. At the last weight measurement, the MNA-SF was administered. In order to assess their own nutritional state, three additional questions were asked after taking the MNA-SF. Results A total of 143 patients gave consent to participate, of which 89 were women and 54 men. The mean age was 83.7 years (SD6.62) with a range of 70 to 100 years. Based on the MNA-SF score measured after six months, 53.1% (76/143) of participants had a normal nutritional status, 37.8% (54/143) scored risk of malnutrition and 4.9% (7/ 143) was malnourished. In order to detect people with (risk of) malnutrition, a PPV of 78.6%, a NPV of 60.7%, a sensitivity of 19.3% and a specificity of 96.0% were established with a weight evolution of ≥ 5% weight loss at six months. To detect malnutrition, our results showed respectively 33.3%, 98.4%, 71.4% and 92.3%. Conclusion In this study, weight evolution has a low sensitivity in screening for (risk of) malnutrition in people over 70 living at home compared to the MNA-SF. However, in order to detect people with malnutrition, this study demonstrated a sensitivity of 71.4% and a specificity of 92.3% for a weight loss of ≥ 5% at six months.

Abstract Introduction Since 2000, an increasing misuse of emergency services in Belgium was noticed. In 2015, a multidisciplinary task-force designed a triage system. Trained operators and integrated triage protocols were installed in a call center for life-threatening and non-life-threatening care needs. Teleconsultations by telephone find their way to planned care and are well studied in this context. Also unplanned care might benefit from telephone-consultations. Method This intervention study investigated the feasibility of teleconsultations in unplanned care according to medical doctors. They were present at the call center during the weekend and on public holidays in the period of April 17, 2021 to November 21, 2021. Their task was to call patients who had contacted the call center to perform a teleconsultation, without interfering with regular care. Results 21 triage doctors participated in the study, they completed 59 surveys and conducted 551 teleconsultations. They perceived the quality of the consultations as good with an average score of 82.85 out of 100 on the sliding scale. The doctors gave an average score of 72.40 for the level of certainty for diagnosis and treatment. For 415 consultations, triage doctors judged that the consultation would gain certainty if followed by a physical examination. Video was mainly considered to be valuable in psychiatric problems, allergic reactions and skin problems. Discussion This study showed that teleconsultations are feasible in unplanned care. Videos add value in particular cases. Only few barriers are reported in terms of communication, technology and equipment. Conclusion Teleconsultations in unplanned primary care could be performed with a high quality and a sufficient level of certainty. The willingness to conduct teleconsultations in unplanned care is high. It would be useful in a future study to investigate the feasibility, obstacles and needs for implementation of video consultations as they may differ from teleconsultations.

Background: Motivating patients to discontinue long-term benzodiazepine receptor agonist (BZRA) use for insomnia remains an important challenge in primary care because of the medication's unfavourable risk-benefit profile. Previous studies have shown that understanding the complexity of patients' motivation is crucial to the primary care physician for providing effective interventions efficiently. Theoretical frameworks about behaviour change show that motivation is a multi-layered concept that interacts with other concepts, which aligns with a holistic perspective or implementation of the biopsychosocial model. Aim: Exploring primary care patients’ views and ideas on what factors helped or hindered them in discontinuing long-term BZRA use, in relation to motivation as conceptualised in the Behaviour Change Wheel, and associated domains of the Theoretical Domains Framework. Design and setting: A qualitative study with semi-structured interviews in primary care in Belgium between September 2020 and March 2021. Method: Eighteen interviews with long-term hypnotic users were audio recorded, transcribed and thematically analyzed, using the Framework Method. Results: The success of discontinuation interventions does not solely rely on patients’ spontaneous sense of striving for improvement. Reinforcement and identity were found to be important domains for motivation. Beliefs about personal capabilities, and about consequences of both BZRA intake and discontinuation, differed between previous and current users. Conclusion: Motivation is a multi-layered concept which is not fixed in time. Patient empowerment and goal setting could help long-term BZRA users to lower their intake. As well as public health interventions that might change social attitudes towards the use of hypnotic medication.

BackgroundLong-term use of benzodiazepine receptor agonists (BZRAs) remains common despite European guidelines advising that these drugs be used in the lowest possible dose and for the shortest possible duration. Half of all BZRAs are prescribed in family practice. This creates a window of opportunity for discontinuation in primary care. Therefore, the effectiveness of blended care for the discontinuation of long-term BZRA use in adult primary care patients with chronic insomnia disorder was tested in a multicenter, pragmatic, and cluster randomized controlled superiority trial in Belgium. In the literature, information on implementing blended care in a primary care setting is scarce. ObjectiveThe study aimed to contribute to a framework for the successful implementation of blended care in a primary care setting by increasing our understanding of this complex intervention through an evaluation of e-tool use and views and ideas of participants in a BZRA discontinuation trial. MethodsBased on a theoretical framework, this study evaluated the processes of recruitment, delivery, and response using 4 components: a survey on recruitment (n=76), semistructured in-depth interviews with patients (n=18), web-based asynchronous focus groups with general practitioners (GPs; n=19), and usage data of the web-based tool. Quantitative data were analyzed descriptively, and qualitative data were analyzed thematically. ResultsFor recruitment, the most common barriers were refusal by the patient and the lack of digital literacy, while facilitators were starting the conversation and the curiosity of patients. The delivery of the intervention to the patients was diverse, ranging from GPs who never informed the patient about their access to the e-tool to GPs consulting the e-tool in between consultations to have discussion points when the patient visited. Concerning response, patients’ and GPs’ narratives also showed much variety. For some GPs, daily practice changed because they received more positive reactions than expected and felt empowered to talk more often about BZRA discontinuation. Conversely, some GPs reported no changes in practice or among patients. In general, patients found follow-up by an expert to be the most important component in blended care, whereas GPs deemed the intrinsic motivation of patients to be the key element of success. An important barrier to implementation by the GP was time. ConclusionsOverall, the participants who had used the e-tool were positive about its structure and content. Nevertheless, many patients desired a more tailored application with feedback from an expert and personal tapering schedules. Strict pragmatic implementation of blended care seems to only reach GPs with an interest in digitalization. Although not superior to usual care, blended care could be a complementary tool that allows tailoring the discontinuation process to the personal style of the GP and the needs of the patient. Trial RegistrationClinicalTrials.gov NCT03937180; https://clinicaltrials.gov/ct2/show/NCT03937180

Abstract Background COVID-19 has changed General Practice (GP) education as well as GP clinical activities. These changes have had an impact on the well-being of medical trainees and the role of GP plays in the society. We have therefore aimed to investigate the impact that COVID-19 has had on GP trainees and trainers in four domains: education, workload, practice organization and the role of GP in society. Design: a cross-sectional study design was used. Methods The Interuniversity Centre for the Education of General Practitioners sent an online survey with close-ended and open-ended questions to all GP trainees and trainers in Flanders, active in the period March – September 2020. Descriptive statistics were performed to analyze the quantitative data and thematic analysis for the qualitative data. Results 216 (response 25%) GP trainees and 311 (response 26%) trainers participated. GP trainees (63%, N = 136) and trainers (76%, N = 236) reported new learning opportunities since the COVID-19 pandemic. The introduction of telehealth consulting and changing guidelines required new communication and organizational skills. Most of the GP trainees (75%, n = 162) and trainers (71%, n = 221) experienced more stress at work and an overload of administrative work. The unfamiliarity with a new infectious disease and the fact that COVID-19 care compromised general GP clinical activities, created insecurity among GP trainers and trainees. Moreover, GP trainees felt that general GP activities were insufficiently covered during the COVID-19 pandemic for their training in GP. GP trainers and trainees experienced mutual support, and secondary support came from other direct colleagues. Measures such as reducing the writing of medical certificates and financial support for administrative and (para) medical support can help to reprioritize the core of GP care. COVID-19 has enhanced the use of digital learning over peer-to-peer learning and lectures. However, GP trainees and trainers preferred blended learning educational activities. Conclusions COVID-19 has created learning opportunities such as telehealth consulting and a flexible organization structure. To ensure quality GP education during the pandemic and beyond, regular GP care should remain the core activity of GP trainees and trainers and a balance between all different learning methods should be found.

Abstract Background The COVID-19 pandemic has profoundly affected assessment practices in medical education necessitating distancing from the traditional classroom. However, safeguarding academic integrity is of particular importance for high-stakes medical exams. We utilised remote proctoring to administer safely and reliably a proficiency-test for admission to the Advanced Master of General Practice (AMGP). We compared exam results of the remote proctored exam group to those of the on-site proctored exam group. Methods A cross-sectional design was adopted with candidates applying for admission to the AMGP. We developed and applied a proctoring software operating on three levels to register suspicious events: recording actions, analysing behaviour, and live supervision. We performed a Mann-Whitney U test to compare exam results from the remote proctored to the on-site proctored group. To get more insight into candidates’ perceptions about proctoring, a post-test questionnaire was administered. An exploratory factor analysis was performed to explore quantitative data, while qualitative data were thematically analysed. Results In total, 472 (79%) candidates took the proficiency-test using the proctoring software, while 121 (20%) were on-site with live supervision. The results indicated that the proctoring type does not influence exam results. Out of 472 candidates, 304 filled in the post-test questionnaire. Two factors were extracted from the analysis and identified as candidates’ appreciation of proctoring and as emotional distress because of proctoring. Four themes were identified in the thematic analysis providing more insight on candidates’ emotional well-being. Conclusions A comparison of exam results revealed that remote proctoring could be a viable solution for administering high-stakes medical exams. With regards to candidates’ educational experience, remote proctoring was met with mixed feelings. Potential privacy issues and increased test anxiety should be taken into consideration when choosing a proctoring protocol. Future research should explore generalizability of these results utilising other proctoring systems in medical education and in other educational settings.

BackgroundContrary to most European guidelines, benzodiazepine receptor agonists (BZRA) are often used continuously at a low dosage, being the most common form of long-term use. In Belgium, BZRA use is monitored by analyzing self-report data about medication use in the last 24 h. This method provides insufficient insight into the terms of use of these psychoactive drugs.AimTo describe trends in BZRA prescribing in Flanders, Belgium, between 2000 and 2019.Design and settingPopulation-based trend analysis and a case-control study for the year 2019 were done with data from a morbidity registry in general practice.MethodsRepeated cross-sectional and joinpoint regression analyses revealed trends in sex- and age-standardized prescription rates among adult patients (18+).ResultsOverall, BZRA prescriptions increased. The highest overall increase was found among male patients 18–44 years old, with an average annual percentage change of 2.5 (95% CI: 0.9, 4.3). Among 65+ female patients, a decrease was found since 2006, with an annual percentage change of −0.7 (95% CI: −1.3, −0.1). In 2019, 12% of registered patients received minimally one prescription, long-term use was observed in 5%, back pain was the most common morbidity significantly associated with a rise in BZRA prescriptions, and zolpidem was the most prescribed BZRA (22%).ConclusionDespite some statistically significant decreasing trends, an overall increase in BZRA prescriptions was observed throughout the 19-year study period, especially among long-term users of 18–44 years and 65-plus. Zolpidem became the most prescribed BZRA and warrants more attention.

Objective The aim of the present study is to describe a stepwise approach to study which contextual factors might moderate the effect of healthcare interventions and to test feasibility of this approach within the D-SCOPE project.Design Exploratory case study.Setting In the D-SCOPE project, a complex intervention by means of home visits was set up to improve access to tailored care in three municipalities (Ghent, Knokke-Heist and Tienen).Methods One designed and tested an approach including five steps: (1) a theoretical/conceptual discussion of relevant contextual factor domains was held; (2) a search was done to find appropriate web-based public datasets which covered these topics with standardised information; (3) a list of all identified contextual factors was made (inventory); (4) to reduce the long list of contextual factors, a concise list of most relevant contextual factors was developed based on the opinion of two independent reviewers and (5) a nominal grouping technique (NGT) was applied.Results Three public web-based datasets were found resulting in an inventory of 157 contextual factors. After the selection by two independent reviewers, 41 contextual factors were left over and presented in a NGT which selected 10 contextual factors. The NGT included seven researchers, all familiar with the D-SCOPE intervention, with various educational backgrounds and expertise and lasted approximately 1 hour.Conclusion The present study shows that a five-step approach is feasible to determine relevant contextual factors that might affect the results of an intervention study. Such information may be used to correct for in the statistical analyses and for interpretation of the outcomes of intervention studies.NCT03168204

Abstract Background In Belgium, General Practitioner Cooperatives (GPC) aim to improve working conditions for unplanned care and to reduce the number of low acuity emergency visits. Although this system is well organized, the number of low acuity visits does not decrease. Methods We explored the view of patients and physicians on the co-location of a GPC and an emergency service for unplanned care. The study was carried out in a cross section design in primary and emergency care services and included patients and physicians. Main outcome measure was the view of patients and physician on co-location of a GPC and an emergency service. Results 404 patients and 488 physicians participated. 334 (82.7%) of all patients favoured a co-location. The major advantages were fast service (104, 25.7) and adequate referral (54, 13.4%). 237 (74%) of the GPs and 38 (95%) of the emergency physicians were in favour of a co-location. The major advantage was a more adequate referral of patients. 254 (79%) of the GPs and 23 (83%) of the emergency physicians believed that a co-location would lower the workload and waiting time and increase care quality (resp. 251 (78%), 224 (70%) and 37 (93%), 34 (85%). Conclusions To close the expectation gap between GP’s, emergency physicians and to reach for high care quality, information campaigns and development of workflows are indispensable for a successful implementation of a co-location of primary and emergency care.

Background In the migrant population, there is a higher risk of dementia. However, dementia is underdiagnosed in this population due to the underuse of appropriate screening tools. The Rowland Universal Dementia Assessment Scale (RUDAS) is designed for culturally and linguistically diverse populations. Objectives To gain insights into the primary care cognitive screening strategy for dementia in migrants and to evaluate the experiences with the RUDAS tool by general practitioners (GPs). Methods GPs were questioned about barriers in dementia screening in the migrant population and asked to apply the RUDAS. A mixed-methods study was conducted among Flemish GPs. In an online survey, the currently used methods for screening for dementia in migrants and the barriers were investigated. In a qualitative pilot study, the user experience of the RUDAS scale was explored. Results A total of 122/322 GPs participated (response rate 38%), 102 (83.6%) of all responding GPs mentioned language problems as the most apparent barrier. Most GPs believed the Mini Mental State Examination was inappropriate for migrants but they were unaware of an alternative. Due to lack of time and target population, only two GPs effectively applied the RUDAS. The tool was found easy to understand and less challenging in case of language problems. The main reason for not using RUDAS was the suspected time consumption. Conclusion GPs find screening for dementia in migrant patients a challenging act, mainly due to language barriers. GPs are not confident enough with the appropriate screening strategies and tools adjusted to the needs of migrant patients. Abbreviations: GP: general practitioner; RUDAS: Rowland Universal Dementia Assessment Scale; MMSE: Mini Mental State Examination.

Abstract Background Efficient selection of medical students in GP training plays an important role in improving healthcare quality. The aim of this study was to collect quantitative and qualitative validity evidence of a multicomponent proficiency-test for identifying underperforming students in cognitive and non-cognitive competencies, prior to entering postgraduate GP Training. From 2016 to 2018, 894 medical GP students in four Flemish universities in Belgium registered to take a multicomponent proficiency-test before admission to postgraduate GP Training. Data on students were obtained from the proficiency-test as a test-score and from traineeship mentors’ narrative reports. Results In total, 849 students took the multicomponent proficiency-test during 2016–2018. Test scores were normally distributed. Five different descriptive labels were extracted from mentors’ narrative reports based on thematic analysis, considering both cognitive and non-cognitive competences. Chi-square tests and odds ratio showed a significant association between students scoring low on the proficiency–test and having gaps in cognitive and non-cognitive competencies during GP traineeship. Conclusion A multicomponent proficiency-test could detect underperforming students prior to postgraduate GP Training. Students that ranked in the lowest score quartile had a higher likelihood of being labelled as underperforming than students in the highest score quartile. Therefore, a low score in the multicomponent proficiency-test could indicate the need for closer guidance and early remediating actions focusing on both cognitive and non-cognitive competencies.

Mild cognitive impairment (MCI) traditionally refers to an intermediate stage between healthy individuals and early Alzheimer disease. Evidence shows grey and white matter volume changes and decrease in several executive functions, albeit the relation between cognitive performance and brain volume remains unclear. Here, we discuss 3 individual cases of MCI by investigating their MRI scans and cognitive test performance. We also recruited age-matched healthy older adults serving as gold standard for both grey and white matter volume and cognitive test outcomes. Our results show the impact of cognitive impairment on cognitive test performance and grey and white matter volumes, and the role played by cognitive and brain reserve on mitigating cognitive decline. Furthermore, we add evidence to previous studies by showing an increase in white matter volume compared to healthy controls, in all 3 patients. This pattern of increased white matter volume might help us to better understand the pathological mechanisms underlying MCI which in turn could contribute to future investigations.

BackgroundIn times of COVID-19, we are challenged to experiment with alternative platforms or software to connect people. In particular, the struggle that arose in health research was how to interact with patients and care professionals. The latter is additionally faced with an extreme workload to fight the pandemic crisis. Creative strategies have been developed to continue research among patients and care professionals to improve quality of care. This paper addresses the issue of synchronous, online, nominal group sessions, a common consensus method used for group brainstorming. ObjectiveThe purpose of this study was to share our experiences with performing online, nominal group sessions using the video conference software Microsoft Teams. In addition, we aimed to create a practical guide with recommendations for researchers. MethodsWe critically analyzed the procedures for the online nominal group technique, according to the Fishbone methodology. ResultsPerforming synchronous, online, nominal group sessions is challenging but offers opportunities. Although interaction with and among the attendees complicates the process, the major advantage of online sessions is their accessibility and comfort because of reduced barriers to participation (eg, lower time investment). The role of the moderators is of major importance, and good preparation beforehand is required. Recommendations for future online, nominal research were formulated. ConclusionsOnline, nominal group sessions seem to be a promising alternative for the real-life commonly used technique. Especially during the COVID-19 pandemic, the benefits must be highlighted. More expertise is needed to further refine the practical guide for using digital software in research and to achieve optimal performance.

ObjectiveTo determine the impact of the affiliate stigma on mental well-being of relatives caring for a person with dementia.DesignThe study was conducted in a cross sectional design.SettingThe study was conducted in a public setting, addressing relatives caring for a person with dementia.ParticipantsParticipants were relatives of patients with a formal diagnosis of dementia. Relatives were defined as caring or living closely to a patient. Participants were recruited with the help of care and welfare organizations.Outcome MeasuresThe main outcome measure was the impact of the affiliate stigma on mental well-being of caring relatives.Results228 participants fully completed the survey. Women, relatives with a higher education and partners experienced more impact of the affiliate stigma on mental well-being than man, relatives with a lower education and relatives with another relationship to the person with dementia (resp. F-ratio = 15.67; p = 0.0001; F-ratio = 2.5865; p = 0.0381; F-ratio = 3.1131; p = 0.0099). The duration of dementia and the age of the caregiver had a clear significant effect on affiliate stigma (F-ratio = 4.9104; p = 0.0083) (F-ratio = 6.5515, p = 0.0112).ConclusionThis study revealed that caregiver related features are predicting the presence of an affiliate stigma. Interventions to prevent or reduce the impact of this stigma might focus on these groups. Education about dementia and the impact on patients, relatives and the broader social context might alter the affiliate stigma surrounding dementia.

Background: Postnatal depression (PND) is one of the most frequent complications in women of childbearing age in the developed world. The onset of PND is influenced by several risk factors. In an attempt to avoid unnecessary long maternity stays, the Short Stay Maternity programme was launched, shifting care from the hospital environment to the outpatient setting. Aim: In order to develop an efficient programme to trace vulnerable women after childbirth and to provide support within primary care, the aim was to create an inventory of the risk factors for PND within the population of women participating in the short-stay programme. Design & setting: This study is a cross-sectional study without follow-up. Women in Belgium were invited by email to participate in the Short Stay Maternity programme within 3 months of delivery. Method: The questionnaire addressed background features and feelings during the maternity period, supplemented with the validated Dutch version of the Edinburgh Postnatal Depression Scale (EPDS). The primary outcome measure of the questionnaire was the score on the EPDS. Results: A total of 131 (27.46%) of the invited women participated. Sixteen participants (12.21%) presented with a positive score on the EPDS. The odds ratio (OR) for a positive score on the EPDS when experiencing negative feelings was 13.5 (95% confidence interval [CI] = 4.14 to 44.01). If only material support was provided, the OR for a positive EPDS score was OR 11.2 (95% CI = 2.72 to 55.5). Conclusion: In this study, two risk factors were identified for PND: negative feelings during pregnancy and the provision of only material support by the partner.

Abstract Background Many instruments to identify frail older people have been developed. One of the consequences is that the prevalence rates of frailty vary widely dependent on the instrument selected. The aims of this study were 1) to examine the concordances and differences between a unidimensional and multidimensional assessment of frailty, 2) to assess to what extent the characteristics of a ‘frail sample’ differ depending on the selected frailty measurement because ‘being frail’ is used in many studies as an inclusion criterion. Method A cross-sectional study was conducted among 196 community-dwelling older adults (≥60 years), which were selected from the census records. Unidimensional frailty was operationalized according to the Fried Phenotype (FP) and multidimensional frailty was measured with the Comprehensive Frailty Assessment Instrument (CFAI). The concordances and differences were examined by prevalence, correlations, observed agreement and Kappa values. Differences between sample characteristics (e.g., age, physical activity, life satisfaction) were investigated with ANOVA and Kruskall-Wallis test. Results The mean age was 72.74 (SD 8.04) and 48.98% was male. According to the FP 23.59% was not-frail, 56.92% pre-frail and 19.49% frail. According to the CFAI, 44.33% was no-to-low frail, 37.63% was mild frail and 18.04% was high frail. The correlation between FP and the CFAI was r = 0.46 and the observed agreement was 52.85%. The Kappa value was κ = 0.35 (quadratic κ = 0.45). In total, 11.92% of the participants were frail according to both measurements, 7.77% was solely frail according to the FP and 6.21% was solely frail according to the CFAI. The ‘frail sample respondents’ according to the FP had higher levels of life satisfaction and net income, but performed less physical activities in comparison to high frail people according to the CFAI. Conclusion The present study shows that the FP and CFAI partly measure the same ‘frailty-construct’, although differences were found for instance in the prevalence of frailty and the composition of the ‘frail participants’. Since ‘being frail’ is an inclusion criterion in many studies, researchers must be aware that the choice of the frailty measurement has an impact on both the estimates of frailty prevalence and the characteristics of the selected sample.

BackgroundThe COVID-19 pandemic has affected education and assessment programs and has resulted in complex planning. Therefore, we organized the proficiency test for admission to the Family Medicine program as a proctored exam. To prevent fraud, we developed a web-based supervisor app for tracking and tracing candidates’ behaviors. ObjectiveWe aimed to assess the efficiency and usability of the proctored exam procedure and to analyze the procedure’s impact on exam scores. MethodsThe application operated on the following three levels to register events: the recording of actions, analyses of behavior, and live supervision. Each suspicious event was given a score. To assess efficiency, we logged the technical issues and the interventions. To test usability, we counted the number of suspicious students and behaviors. To analyze the impact that the supervisor app had on students’ exam outcomes, we compared the scores of the proctored group and those of the on-campus group. Candidates were free to register for off-campus participation or on-campus participation. ResultsOf the 593 candidates who subscribed to the exam, 472 (79.6%) used the supervisor app and 121 (20.4%) were on campus. The test results of both groups were comparable. We registered 15 technical issues that occurred off campus. Further, 2 candidates experienced a negative impact on their exams due to technical issues. The application detected 22 candidates with a suspicion rating of >1. Suspicion ratings mainly increased due to background noise. All events occurred without fraudulent intent. ConclusionsThis pilot observational study demonstrated that a supervisor app that records and registers behavior was able to detect suspicious events without having an impact on exams. Background noise was the most critical event. There was no fraud detected. A supervisor app that registers and records behavior to prevent fraud during exams was efficient and did not affect exam outcomes. In future research, a controlled study design should be used to compare the cost-benefit balance between the complex interventions of the supervisor app and candidates’ awareness of being monitored via a safe browser plug-in for exams.

Cognitive reserve (CR) postulates that individual differences in task performance can be attributed to differences in the brain’s ability to recruit additional networks or adopt alternative cognitive strategies. Variables that are descriptive of lifetime experience such as socioeconomic status, educational attainment, and leisure activity are common proxies of CR. CR is mostly studied using neuroimaging techniques such as functional MRI (fMRI) in which case individuals with a higher CR were observed to activate a smaller brain network compared to individuals with a lower CR, when performing a task equally effectively (higher efficiency), and electroencephalography (EEG) where a particular EEG component (P300) that reflects the attention and working memory load, has been targeted. Despite the contribution of multiple factors such as age, education (formal and informal), working, leisure, and household activities in CR formation, most neuroimaging studies, and those using EEG in particular, focus on formal education level only. The aim of the current EEG study is to investigate how the P300 component, evoked in response to an oddball paradigm, is associated with other components of CR besides education, such as working and leisure activity in older adults. We have used hereto a recently introduced CR index questionnaire (CRIq) that quantifies both professional and leisure activities in terms of their cognitive demand and number of years practiced, as well as a data-driven approach for EEG analysis. We observed complex relationships between CRIq subcomponents and P300 characteristics. These results are especially important given that, unlike previous studies, our measurements (P300 and CRIq) do not require active use of the same executive function and, thus, render our results free of a collinearity bias.

We wanted to investigate the relationship of medical and non-medical factors with the clinical decision-making of pediatricians. We hypothesize that the addition of relevant medical information (either alarming or reassuring) will influence the physician’s decision-making, but that the addition of non-medical information will also play a role. To investigate this, we designed an online questionnaire containing ten clinical case-based scenarios, of which five focused on medical factors and five on non-medical/context factors, each scored on a five-point Likert scale. In total, 113 pediatricians completed the online questionnaire. Both medical and non-medical/context factors were considered relevant to change the initial decision in most cases. Additional information of an alarming nature induces the physician to become more worried, whereas reassuring information decreases this worry. In some cases, with the medical factors, the gender and the age of the pediatrician does have some effect on the clinical decision-making. We conclude that medical decision-making is affected by multiple intrinsic and extrinsic factors that differ between physicians. Our data indicate that these non-medical factors must be considered when making a medical decision, as it is crucial to be aware that they have a substantial influence on that decision-making.

Abstract Background According to some studies, interventions can prevent or delay frailty, but their effect in preventing adverse outcomes in frail community-dwelling older people is unclear. The aim is to investigate the effect of an intervention on adverse outcomes in frail older adults. Methods A systematic review and meta-analysis of Medline, Embase, the Cochrane Library, and Social Sciences Citation Index. Randomized controlled studies that aimed to treat frail community-dwelling older adults, were included. The outcomes were mortality, hospitalization, formal health costs, accidental falls, and institutionalization. Several sub-analyses were performed (duration of intervention, average age, dimension, recruitment). Results Twenty-five articles (16 original studies) were included. Six types of interventions were found. The pooled odds ratios (OR) for mortality when allocated in the experimental group were 0.99 [95% CI: 0.79, 1.25] for case management and 0.78 [95% CI: 0.41, 1.45] for provision information intervention. For institutionalization, the pooled OR with case management was 0.92 [95% CI: 0.63, 1.32], and the pooled OR for information provision intervention was 1.53 [95% CI: 0.64, 3.65]. The pooled OR for hospitalization when allocated in the experimental group was 1.13 [95% CI: 0.95, 1.35] for case management. Further sub-analyses did not yield any significant findings. Conclusion This systematic review and meta-analysis does not provide sufficient scientific evidence that interventions by frail older adults can be protective against the included adverse outcomes. A sub-analysis for some variables yielded no significant effects, although some findings suggested a decrease in adverse outcomes. Trial registration Prospero registration CRD42016035429.

Abstract Background Frail community-dwelling older adults, whom might experience problems regarding physical, cognitive, psychological, social and environmental factors, are at risk for adverse outcomes such as disability, institutionalization and mortality. People in need of help do not always find their way to care and support services and are left undetected. The aim of the D-SCOPE project is to detect frail community-dwelling older adults who previously went unnoticed and to improve their access to care and support. Goal is to increase their frailty-balance, quality of life, meaning in life, life satisfaction, mastery, community inclusion and ageing well in place. Methods/design The study is a prospective, longitudinal randomized four-armed controlled trial with follow-up at 6 months. The study group aims to include 900 community-dwelling older adults aged 60 years and over from 3 municipalities in Flanders (Belgium). While selecting the study group, risk profiles for frailty will be taken into account. Participants will be randomly selected from the census records in each municipality. Data will be collected prospectively at baseline (T0) and at follow-up, 6 months after baseline (T1). At baseline, participants who are at least mild frail on one of the 5 domains of frailty (CFAI-plus) or feel frail based on the subjective assessment of frailty will be randomly assigned to (1) the study group or (2) the control group. A mixed method design with the inclusion of quantitative and qualitative data analyses will be used to evaluate the efficacy and experiences of the detection and prevention program on frailty. Discussion The study will contribute to an innovative vision concerning the organization of care and support, and a timely and accurate detection and support of community-dwelling older adults at risk for frailty. Trial registration This trial was registered at ClinicalTrials.gov, on May 26, 2017, identifier: NCT03168204.

Abstract Background Due to the rapid changes in the medical world and the aging population, the need for advanced care planning grows. Despite efforts to make this topic discussed, only a minority of patients discusses the advance directive with their general practitioner (GP). This study aimed to map thresholds: What barriers are identified by GPs and patients in preparing and discussing an advance directive? Methods A cross section survey in patients and GP’s was performed. Citizens were recruited by multimedia and by street interviews. GP’s were recruited by mailing. Results Most of the 502 citizens already heard of an advance directive but only 17 had declared one while 21 never want one. Eighty percent wants to take the initiative themselves but half of the participants wants the GP to be actively involved. Thirty percent finds the document too difficult to understand. The need to draw an advance directive grew with increasing age. Of the 117 GP’s involved, 65% drafted five or less advance directives the past year. A lack of time, experience and a poor access to the correct administrative requirements were only a few of the barriers. Conclusions Preparing and drafting an advance directive is a time-consuming and difficult procedure. Patients and GP’s have the right to be informed and instructed on how to prepare an advance directive.

Theory: In Belgium, there are no family medicine admission requirements. A three-phase admission program is developed and implemented by the collaboration of four involved universities. Hypotheses: A pilot testing of phase 2, comprising actual proficiency test, is designed as answer to two research questions: What is the validity and reliability of a multicomponent proficiency test? How does a multicomponent proficiency test proportionate to the final grades of family medicine master candidates? Methods: The population consisted of all last master-phase students applying for family medicine education in Flanders. Students completed a machine-assisted test on knowledge and situational judgment skills and evidence-based medicine appraisal. Results: In total, 322 students completed the test. A regression analysis measuring the relationship between the master grades and the test score revealed an odds ratio of 1.1. Analysis of variance showed that the differences were significant between the upper quartile and the lowest quartile of the test results. A qualitative appraisal of the test results showed that the highest and lowest quartiles of the full-test score included the students who were, respectively, known as “very good” or “very poor.” Conclusion: The test scores were in agreement with the performance and profiling of the participating students. The test succeeded in identifying poor-performing students and in confirming competences of the average- and high-performing students. In the future, retesting will add to the statements on reliability and will refine the test construction. Follow-up will address validity.

Abstract Background The debate on frailty in later life focuses primarily on deficits and their associations with adverse (health) outcomes. In addition to deficits, it may also be important to consider the abilities and resources of older adults. This study was designed to gain insights into the lived experiences of frailty among older adults to determine which strengths can balance the deficits that affect frailty. Methods Data from 121 potentially frail community-dwelling older adults in Flemish-speaking Region of Belgium and Brussels were collected using a mixed-methods approach. Quantitative data were collected using the Comprehensive Frailty Assessment Instrument (CFAI), Montreal Cognitive Assessment (MoCA), and numeric rating scales (NRS) for quality of life (QoL), care and support, meaning in life, and mastery. Bivariate analyses, paired samples t-tests and means were performed. Qualitative data on experiences of frailty, frailty balance, QoL, care and support, meaning in life, and mastery were collected using semi-structured interviews. Interviews were subjected to thematic content analysis. Results The “no to mild frailty” group had higher QoL, care and support, meaning in life, and mastery scores than the “severe frailty” group. Nevertheless, qualitative results indicate that, despite being classified as frail, many older adults experienced high levels of QoL, care and support, meaning in life, and mastery. Respondents mentioned multiple balancing factors for frailty, comprising individual-level circumstances (e.g., personality traits, coping strategies, resilience), environmental influences (e.g., caregivers, neighborhood, social participation), and macro-level features (e.g., health literacy, adequate financial compensation). Respondents also highlighted that life changes affected their frailty balance, including changes in health, finances, personal relationships, and living situation. Conclusion The findings indicate that frailty among older individuals can be considered as a dynamic state and, regardless of frailty, balancing factors are important in maintaining a good QoL. The study investigated not only the deficits, but also the abilities, and resources of frail, older adults. Public policymakers and healthcare organizations are encouraged to include these abilities, supplementary or even complementary to the usual focus on deficits.

Background: In Belgium law prohibits euthanasia at the end stage of dementia when patients are no longer able to formulate their will. The number of applications for euthanasia based on dementia is low, but patients and their relatives are searching for access to euthanasia. Aim: This study assessed the opinions of GPs facing requests for euthanasia in patients with dementia. Design & setting: A cross-sectional survey was performed in general practice. Flemish GPs were invited by email to participate in the study. Method: GPs were reached through the regional GP association and the online survey was open for 4 weeks. The data were then anonymised, analysed, and interpreted. The outcome of interest addresses opinions of Flemish GPs regarding euthanasia in patients with dementia. Results: A total of 113/308 doctors participated. It was found that 69% agreed that euthanasia in patients without dementia is more acceptable than in patients with dementia. When patients with dementia had concomitant diseases, 59% stated that euthanasia was more acceptable than when patients were ‘healthy’. It was also found that 56% agreed the euthanasia law needs adjustments towards patients with dementia. Legal adjustments were supported more by GPs of a younger generation. Non-religious doctors were twice as likely to be in favour of legal adjustments than their religious colleagues; 51% believed that the ability of patients to repeat their will is essential; while 72% of GPs feared pressure from relatives to follow the declaration of will. Conclusion: The Belgian GP has an open attitude towards euthanasia for patients with dementia. There was a willingness to perform euthanasia as the stage of dementia worsened and in cases of terminal conditions. Debate, education, and experience will influence opinion and the legislation process.

Objective To find out if there is evidence on interventions to prevent aggression against doctors.Design This systematic review searched the literature and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.Data sources Pubmed, Embase, Turning Research into Practice (TRIP), Cochrane and Psycharticle, GoogleScholar and www.guideline.gov were consulted.Eligibility criteria Abstracts published in English between January 2000 and January 2018 were screened. Eligible studies focused on prevention and risk factors of type II workplace violence in general healthcare, psychiatric departments, emergency departments, emergency primary care, general practice.Data extraction and synthesis The selected intervention studies were grouped into quantitative and qualitative studies. Systematic reviews were reported separately. For each study, the design, type of intervention and key findings were analysed. Quality rating was based on Grading of Recommendations, Assessment, Development and Evaluation (GRADE) and GRADE-Confidence in the Evidence from Reviews of Qualitative Research (CERQUAL).Results 44 studies are included. One randomised controlled trial (RCT) provided moderate evidence that a violence prevention programme was effective in decreasing risks of violence. Major risk factors are long waiting times, discrepancy between patients’ expectations and services, substance abuse by the patient and psychiatric conditions. Appropriate workplace design and policies aim to reduce risk factors but there is no hard evidence on the effectiveness. One RCT provided evidence that a patient risk assessment combined with tailored actions decreased severe aggression events in psychiatric wards. Applying de-escalation techniques during an aggressive event is highly recommended. Postincident reporting followed by root cause analysis of the incident provides the basic input for review and optimisation of violence prevention programmes.Conclusions This review documented interventions to prevent and de-escalate aggression against doctors. Aggression against physicians is a serious occupational hazard. There is moderate evidence that an integrated violence prevention programme decreases the risks of patient-to-worker violence. The review failed to gather sufficient numerical data to perform a meta-analysis. A large-scale cohort study would add to a better understanding of the effectiveness of interventions.

We investigated whether P300-ERP and cognitive test performance differ for age, sex, and education in two groups of healthy elderly, and verified whether any correlations exist between P300 amplitude and latency and gray matter volume using whole brain voxel-by-voxel-based mapping, controlling for age, education, sex and Total Intracranial Volume (TIV). We used 32 channel electroencephalograms (EEG) to record the P300 responses and 3T Magnetic Resonance Imaging (MRI) to determine gray matter volume. We recruited 36 native-Dutch speaking healthy older subjects, equally divided in two sub-groups of 52–64 and 65–76 years old, administered a battery of cognitive tests and recorded their demographics, EEGs and task performance; additionally, 16 adults from the second sub-group underwent an MRI scan. We found significant differences between age groups in their cognitive tests performance, P300 amplitudes for the frontal and parietal electrodes for the most difficult task, and P300 latencies for frontal, central and parietal electrodes for all three tasks difficulty levels. Interesting, sex and education affected cognitive and P300 results. Higher education was related to higher accuracy, and P300 amplitudes and shorter latencies. Moreover, females exhibited higher P300 amplitudes and shorter latencies, and better cognitive tasks performance compared to males. Additionally, for the 16 adults underwent to MRI scan, we found positive correlations between P300 characteristics in frontal, central and parietal areas and gray matter volume, controlling for demographic variables and TIV, but also showing that age, sex, and education correlate with gray matter volume. These findings provide support that age, sex, and education affect an individual’s cognitive, neurophysiological and structural characteristics, and therefore motivate the need to further investigate these in relation to P300 responses and gray matter volume in healthy elderly.

Background: Burnout has been on the rise in recent years. Is this increasing prevalence due to changing working circumstances, or also to a changing societal context? Aim: The aim of the study was to explore intergenerational differences in burnout. Design & setting: The study used a mixed quantitative and qualitative design, and tested the theory of the job demands–resources model (JD-RM). The target group of this research was the working population in Belgium, aged between 21–65 years. The study was performed in a public setting with people recruited through social media. Method: A quantitative web survey was distributed among the participants to explore the prevalence of burnout, work ethic, work engagement, and norms and values. The second part of the study used a focus group technique to explore in depth the eight statements that were formulated from the quantitative survey. Results: A total of 309 people participated in the web survey and 21.5% met the criteria for 'burnout', while 22.6% scored high on the criteria for 'engagement'. It was found that 12.6% of all men and 3.0% of all women could not identify with the portrait of 'equivalence’. The value 'benevolence' was positively rated by 100%. In the youngest generation, 71.3 % identified with the portrait of ‘stimulation', while 70.8% of older men identified with the portrait ‘traditions’. The results also revealed that 43.1% of the younger generation agreed with the statement: 'I often think I would be more successful if I gave up certain pleasures' Conclusion: Burnout is more common among young people. In the older generation, a good ability to put things into perspective, a good balance between work and leisure, and a strong sense of tradition appear to be resources to aid against burnout. The younger generation often deals with stressors. This younger generation appears to have a higher work ethic and commitment.

Aging is often associated with changes in brain structures as well as in cognitive functions. Structural changes can be visualized with Magnetic Resonance Imaging (MRI) using voxel-based grey matter morphometry (VBM) and visual rating scales to assess atrophy level. Several MRI studies have shown that possible neural correlates of cognitive changes can be seen in normal aging. It is still not fully understood how cognitive function as measured by tests and demographic factors are related to brain changes in the MRI. We recruited 55 healthy elderly subjects aged 50–79 years. A battery of cognitive tests was administered to all subjects prior to MRI scanning. Our aim was to assess correlations between age, sex, education, cognitive test performance, and the said two MRI-based measures. Our results show significant differences in VBM grey matter volume for education level (≤ 12 vs. > 12 years), with a smaller amount of grey matter volume in subjects with lower educational levels, and for age in interaction with education, indicating larger grey matter volume for young, higher educated adults. Also, grey matter volume was found to be correlated with working memory function (Digit Span Backward). Furthermore, significant positive correlations were found between visual ratings and both age and education, showing larger atrophy levels with increasing age and decreasing level of education. These findings provide supportive evidence that MRI-VBM detects structural differences for education level, and correlates with educational level and age, and working memory task performance. Keywords: MRI, Voxel-based morphometry, Visual rating scales, Atrophy level, Grey matter volume, Cognitive tests, Elderly

Background: Aggression against GPs has increased in the past decade. Depending on experience, interpretation, and personality, the interpretation of aggressive patient behaviour will differ among doctors. Aim: To investigate how often GPs experience aggression in a 1-year time span and what the relationship is between the GP's personality (based on the 'Big Five' personality traits) and the reporting of aggression. Secondly, to investigate how personality is related to feeling safe. Design & setting: Flemish (Belgian Federal State) GPs were questioned in a cross-sectional design by online survey. GPs were recruited and questioned in their professional environment. Method: Outcome measures were the 'Big Five' personality traits ('reserved' versus 'outgoing', 'compassionate' versus 'challenging', 'efficient' versus 'careless', 'confident' versus 'nervous', and 'cautious' versus 'innovative', based on Cattel's 'Big Five' model of personality), the type of aggression, the reporting of aggression, and feeling safe. Results: Both (n = 247) male and female doctors considered physical contact and verbal intimidation as aggression. Female doctors were more likely to consider sexual harassment as aggression. The majority of GPs were confronted with verbal aggression. More than half considered physical aggression as the most threatening. GPs with 'reserved' and 'careless' personality types were more likely to experience aggression. GPs with 'innovative', 'challenging', or 'confident' personality types were also at increased risk, but to a lesser extent than those with 'reserved' and 'careless' personalities. GPs with 'efficient' and 'innovative' personalities were more likely to report incidents. Male GPs and those with 'efficient' personalities felt safer. GPs with 'confident' and 'cautious' personalities were more likely to feel unsafe. Conclusion: The results of this study might help future interventions and support strategies (designed to prevent aggressive incidents or help GPs cope with them) to target the vulnerable groups. Further research should therefore explore the results of these data in depth and on a larger sample size.

Background: Two-thirds of all patients search the internet prior to a health consultation. Aim: To explore how searching for online health information before visiting a doctor influences patients’ behaviour during the consultation. Design & setting: A quantitative, observational, and cross-sectional study of 18–75-year-old patients who used the internet. Method: Patients were recruited by social media for the quantitative study. This was followed by a qualitiative study of GPs who were questioned in focus groups. Two questions were addressed: What is the effect of searching online health information on the behaviour of the patients? How does the GP handle this information? Results: Almost half of all responders (total n = 963) usually went to the doctor after the online information search but two-thirds were not reassured by the internet search. More than half of responders had more confidence in their GP after searching online. The older the responders, the more they went to the doctor after their internet search and the younger the responders, the more they were worried. The more frequently people consulted the internet for specific complaints, the more likely they reported reassurance. Discussion: Patients usually made an appointment with their GP after the internet search. New symptoms are rarely noticed and the search usually did not lead patients to distrust their GP. The majority of GPs described positive effects of the online search behaviour on the consultation. Conclusion: The emerging use of the internet for searching health information, commonly referred to as 'Dr Google', is not seen as a threat by GPs and leads to a better mutual understanding of symptoms and diagnosis.

Interdisciplinary collaboration is gaining importance. Although general practices (GP’s) have a comprehensive experience in collaboration with psychologists, research on this topic is scarce. In house referrals to a psychologist are assumed to lower the thresholds for patients and GP’s. In this study it was investigated whether the GP’s reasons to refer in were accordance with the treatment strategy of the residing psychologist. The study is performed in a retrospective, observational cross section design. The studied population were the residing psychologist and GP’s. Both were asked to complete a questionnaire. Outcome measures where the referral reasons of the GP’s and the treatment strategy of the psychologist. A total sample of 92 patients of 6 GP’s was studied. Over 60% of the patients were referred for counseling but only in 25% of the cases this proposal was carried out by the psychologist. Overall, the referral reasons of the GP’s were not in accordance with the treatment strategy of the psychologist. A close collaboration and communication between general practitioners and psychologists is both difficult and indispensable. This practice research demonstrated that the referral motives of the GP’s usually do not correspond to the treatment policy of the psychologist. This observation is partly explained by a lack of understanding of the GP in the treatment strategies of the psychologists. Another part of the explanation is that there is a pre-selection of the GPs referrals rather influenced by patient characteristics than by pathology.