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Background In current cancer care, multidisciplinary team meetings (MDTMs) aim at uniting care professionals from different disciplines to decide upon the best possible treatment plan for the patients based on the available scientific evidence. In Belgium, the multidisciplinary approach is mandatory and formally regulated since 2003. Current research indicates that MDTMs are not always truly multidisciplinary, ie, with a mix of medical as well as paramedical disciplines, and that the medical profession (physicians and medical specialists) tends to dominate the interaction in MDTMs. To ensure that MDTMs can benefit from their diverse membership to achieve their full potential, significant attention should be devoted to the multidisciplinary character of these meetings. The aim of this study is to explore and describe the multidisciplinary character in MDTMs and how it is actually shaped in practice in different Flemish medical oncology departments. Methods For this study, we carried out an observational comparative case study. We studied 59 multidisciplinary team meetings at inpatient medical oncology departments in five different Belgian hospitals (academic as well as general) and explored multidisciplinarity and how it is actually shaped in practice. Results The study is unique in identifying and analyzing three distinct types of MDTMs. The analysis of the three types revealed an inconsistent and, at times, contradictory picture of multidisciplinary team meetings. The findings also align with previous studies arguing that MDTMs in oncology are typically driven by doctors, with limited input of nurses and other nonmedical staff in which decisions are argued on biomedical information and far less consideration of psychosocial aspects. Conclusion The concept of a MDTM should not merely be a group of care professionals who work essentially independently and occasionally liaise with one another. Yet, this study has shown a worryingly low awareness of the true character of multidisciplinarity, particularly among medical disciplines.

Aim: To clarify organizational perspectives on diagnostic evaluations for children with neurodevelopmental disorders (NDD), with the goal to enhance interorganizational collaboration and improve accessibility. Method: Focus groups with expert stakeholders in Flanders, Belgium, were organized. Data were analyzed in a continuous, comparative method with researcher and data triangulation, and a member check validation. Results: Fifty-nine people participated in six focus groups. Organizations had no shared vision on diagnostic evaluations of NDD. An interdisciplinary team approach was considered essential. All stakeholders agreed that a diagnostic evaluation is an iterative process along the trajectory of the child. Interpretation: Diagnostic evaluations of NDD should be conceptualized as an integrated process of the child’s care trajectory, differentiating needs-based goals in each phase, and requiring an interdisciplinary team approach. This conceptualization will support a health systems model, allowing interorganizational collaboration to optimize available capacity and increase accessibility.

Background: Multidisciplinary teamwork has become the standard in care for oncological patients and their treatment trajectory when comprehensive, holistic, and high-quality cancer care is needed. Working together from a variety of perspectives is difficult to achieve and has well-known pitfalls, such as miscommunication and poor coordination. Objective: To describe and synthesize the factors influencing and the processes underlying optimal multidisciplinary teamwork. Methods: An integrative review was conducted, guided by the framework of Whittemore and Knafl. The systematic search for literature published since 2010 in 3 databases (PubMed, Web of Science, and Scopus) yielded 49 articles. Results: Eighty-eight percent of the included studies focus on multidisciplinary team meetings, rather than on the wider notion of multidisciplinary teamwork. We identified influencing factors on the basis of structural features of the team, hospital, and health system, as well as process features of multidisciplinary teamwork in multidisciplinary team meetings. Conclusion: To improve multidisciplinary teamwork, the focus needs to be on the process of collaboration throughout the cancer care trajectory of the patient. A more integrated, interdisciplinary approach should be aimed for to recognize the role and contribution of all disciplines involved. Implications: A cultural change is needed toward interdisciplinary practice in hospitals to reach partnership between all involved professionals as part of a participatory, collaborative, and coordinated approach.

BACKGROUND Patients with pancreatic cancer do not feel involved in the development of their treatment and care plans. In Belgium, these plans are decided on during multidisciplinary team meetings. However, limited time is spent on the discussion of the preferences of the patient during these meetings. This research project aims to develop a patient-reported experience measure (PREM) for pancreatic cancer and assess if its use can support collaborative treatment decision-making. OBJECTIVE This paper aims to outline the protocol for a multi-method research project to improve person-centered pancreatic cancer care in Belgium. Three subobjectives are pursued: (1) to develop a PREM to assess the experiences of care-related aspects in pancreatic cancer care, (2) to validate the PREM, and (3) to develop and evaluate an educational intervention to support the use of the PREM’s results. METHODS For the development of the PREM, an exploratory mixed methods study design will be used. The study will start with a survey followed by a telephone interview involving patients with pancreatic cancer and digestive oncology health care professionals. Study two is the testing of the content and construct validity of the PREM. Study three involves the implementation study according to the Medical Research Council framework of a complex intervention introducing the PREM in practice. The effectiveness of the intervention will be investigated using a pragmatic randomized controlled trial study design. RESULTS The protocol presents the entire structure of the research project. Ethics approval to conduct the exploratory mixed methods study (objective 1) has been obtained, and recruitment has started since January 2022. CONCLUSIONS The poor prognosis of patients with pancreatic cancer should not be considered a hurdle to not study this patient population group. Involving patients in the research and decision-making processes early on is key. This project aims to realize a scientifically sound research process providing research outputs that can easily and timely be implemented in the care trajectory of patients with pancreatic cancer. This research project will also lead to recommendations on how to involve patients with pancreatic cancer and how the methodology of this research project can be translated to other patient groups. INTERNATIONAL REGISTERED REPORT PRR1-10.2196/29004

Appropriate care delivery for patients with severe mental illness (SMI) requires a high level of collaboration quality between primary, mental health, and social care services. Few studies have addressed the interpersonal and inter-organizational components of collaboration within one unique study setting and it is unclear how these components contribute to overall collaboration quality. Using a comprehensive model that includes ten key indicators of collaboration in relation to both components, we evaluated how interpersonal and inter-organizational collaboration quality were associated in 19 networks that included 994 services across Belgium. Interpersonal collaboration was significantly higher than inter-organizational collaboration. Despite the internal consistency of the model, analysis showed that respondents perceived a conflict between client-centered care and leadership in the network. Our results reveal two approaches to collaborative service networks, one relying on interpersonal interactions and driven by client needs and another based on formalization and driven by governance procedures. The results reflect a lack of strategy on the part of network leaders for supporting client-centered care and hence, the persistence of the high level of fragmentation that networks were expected to address. Policy-makers should pay more attention to network formalization and governance. mechanisms with a view to achieving effective client-centered outcomes.

Background Neurodevelopmental disorders start in early childhood and may restrict personal, scholastic, social and professional development and functioning. Early detection and smooth trajectories of diagnostics, rehabilitation and support affect the child's development and opportunities. A specialized multidisciplinary team must do a diagnostic evaluation. While accessibility to multidisciplinary diagnostics for all children in Flanders (Belgium) is problematic in regular times, the lockdown measures taken by the end of March 2020 in response to the SARS-CoV-2 pandemic could amplify this problem. This article aims to explore the impact of lockdown policy measures on the accessibility of multidisciplinary diagnostics of developmental disorders.Methods This “rapid response” study was commissioned by the Flemish authorities, as a follow up of a broader study on accessibility of multidisciplinary diagnostics. A questionnaire with open-ended questions was sent out to respondents of three key types of facilities: the Centers for Ambulatory Rehabilitation, Autism Reference Centers and Centers for Developmental Disorders. Qualitative data were thematically analyzed in an iterative process by researcher triangulation.Results Measures taken in response to the SARS-CoV-2 pandemic negatively impacted on waiting periods which lengthened with at least three months and even longer for certain target groups. Specific guidelines to minimize the risk of virus contamination, impact on planning, time management and the quality of the diagnostic assessments. Respondents reported them as being time consuming, uncomfortable, with an increasing workload and leading to a reduction in the number of daily diagnostic activities. Suggested catching-up strategies were increase of public funding, a less rigid application of regulations and a complete or partial assignment stop.Conclusion The SARS-CoV-2 pandemic reinforced the existing problem of accessibility because of a general shortage of diagnostic capacity. On a shorter term accessibility problems can be tempered by providing “bridging care” during waiting periods. On the longer term, strengthening regional interorganisational collaboration is required, to enhance more efficient and effective diagnostic trajectories in facilities providing adapted services to the needs of the children.

Introduction Coordinating cancer care is challenging because of its complexity. To partly encounter this complexity, multidisciplinary team meetings (MDTMs) were implemented to evaluate diagnosis, discuss treatment options and collectively decide upon the most optimal patient care and treatment plan. In cancer trajectories, medical professionals have a coordinating role and final decision responsibility. As a consequence patient-centred non-biomedical information are easily overlooked during discussions in MDTMs. This study aims to uncover physicians’ perceived barriers regarding the uptake of psychosocial aspects and/or patient preferences in the cancer treatment decision-making process during Multidisciplinary Oncology Consultations (MOCs), a specific type of MDTM in Belgium. Methods Between March 2019 and May 2019 semi-structured interviews were conducted with twenty medical professionals specialized in oncology. Grounded theory principles were used to detect and classify perceived barriers and patterns emerging regarding the uptake of psychosocial information in the cancer treatment decision-making process. Results Although physicians showed an open attitude towards taking into account psychosocial aspects and patient preferences in treatment decisions, the majority of respondents is not convinced the MOC is the best place to discuss these aspects. Physicians reported organisational, work process, and health system related barriers. Discussion The MOC emerges as a medicalized form of team discussion that, in its current form, does not reach its objective of truly integrated multidisciplinarity as cancer care is demanding. The working practices of the MOC can be optimized to evolve towards a truly interdisciplinary approach.

Background 20% of all children suffer a neurodevelopmental disorder (NDD) worldwide. Each child with a (suspected) NDD should have access to a specialised multidisciplinary diagnostic setting to pass a qualitative and adequate diagnostic trajectory. In Flanders, Belgium, 6 types of public organisations offer multidisciplinary diagnostics of NDD for children. However the objective of timely diagnostics for the population is not realized. Methods Literature review, document- and website analysis, surveys and focus groups were done. Results of the surveys have been analysed by SPSS, focus groups have been thematically analysed by a process of data- and researchers triangulation. Results were discussed and validated by experts in focus groups. Results The response on the survey was 155. 67 surveys were included for analysis. 71 professionals participated in a focus group. As a result of an historical dispersed development, the field of organisations offering diagnostics of NDD in Flanders is heterogeneous. Diagnostics are provided in each region, but not in every region the same competences, knowledge, expertise and capacity are available. Overall it lacks sufficient capacity. The accessibility, nature of the diagnostics, target groups, composition of the diagnostic teams and working processes differ between organisations and are not coordinated. There is no shared interorganisational opinion on the concept and content of diagnostics. An important hampering factor for interorganisational collaboration is the lack of trust in the quality of diagnostics by other organisations. Many ruptures in the overall trajectory hamper continuity of care for NDD. Conclusions Besides creating more diagnostic capacity according to a geographical planning, interorganisational collaboration will tackle the accessibility problem. A coordinated common framework grounded in the logics of cooperation and collaboration of a heterogeneous mix of organisations providing diagnostics, is needed. Key messages Development of collaborative networks of different types of services offering diagnostics will improve the accessibility of early and timely multidisciplinary diagnostics for children with NDD. A shared interorganisational opinion on the concept and content of diagnostics aiming to improve interorganisational trust in the quality of diagnostics, must be developed.

Purpose The purpose of this paper is to better understand facilitators’ perceived role and influence on a policy dialogue’s (PD) process and impact. PDs enable interactions between policy makers, researchers and other stakeholders – one of the factors associated with promoting evidence-informed policy making. Design/methodology/approach This is an exploratory study based on semi-structured interviews with ten key informants from sub-Saharan Africa, the Middle East, North and South America. Participants were purposefully sampled based on their experience in facilitating or observing PDs organized by the WHO’s Evidence-informed Policy Network. Data were analyzed using a constant comparative method. Findings A successful PD relies on a structured process used to catalyze impact. Facilitators contribute to a successful PD through their facilitation skills, for example, helping to get to an informed judgment; knowledge, for example, about the health system; attitudes, for example, valuing the PD process over its outcomes; and personal attributes, for example, credibility. Facilitators’ involvement in preparatory and follow-up actions are equally paramount for a PD’s success. Challenges in implementing PDs can be prevented/attenuated, for example, through stakeholder analysis to identify suitable PD participants, and anticipate power constellations or potential conflicts. Research limitations/implications Research should focus on the overall process of a PD – especially on preparation and follow-up activities and their influence on a PD’s success. Originality/value Informed by harnessing practical experiences, this paper outlines facilitators’ skills, attributes, attitudes, knowledge and how these can be used to influence a PD’s success.

Introduction: An early and fluent diagnostic trajectory, accessible for every child, is currently not guaranteed in Flanders despite the availability of different types of settings offering multidisciplinary diagnostics for neurobiological developmental delays or disorders NDDD. Regulative, organizational and work practice differences potentially impact on the development of collaborative networks guaranteeing accessible and integrated diagnostics, along the trajectories of children. Methods: Mapping the regulative frameworks at the federal and community levels for specialized multidisciplinary diagnostic teams for children with suspected NDDD in Flanders. Analysis of policy documents and legal frameworks of the centers for ambulatory rehabilitation CAR, centers for developmental disorders CDD, student guidance centers SGC, ambulatory mental health care centers MHC, autism reference centers ARC, ambulatory hospital services for pediatric neuropsychiatry APP. Results: Organizations are currently regulated by Federal or Community regulations. The different organizations providing multidisciplinary diagnostics for NDDD fall under different policy domains mental health, rehabilitation, hospitals, education. Federal regulations are more detailed and regulate more aspect than community regulations. For diagnostics at a CAR or MHC, children have to be referred. The regulations on target group facility for the CAR, ARC and MHC, is pathology-based; on CDD, SGC and APP more generally described. In a CAR, MHC and APP diagnostics aim at support and rehabilitation. Diagnostics at SGC aims at support, referral and coordination. ARC and CDD do clinical classifying diagnostics, referral and further coordination. The ARC uses a standardized protocol for diagnostics. The regulations on team composition numbers and disciplines are set for the CDD and MHC; more detailed rules are set for ARC, CAR, SGC and APP. Discussion: Literature on policy or mandated networks suggests that network approaches help to tackle complex problems, if settings offer complementary services and are mutually dependent to reach societal goals. The current confusion and ineffectiveness in the field is partly affected by regulations that do not promote collaboration and complementarity. Services were historically regulated specifically in different fields sectors. Those regulations do not refer to collaboration or cooperation. For the population, it is not clear what types of service are offered, how they differ from or overlap with each other, or for what purpose different organizations can be consulted. Conclusion: Regulations in public services impact on the organization of services and clinical practice. Current regulations in Flanders are not adapted to support network practice and an integrated way of providing accessible diagnostics along NDDD trajectories. Lessons learned: Current regulative frameworks for multidisciplinary diagnostics of NDDD are not adequately adapted to implement accessible and integrated care. The literature on mandated or policy networks urges to develop supportive regulative frameworks identifying complementarities of the different types of facilities. Limitations: Private, non-subsidized multidisciplinary settings are not included. Suggestions for future research: Additional health service research is needed on differences in organizational practice in the field of multidisciplinary diagnostics of NDDD, affecting network development, and on governance mechanisms supporting the development of integrated care. This should include research on factors affecting the accessibility of services.

Background : In 2016 The Belgian government launched a Masterplan to improve healthcare for Mentally Ill Offenders (MIO). The Plan aims at improving collaboration between different organizations to guarantee integrated healthcare trajectories. The core question of this contribution is to assess to what extent the policy framework and guidance facilitates or hampers the implementation of collaboration and integrated care for MIO’s. Methods : Qualitative data were collected using document analysis of the Reform program and semi structured interviews with representatives of hospitals, justice houses and regional coordinators. Data-analysis was done with a continuous comparative method of coding and analysis including researcher triangulation. Results : The Masterplan, the general reference text on the Reform, mandates locoregional steering groups to implement the reform. These groups are supported by formally appointed and funded regional coordinators. Locoregional actors get leeway to implement the reform within the overall framework. The interviews learn that intersectoral collaborations are needed to tackle problems on offering healthcare for MIO. Implementation problems emerge from the heterogeneous composition of steering groups and diverging interests, power struggles and differences in culture. Some participating organizations focus on forensic thinking while others have a broader overall mental health care approach. The steering groups need to find a balance between mutual interdependence and organizational interests. Historical partnerships versus integrating new services in this MIO-field challenge the definition of common goals and working practices. Moreover participating organizations are represented by different professional backgrounds (managers vs clinical professionals) which affects the view on the problem and collaboration. At last, the interactions are affected by the regulations of the partners from different policy sectors. Discussion : Heterogeneity and complexity challenges collaboration. Policy implementation networks need learning time and mutual adaptations in order to become sustainable. The experiences drawn from the Belgian MIO field converge with findings in network literature, but vary because of the particular MIO field characteristics in Belgium. Conclusion : The choice of the Belgian government to initiate locoregional mandated heterogeneous networks is a potentially useful tool to tackle the complex problem of integrated care for MIO. However because of this heterogeneity governance questions are undervalued. Limitations : This implementation study relies on an inventory of experiences of an ongoing change process. The collaborative networks have not matured yet. Therefore we could not yet address the issue of the life circle of a reform program and the maturing of networks. Suggestions for further research : Further research is needed on steering mechanisms. It currently lacks research on how facilitating instruments like coaching sessions, exchange programs etc. could support the development of innovative networks aiming at integration of care.

Introduction: Children with a (suspected) neurobiological developmental delay or disorder (NDDD) are clinically expected to be diagnosed by a multidisciplinary team as early as possible, given the impact on subsequent development. In different stages of the disorder trajectory and health care use trajectory of the child, diagnostics are needed to clear out development, evolution and recent symptoms. Currently, there is no evidence on the types and organization of diagnostics and follow-up care children with NDDD need, related to the phases of the trajectory. Methods: Systematicliterature review on neurobiological developmental disorders, (multidisciplinary) diagnostics, disease trajectories. Results: Neurobiological developmental delays and disorders (NDDD) are dysfunctions in the development, involving a large variety in etiology, expression and severity. Assessment at all areas of development (verbal and non-verbal cognition, expressive and receptive language, fine and gross motor development, social communication, social-emotional development) is needed. Classifying and action-oriented diagnostics can be distinguished, as well as mono- and multidisciplinary diagnostics. Mostly, diagnostics are followed by interventions (rehabilitation, support), which may prevent academic failure, behavior problems, dropout, delinquency and the development of more severe mental health issues in later life. These interventions are based on the diagnostic outcome and partly determine the health care use and personal functioning trajectory of a child. Discussion: Diagnostics with different goals are needed at different stages of the trajectory of the child, because of the complexity and dynamic characteristics of NDDD. Mono- or multidisciplinary diagnostics and classifying or action-oriented diagnostics need to be organized in an effective and efficient way and should be easy accessible both on population level, and in different stages of NDDD trajectory. This type of services can be provided in an network model of services integrating types of diagnostics and care. Literature on policy or mandated interorganizational networks suggests that network approaches help to tackle complex problems, if autonomous settings offer complementary services and become mutually dependent to reach common goals. Conclusion: Children with NDDD follow a non-linear trajectory of diagnostics, rehabilitation and support. Specialized diagnostics are needed at different stages along the trajectory of the child. An integrated health care approach taking into account the characteristics of trajectories needs to be enhanced through whole (mandated) networks. Lessons learned: Timely accessible multi- and monodisciplinary classifying and action-oriented diagnostics are needed during the trajectory of a child with a NDDD. Integration of diagnostic and other health services can be realized through (mandated) networks taking into account the health system characteristics. Limitations: This review is conceptual in nature and needs further empirical validation. The empirical part would allow to better understand how local context and health system-characteristics affect the development and implementation of effective networks. Suggestions for future research: Further research on disorder trajectories, health care use trajectories and personal functioning trajectories of children with a NDDD is needed, as well as research on the implementation of (mandated) networks in order to provide accessible quality care for children with a NDDD.

Background: Multidisciplinary team meetings (MDTMs) have become standard practice in oncology and gained the status of the key decision-making forum for cancer patient management. The current literature provides evidence that MDTMs are achieving their intended objectives but there are also indications to question the positive impact of MDTMs in oncology settings. For cancer management to be patient-centered, it is crucial that medical information as well as psychosocial aspects—such as the patients’ living situation, possible family problems, patients' mental state, and patients’ perceptions and values or preferences towards treatment or care—are considered and discussed during MDTMs. Previous studies demonstrate that failure to account for patients’ psychosocial information has a negative impact on the implementation of the treatment recommendations formulated during MDTMs. Few empirical studies have demonstrated the predominant role of physicians during MDTMs, leading to the phenomenon that medical information is shared almost exclusively at the expense of psychosocial information. However, more in-depth insight on the underlying reasons why MDTMs fail to take into account psychosocial information of cancer patients is needed. Objective: This paper presents a research protocol for a cross-sectional observational study that will focus on exploring the barriers to considering psychosocial information during MDTMs at medical oncology departments. Methods: This protocol encompasses a cross-sectional comparative case study of MDTMs at medical oncology departments in Flanders, Belgium. MDTMs from various oncology subspecialties at inpatient medical oncology departments in multiple hospitals (academic as well as general hospitals) are compared. The observations focus on the “multidisciplinary oncology consultation” (MOC), a formally regulated and financed type of MDTM in Belgian oncology since 2003. Data are collected through nonparticipant observations of MOC–meetings. Observational data are supplemented with semi-structured individual interviews with members of the MOC–meetings. Results: The protocol is part of a larger research project on communication and multidisciplinary collaboration in oncology departments. Results of this study will particularly focus on the input of psychosocial information during MDTMs. Conclusions: The concept of an MDTM should not merely be a group of care professionals who mostly work independently and occasionally liaise with one another. Interventions aiming to enhance the input of psychosocial information are crucial to ensure that MDTMs can benefit from their diverse membership to achieve their full potential. The findings from this study can be used to design nonclinical and organizational interventions that enhance multidisciplinary decision-making in oncology. [JMIR Res Protoc 2018;7(2):e64]

BACKGROUND Multidisciplinary team meetings (MDTMs) have become standard practice in oncology and gained the status of the key decision-making forum for cancer patient management. The current literature provides evidence that MDTMs are achieving their intended objectives but there are also indications to question the positive impact of MDTMs in oncology settings. For cancer management to be patient-centered, it is crucial that medical information as well as psychosocial aspects—such as the patients’ living situation, possible family problems, patients' mental state, and patients’ perceptions and values or preferences towards treatment or care—are considered and discussed during MDTMs. Previous studies demonstrate that failure to account for patients’ psychosocial information has a negative impact on the implementation of the treatment recommendations formulated during MDTMs. Few empirical studies have demonstrated the predominant role of physicians during MDTMs, leading to the phenomenon that medical information is shared almost exclusively at the expense of psychosocial information. However, more in-depth insight on the underlying reasons why MDTMs fail to take into account psychosocial information of cancer patients is needed. OBJECTIVE This paper presents a research protocol for a cross-sectional observational study that will focus on exploring the barriers to considering psychosocial information during MDTMs at medical oncology departments. METHODS This protocol encompasses a cross-sectional comparative case study of MDTMs at medical oncology departments in Flanders, Belgium. MDTMs from various oncology subspecialties at inpatient medical oncology departments in multiple hospitals (academic as well as general hospitals) are compared. The observations focus on the “multidisciplinary oncology consultation” (MOC), a formally regulated and financed type of MDTM in Belgian oncology since 2003. Data are collected through nonparticipant observations of MOC–meetings. Observational data are supplemented with semi-structured individual interviews with members of the MOC–meetings. RESULTS The protocol is part of a larger research project on communication and multidisciplinary collaboration in oncology departments. Results of this study will particularly focus on the input of psychosocial information during MDTMs. CONCLUSIONS The concept of an MDTM should not merely be a group of care professionals who mostly work independently and occasionally liaise with one another. Interventions aiming to enhance the input of psychosocial information are crucial to ensure that MDTMs can benefit from their diverse membership to achieve their full potential. The findings from this study can be used to design nonclinical and organizational interventions that enhance multidisciplinary decision-making in oncology.

Background Implementing ecosystem services (ES)-based planning and management processes in practice, and mainstreaming the results in decision-making, is limited. Literature suggests this can be explained by a limited overlap between the ES concept and stakeholders’ representations of nature. Aims We introduce social representations theory as an approach to discuss whether the theoretical ES concept is compatible with stakeholders’ social representations of nature. Methods Thirty-nine stakeholders actively involved in the use and management of a peri-urban study area in Belgium were interviewed about their representation of nature. Conclusions Like the ES concept, stakeholders’ representation of nature includes an anthropocentric view, but stakeholders also stress the role and responsibility of humans in sustaining ecosystems and regulating nature (which is a relational value). From the qualitative analysis we conclude that the theoretical ES concept and ES classifications are not sufficiently reflecting stakeholders’ representations of nature, mainly on the human-nature relationship. The social representations technique provides handles to design ES-based processes according to stakeholders’ representations. This can result in more effective ES-based planning and management processes and improved understanding among stakeholders and between stakeholders and process managers.

Background: Palliative care is considered an integral part of oncology and communicating this with patients is an unavoidable task for oncologists. This contribution investigated to what extent communication skills for communicating palliative care with patients are trained in the formal academic training program in medical oncology in Flanders, Belgium. The programme is based on the recommendations for a Global Core Curriculum in Medical Oncology, developed by The American Society of Clinical Oncology (ASCO) together with the European Society for Medical Oncology (ESMO). Methods: For this qualitative study, data were collected using document analysis from the ESMO/ASCO recommendations and the documents of the Flanders’ medical oncology programme complemented with interviews with Flemish medical oncology trainees. Results: Few recommendations for training communication skills to communicate about palliative care were found in the ASMO/ASCO recommendations and even less in the Flanders’ programme documents. Trainees are mainly exposed to palliative care communication during the clinical practice of their training. Only very few lectures or seminars are devoted to palliative care and even less on communication about palliative care. They reported several barriers to communicate about palliative care. Conclusions: This study revealed promising developments for the training of Flemish medical oncologists to discuss palliative care. However, there is still a need for more theoretical training on palliative care complemented with communication skills trainings. Communication training in general needs to be fully integrated as a core skill within the medical curriculum at large and should be promoted as lifelong learning and competency development.

Background: Multidisciplinary care, as a form of an integrated team approach, holds that different types of health care professionals consider and discuss all relevant treatment options and collaboratively develop a treatment plan for each patient. In Belgium this multidisciplinary approach is mandatory in cancer care. Multidisciplinary care teams (MDT) consist of people with different professional backgrounds and experience levels. Research in cancer care has demonstrated that such teams lead to revisions of cancer diagnoses and lead to adaptions of treatment plans, and enhance the use of evidence-based guidelines. Some research shows that patient satisfaction is quite high in settings with multidisciplinary teams. However the organizational aspect of multidisciplinary teams can vary (how many meetings, the organization of the ward team, the members of the team, etc…). One of the less understood problems in the integration of the tasks and activities of different disciplines is the issue of adequate communication within the team and with the patients. Cancer care can be complex, and given the different backgrounds of the professionals involved, an enormous risk for poor coordination and miscommunication exists. Even more specific questions arise in the stage where the patient has to be told that the cancer is incurable. Especially in this phase the patients experience a range of wider psychosocial needs, to be addressed by the oncologist, the (palliative) nurse, social workers, psychologists, etc. In oncology, communication skills are a key to giving bad news and other information about the illness, establishing trust and rapport, addressing patient emotions and eliciting their concerns. Effective and supportive communication can assist the patient and his or her family in navigating a successful transition to palliative care. Aims: This contribution addresses the issue on how communication training intervention programs adapted to experiences and background of professional staff could support the coordination of communication within the care teams and towards the patients. These trainings are considered as supportive tools for integrating multidisciplinary cancer care Methods: We conducted an exploratory qualitative research. We conducted open, face-to-face interviews with 15 certified medical oncologists from academic as well as non-academic Medical Oncology Departments in Flanders and 9 oncology trainees. The interviews were transcribed verbatim and the transcripts were inductively analysed in an iterative process to trace experiences with communication training and tracking down their needs for support. Results: The research learns that experienced and trainee oncologists have not received communication support to deal with patients in incurable oncology situations. Neither is there very much knowledge on the communication support needs to support the range of professionals in MDT. As a consequence very little reflections are currently made on how communication competencies could be supported by adequatelydesigned communication training interventions, adapted to the needs of the MDT members. Discussion: Despite the research advances on the organization, functioning and performance of multidisciplinary care teams in cancer settings, this study exposes major shortcomings in the medical education and a lack of training for adequate communication skills to manage and entertain this form of integrated team approach, in particular for oncologists mostly being the coordinator of such teams., Background: Multidisciplinary care, as a form of an integrated team approach, holds that different types of health care professionals consider and discuss all relevant treatment options and collaboratively develop a treatment plan for each patient. In Belgium this multidisciplinary approach is mandatory in cancer care. Multidisciplinary care teams (MDT) consist of people with different professional backgrounds and experience levels. Research in cancer care has demonstrated that such teams lead to revisions of cancer diagnoses and lead to adaptions of treatment plans, and enhance the use of evidence-based guidelines. Some research shows that patient satisfaction is quite high in settings with multidisciplinary teams. However the organizational aspect of multidisciplinary teams can vary (how many meetings, the organization of the ward team, the members of the team, etc…). One of the less understood problems in the integration of the tasks and activities of different disciplines is the issue of adequate communication within the team and with the patients. Cancer care can be complex, and given the different backgrounds of the professionals involved, an enormous risk for poor coordination and miscommunication exists. Even more specific questions arise in the stage where the patient has to be told that the cancer is incurable. Especially in this phase the patients experience a range of wider psychosocial needs, to be addressed by the oncologist, the (palliative) nurse, social workers, psychologists, etc. In oncology, communication skills are a key to giving bad news and other information about the illness, establishing trust and rapport, addressing patient emotions and eliciting their concerns. Effective and supportive communication can assist the patient and his or her family in navigating a successful transition to palliative care. Aims: This contribution addresses the issue on how communication training intervention programs adapted to experiences and background of professional staff could support the coordination of communication within the care teams and towards the patients. These trainings are considered as supportive tools for integrating multidisciplinary cancer care Methods: We conducted an exploratory qualitative research. We conducted open, face-to-face interviews with 15 certified medical oncologists from academic as well as non-academic Medical Oncology Departments in Flanders and 9 oncology trainees. The interviews were transcribed verbatim and the transcripts were inductively analysed in an iterative process to trace experiences with communication training and tracking down their needs for support. Results: The research learns that experienced and trainee oncologists have not received communication support to deal with patients in incurable oncology situations. Neither is there very much knowledge on the communication support needs to support the range of professionals in MDT. As a consequence very little reflections are currently made on how communication competencies could be supported by adequately designed communication training interventions, adapted to the needs of the MDT members. Discussion: Despite the research advances on the organization, functioning and performance of multidisciplinary care teams in cancer settings, this study exposes major shortcomings in the medical education and a lack of training for adequate communication skills to manage and entertain this form of integrated team approach, in particular for oncologists mostly being the coordinator of such teams.

This paper contributes to the discussion on integrating societal considerations, stakeholders' perceptions and laymen knowledge into ecosystem services (ES) assessments. The paper illustrates how social mapping of perceived ES supply (or alternatively demand) can contribute to integrated ES assessment. Based on sketched locations of the, according to 38 respondents, most important ES at the local scale, we describe the perceived ES distribution with social landscape metrics (abundance, diversity, richness, risk, rarity) based on traditional landscape ecology indicators. We illustrate how social landscape metrics can inform ES management and planning and describe how synergies between ES as stated by the respondents differ from calculated synergies (the latter based on correlation coefficients between perceived ES abundance). We present indicators pointing to locations where (multiple) ES synergies are perceived by stakeholders (stated synergy index), and to conflicting ES and ES perceived to be at risk (risk index). Overlapping social ES hotspots based on the social landscape metrics with ES hotspots based on more traditional biophysical modelling (biophysical hotspots) and ecological inventories (ecological hotspots) results in social–ecological or social–biophysical hotspots, coldspots and warmspots relevant for nature and landscape planning, management and governance. Based on an analysis of the overlaps between social, biophysical and ecological hotspots on the one hand, and the contribution of ecological quality, land zoning categories and conservation statuses on the other hand, we discuss the added value of integrating social ES mapping in integrated ES assessment, above ES assessments based on biophysical or ecological attributes. Given the limited overlap between social hotspots and ecological or biophysical hotspots, we conclude that integrating stakeholders' mapping of perceived ES supply (or demand) into ES assessments is necessary to reflect the societal aspects of ES in ES assessments. However, with a limited sample of respondents, there is a risk of collectivisation of respondents' viewpoints as a common, societal stance. Moreover, the social landscape metrics are not suitable for describing the distribution of ES with low perceived abundance. Finally, we explain how social ES assessment can result in mainstreaming ES in planning, policy and practice.

BACKGROUND: Internet use became an integral part of the healthcare relationship. Literature indicates that the illness trajectory plays a role in the use of Internet as a health information tool. This study focuses on infants admitted to a neonatal intensive care unit. AIM: This study aims to understand how the illness trajectory triggers the use of Internet by parents of infants admitted to a neonatal intensive care unit, using a conceptual framework influenced by Corbin and Strauss' illness trajectory. DESIGN: This study was based on a qualitative longitudinal multiple-case study design. METHODS: From July 2007-August 2008 and from June 2009-May 2010, parents with newborns were prospectively interviewed over a period of 10 months. Parents were recruited in four neonatal intensive care units. The interviews were subject of a thematic content analysis. RESULTS: The multi-layered illness trajectory triggers Internet use. Parents' online health information behaviour interacts with other information channelstoo (such as interaction with healthcare professionals). Parents accumulate knowledge along the illness trajectory affecting their information needs. The sickness trajectory helps to understand the complexity of the information behaviour. Labels have a major impact on the effectiveness of search strategies. CONCLUSIONS: Nursing and other healthcare professionals should become more aware about the complex relationship between information needs and Internet use along the illness trajectory of an infant. As such, they will be more able to assist parents in finding and evaluating high-quality online information at the right time.

Purpose. To document the prevalence, severity and time course of anxiety and depression in stroke rehabilitation patients in four European countries. Method. At two, four and six months post-stroke, the prevalence and severity of anxiety and depression were determined in 532 consecutively recruited patients, using the Hospital Anxiety and Depression Scale. Time course of prevalence and severity was examined, using Cochran-Q and Friedman-tests, respectively. We identified whether the numbers of anxious/depressed patients at each time point comprised the same individuals. Results. Prevalence of anxiety ranged between 22% and 25%; depression between 24% and 30%. Median severity ranged between 4 and 5. No significant differences between centres occurred (p > 0.05). Prevalence of both disorders was not significantly different over time. Severity of anxiety decreased between four and six months; severity of depression remained stable. About 40% of the patients with initial anxiety remained anxious at six months. Some 11% and 7% of those initially not anxious became anxious at four or six months after stroke, respectively. Depression showed a similar pattern. Conclusions. Despite differences in patient profiles and intensity of rehabilitation, no significant differences occurred between centres in prevalence and severity of both disorders. Anxiety was almost as common as depression and additional patients became anxious/depressed at each time point.

Background and Purpose— Outcome after first stroke varies significantly across Europe. This study was designed to compare motor and functional recovery after stroke between four European rehabilitation centers. Methods— Consecutive stroke patients (532 patients) were recruited. They were assessed on admission and at 2, 4, and 6 months after stroke with the Barthel Index, Rivermead Motor Assessment of Gross Function, Rivermead Motor Assessment of Leg/Trunk, Rivermead Motor Assessment of Arm, and Nottingham Extended Activities of Daily Living (except on admission). Data were analyzed using random effects ordinal logistic models adjusting for case-mix and multiple testing. Results— Patients in the UK center were more likely to stay in lower Rivermead Motor Assessment of Gross Function classes compared with patients in the German center (ΔOR, 2.4; 95% CI, 1.3 to 4.3). In the Swiss center, patients were less likely to stay in lower Nottingham Extended Activities of Daily Living classes compared with patients in the UK center (ΔOR, 0.7; 95% CI, 0.5 to 0.9). The latter were less likely to stay in lower Barthel Index classes compared with the patients in the German center (ΔOR, 0.6; 95%CI, 0.4 to 0.8). Recovery patterns of Rivermead Motor Assessment of Leg/Trunk and Rivermead Motor Assessment of Arm were not significantly different between centers. Conclusions— Gross motor and functional recovery were better in the German and Swiss centers compared with the UK center, respectively. Personal self-care recovery was better in the UK compared with the German center. Previous studies in the same centers indicated that German and Swiss patients received more therapy per day. This was not the result of more staff but of a more efficient use of human resources. This study indicates potential for improving rehabilitation outcomes in the UK and Belgian centers.

OBJECTIVE To explore the clinical and non-clinical factors involved in decision-making concerning admission to European stroke rehabilitation units. DESIGN Observational study on case-mix at intake combined with questionnaires and semi-structured interviews with the medical consultants of each European stroke rehabilitation unit. PATIENTS AND SETTINGS Clinical data on 532 first-ever patients after stroke. Medical consultants from 6 European stroke rehabilitation units in 4 European countries (UK, Belgium, Germany and Switzerland). METHODS Standardized clinical assessments within 2 days after admission. Questionnaires to each medical consultants followed by a qualitative round of semi-structured interviews. RESULTS Case-mix of patients after stroke was significantly different between European stroke rehabilitation units. Clinical criteria for admission were seldom explicit and were evaluated differently between the European stroke rehabilitation units. In the UK units, diagnosis of stroke was the only criterion for admission. In the Belgian, German and Swiss units, pre-morbid conditions were taken into account in admission decisions. The likelihood of discharge home was considered highly important in the Swiss units. CONCLUSION Case-mix differences at intake could be linked to different appraisals of clinical and non-clinical factors of patients after stroke. The findings urge us to be more explicit about decision-making processes at admission in order to provide a more comprehensive insight into the interplay between context and process of care.

Background and Purpose— Physiotherapy (PT) and occupational therapy (OT) are key components of stroke rehabilitation. Little is known about their content. This study aimed to define and compare the content of PT and OT for stroke patients between 4 European rehabilitation centers. Methods— In each center, 15 individual PT and 15 OT sessions of patients fitting predetermined criteria were videotaped. The content was recorded using a list comprising 12 therapeutic categories. A generalized estimating equation model was fitted to the relative frequency of each category resulting in odds ratios. Results— Comparison of PT and OT between centers revealed significant differences for only 2 of the 12 categories: ambulatory exercises and selective movements. Comparison of the 2 therapeutic disciplines on the pooled data of the 4 centers revealed that ambulatory exercises, transfers, exercises, and balance in standing and lying occurred significantly more often in PT sessions. Activities of daily living, domestic activities, leisure activities, and sensory, perceptual training, and cognition occurred significantly more often in OT sessions. Conclusion— This study revealed that the content of each therapeutic discipline was consistent between the 4 centers. PT and OT proved to be distinct professions with clear demarcation of roles.

The aim of this study was to compare the time allocated to therapeutic activities (TA) and non-therapeutic activities (NTA) of physiotherapists (PT) and occupational therapists (OT) in stroke rehabilitation units in four European countries.Therapists documented their activities in 15-min periods for two weeks. They recorded: activity, number of patients, number of stroke patients, involvement of other people, location and frequency of each activity. Kruskal-Wallis tests and negative binomial regression models were used to compare activities between professional groups and between units.The average proportion of TA per day ranged between 32.9% and 66.1% and was higher for PT than for OT in each unit. For OT, significant differences emerged between the units in the proportion of time allocated to TA compared to NTA with British OTs spending significantly less time in TA. In the Belgian unit, three times less time was spent on patient-related co-ordination activities (e.g., administration, ward rounds) compared to the British and Swiss units.Time allocation differed between PT and OT and between units, affecting the time available for TA. Further investigation is necessary to study the effect of work organization in stroke rehabilitation units on the efficiency of rehabilitation regimes.

Objectives: Over the years, increasing numbers of children and adolescents have sought help for acute psychiatric problems. The responses to this treatment-seeking behavior are heterogeneous in different settings and nations. This review aimed to provide an answer to the questions "which care should be offered to children and adolescents presenting with a psychiatric emergency or crisis and how should it be organized." Methods: We committed a literature review to find out if any recommendations can be made regarding the organization of emergency care for children and adolescents with acute mental health problems. Results: The lack of a clear definition of emergencies or urgencies hampered this review; we note the differences between adult and child or adolescent psychiatry. The theoretical models of care found in the literature are built up from several process and structural components, which we describe in greater detail. Furthermore, we review the main service delivery models that exist for children and adolescents. Conclusions: Currently, emergency psychiatric care for children and adolescents is practiced within a wide range of care models. There is no consensus on recommended care or recommended setting for this population. More research is needed to make exact recommendations on the standardization of psychiatric care for young people in emergency settings.

Belgium is going through a structural reform of the mental health care system. Key of the reform is is a policy strategy with the ambition to deinstitutionalise the mental health care provision (reduction of beds) through a balanced care approach and by means of establishing regional multisectorial mental health care networks. Each network will cover a range of activities (" 5 functions" from prevention over ambulatory care, over housing and social care, over rehabilitation,...) The government program was launched in 2012. This contribution will provide a state of the art process evaluation of the implementation of multisectorial networks. The methodological approach used is grounded in realist evaluation and takes into account knowledge from implementation science. We will report findings of 19 networks. Data were mainly collected through qualitative datacollection techniques. This contribution will highlight the facilitating and hampering factors when implementing interorgansation networks in mental health care: Particular attention will be paid to the governance of these networks and the impact of intsitutional fields in which different sectors operate on the establishment of networks. Based on the empirical analysis we wil present a number of lessons learned, reflections and recommendations on how the organisational and multisectorial intergration of mental health care could become more effective, and we will stress the importance of a context-sensitive approach in order to adress the issue of integration of care.

This contrubution wil make a cross comparative analysis of research done in innovation strategies in elderly care, mental health care and chronic care in Belgium. The aim of this analysis is to better understand which factors hamper or facilitate multisectorial collabration in order the enhance integrated care (on the organisational level). The added value of a cross comparative analysis of innovation paths in different sectors, is that it allows for identifying idiosyncratic issues in certain care domains, but more importantly, transversal barriers and facilitating or hampering factors regardless of the health or social issue that is being adressed. The contribition is grounded in empirical process evaluation research (realist eveluation) of a number of recent Belgian initiatives to enhance integrated care. Contentwise, the contribution relies on theoretical insights from health system approaches, interorganisational network literature and institutional field studies. The cross comparative analysis will lead to a number of lessons to be taken on board when trying to enhance integrated care activities. thses lessons will be discussed agans the background of exstsing theoretical debates on multisectorial collaborations and integrated care.

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Background Care after discharge from inpatient stroke rehabilitation units varies across Europe. The aim of this study was to compare service delivery after discharge. Methods A total of 532 consecutive patients after stroke were recruited from 4 European rehabilitation centres in Germany, Switzerland, Belgium and the UK. At 2-month intervals, clinical assessments and structured interviews were carried out to document functional status and delivery of services after discharge. Significant factors for receiving follow-up services were analysed using a logistic generalized estimating equation model. Results After controlling for case-mix, the results showed that Belgian patients were most likely to receive physical therapy but least likely to receive occupational therapy. German patients were least likely to receive nursing care. UK patients were less likely to receive medical care from their general practitioner compared with the other patient groups. Conclusion Clinical characteristics did not explain the variations in service delivery after discharge from in-patient stroke rehabilitation. The decision-making processes involved in the provision of follow-up services need to be better documented. To improve our understanding of events post-discharge, the influence of non-clinical factors, such as healthcare regulations, should be explored further.

This literature review focuses on information and communication needs of parents of children admitted to the NICU and on their use of information sources in the illness trajectories at NICU.Literature search in 4 electronic databases (Ovid Medline, PsycINFO, CINAHL and Sociological Abstracts), covering 1990-March 2008.The seventy-eight included articles revealed that NICU parents have high information needs. The illness trajectory mediates parental information needs and induces a changing pattern in information use and information needs. Most attention is paid to the prenatal and acute phases, while information behaviour in sudden events and later phases receives limited attention.In-depth studies on information needs and corresponding use of information sources are lacking. More longitudinal studies are needed, taking the illness trajectory into account and investigating the determinants and outcomes of the information and communication needs of NICU parents.Healthcare professionals should adapt their information provision along the illness trajectory. The development of guidelines of information provision during the illness trajectory at NICU would support all professionals.

Background Epidemiological shifts, financial pressures and changing policy priorities in healthcare initiate reflections on innovative ways to deliver care. Technologies offer opportunities to change health services delivery. One of the emerging fields is telehomecare-applications. Yet, these applications are not always adapted to the user needs and characteristics of the homecare setting, resulting in system failure. Objectives We describe a generic methodological model to incorporate user perspectives in the design and development process of e-health systems. The model aims at grounding the choice of the technology in a clear understanding of the homecare field, and on interactive reflections with the technology developers. Methods and results The methodological model develops over three phases. A first phase aims to identify and to select potential patient groups for which the technology will be developed: It holds (a) gathering of epidemiological data; (b) identifying relevant inclusion criteria to select patient groups; (c) qualitative weighting based on the inclusion criteria to include potential patient groups and (d) plenary discussion with the technology developers. In a second phase, the particular needs of the selected patient groups are assessed through literature review, document analysis and explorative interviews with key informants. In the third phase, social use cases are developed in which the use of potential technologies is written as virtual storylines. The writing of the use cases is prepared through a semi-structured questionnaire for all partners listing the visions and expectations on the technology and user context. The use cases are the source documents for a plenary discussion with the technology developers in which priorities are set for functionalities of the e-homecare platform. The methodological approach is illustrated within the Coplintho-project. It is a Flemish initiative developing an e-homecare platform offering a package of services on a dedicated device to support the social integration and independent living of people in their home environment. Discussion Our methodological approach provides a practical framework for understanding and considering user perspectives. The application of the method within the development of the Coplintho-e-homecare platform demonstrated its usefulness. The experience within the Coplintho-pilot project learned important lessons about the operational use of the method. The methodology is time-consuming and requires scientific input to assess and to document potential user needs, requiring specific means and human resources. The method also requires a very explicit project management of the preparatory phase.

Background: Previous studies have shown an inverse gradient in socioeconomic status for disability after stroke. However, no distinction has been made between the period in the stroke rehabilitation unit (SRU) and the period after discharge. The purpose of this study was to examine the impact of education and equivalent income on motor and functional recovery for both periods. Methods: 419 consecutive patients were recruited from six SRUs across Europe. The Barthel Index (BI) and Rivermead Motor Assessment (RMA) were measured on admission, at discharge and 6 months after stroke. Ordinal logistic regression models were used, adjusting for case mix. Cumulative odds ratios (OR) were calculated to measure differences in recovery between educational levels and income groups with adjustments for case mix. Results: Patients with a low educational level were less likely to improve on the BI (OR 0.53; 95% CI 0.32 to 0.87) and the RMA arm during inpatient stay (OR 0.54; 95% CI 0.31 to 0.94). For this period, no differences in recovery were found between income groups. After discharge, patients with a low equivalent income were less likely to improve on all three sections of the RMA: gross function (OR 0.20; 95% CI 0.06 to 0.66), leg and trunk (OR 0.22; 95% CI 0.09 to 0.55) and arm (OR 0.30; 95% CI 0.10 to 0.87). No differences were found for education. Conclusions: During inpatient rehabilitation, educational level was a determinant of recovery, while after discharge, equivalent income played an important role. This study suggests that it is important to develop a better understanding of how socioeconomic factors affect the recovery of stroke patients.

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Leukoreduction, filtering white blood cells from transfusion blood, effectively avoids leukocyte-related complications of blood transfusion. The technology has proven its relative cost-effectiveness for specific patient populations. With the advent of variant Creutzfeldt–Jakob disease, a transmittable spongiform encephalopathy caused by mad cow disease (bovine spongiform encephalopathy), the hard hit United Kingdom introduced universal leukoreduction for all patients as a precaution for transmission of prions in 1999. This costly policy was followed by many other countries, in the absence of much evidence of an actual health problem or of a more than presumed effectiveness of leukoreduction in preventing prion transmission. The core problem proved to be legal. The blood banks are legally accountable for blood safety. This accountability is absolute, based on avoidance of all possible risks, regardless of costs. This strategy leads to inefficiencies in health care: (i) blood safety management is guided by available rather than cost-effective technology, and (ii) private insurance premiums for civil liability are sharply increasing, while they are in no way related to the expected returns and the high and ncreasing blood safety. A rational safety policy is to be optimal, taking into account costs and effects of the safety procedures. This issue will need an open discussion with the general public of the real risks and a clear and unambiguous definition of proportionality in the precautionary principle, based on the European law. Keywords: blood transfusion, Creutzfeldt–Jakob syndrome, disease transmission, public policy, public opinion