With increased pressure to work until older age, one of the major challenges for Western societies lies in ensuring that the more vulnerable groups, such as low educated workers and those in ill health, will be able to remain at work until retirement age. Men and women with a chronic illness have considerable less access to the labour market than their healthy counterparts, especially among lower educated persons. This weaker position of lower educated persons is mostly related to the higher prevalence of ill health among this group, not to a difference in the strength of the association.
This thesis furthermore describes the influence of substantially changing working conditions on the risk of exit from paid employment for workers with ill health and concludes the more adverse changes in working conditions, the higher the risk of exit from paid employment. Looking at differences in working years lost for different socioeconomic groups these are primarily attributable to unemployment, while differences in working years lost between workers with different physical work load factors was primarily attributable to disability.
The research is important because it adds to the theory building as well as to practice – namely, how can we keep vulnerable groups being in paid employment. Insights that emerge from this research project will be of use to policy makers and practitioners, contributing to knowledge building that can, for instance, strengthen the use of social indicators such as working life expectancy and working years lost into public administration.
Breast cancer is a major public health problem in Europe. It is the most frequently diagnosed neoplasm and leading cause of death in European women. But encouragingly, breast cancer mortality has been declining, essentially due to advancements in early diagnosis and improved treatment.
Breast cancer screening aims to reduce morbidity associated with advanced stages of the disease, as well as cancer-specific mortality. At present, breast cancer screening programs are well established in most European countries. But the burden of breast cancer as well as breast cancer screening programs vary considerably throughout Europe and the long-term effectiveness of screening has only been assessed in a few countries. These substantial differences may result in inappropriate interventions, excessive screening, and overtreatment on the one hand, or under-screening, delayed provision of appropriate treatment on the other.
In this thesis, the consequences of variations of breast cancer screening practices and potential ways to (further) optimize screening programs across Europe are investigated. Part 1 describes the effectiveness of breast cancer screening in Europe. In Part 2, an established microsimulation model (MISCAN-Breast) was used to estimate the impact of current screening policies and the potential harms and benefits of specific health policy changes. Furthermore, MISCAN-Breast was standardized into a user-friendly online application as part of the EU-TOPIA project (www.eu-topia.org).
With this study on mortality, health problems, accessibility to care, we show that homeless people belong to an extremely vulnerable group.
We observe a variety of serious diseases and disorders among homeless people in a shorter life. Homeless people do not die from homelessness but from preventable and/or treatable causes and health problems.
In terms of accessibility of care, a constant fight against deterioration was needed. New regulations in 2015 -homeless people have since lost their health care insurance if they no longer have an address- has complicated the accessibility of care.
We have presented recommendations for future research. A scheme for the uninsured can contribute to solving the problems around uninsured people, but the application of the scheme in practice must be improved. Furthermore, social medical care for homeless people must be intensified in all municipalities in the Netherlands.
Policies to prevent homelessness remain needed and should be intensified. This study describes the value of a national action plan to combat homelessness.
Taking good care of homeless people is beneficial for homeless people themselves and for the general population. This thesis argues for inclusion of homeless people in our society.
Most studies described in this thesis were part of a consortium-inspired research program ‘Transmural collaboration in palliative care’ in the southwest region of the Netherlands.
The first aim was to gain insight into the perspectives and experiences of nurses and physicians working in different care settings on transmural collaboration in palliative care and into their underlying attitudes towards transmural collaboration. We found that most healthcare professionals attach much importance to transmural collaboration and continuity of palliative care for patients and their relatives. However, in clinical practice transmural collaboration and information exchange are often perceived as sub-optimal. Our findings indicate that healthcare professionals need more shared professional attitudes towards transmural collaboration in palliative care.
The second aim was to gain insight into how transmural collaboration in palliative care can be efficiently organized. We found that nurses and physicians need more guidance in defining shared views on goals, activities and working procedures and on organizational issues.
Livestream link: https://youtu.be/QXSnbPzqUZE
Traumatic Brain Injury (TBI) and stroke are major public health concerns and these patients are often admitted to neurocritical care for intensive monitoring and treatments. Comparative Effectiveness Research has been proposed to study the effect treatments and management strategies for patients admitted to neurocritical care. The objective of this thesis was to describe the contemporary landscape of neurocritical care in Europe and Australia and to assess the effectiveness and quality of neurocritical care. This research was part of the CENTER-TBI study and the OzENTER-TBI study, prospective observational cohort studies of patients with TBI in Europe, Israel and Australia and the MR CLEAN study, a Dutch collaboration of patients with ischemic stroke that are treat with Endovascular Thrombectomy. Results from this thesis demonstrated that compared to previous studies, patients with TBI in neurocritical care are older, more often have mild TBI and a substantial part stays in the ICU for less than 72 hours. We observed large variation between centres, regions, and countries regarding to case-mix, specific interventions, and management aspects in neurocritical care, but variation in outcome between centres and countries were smaller. In critically ill patients with TBI, more positive fluid balances were associated with worse outcomes.
In this thesis we studied the perception of leprosy, interventions to change these perceptions, and interventions to reduce the impact of leprosy at individual and family level. We showed that interventions that focus on the entire family and that aim to strengthen resilience or social support and social connection, have the potential to reduce the impact of leprosy at individual and family level. While these interventions can the reduce the impact of leprosy at individual and family level, they do not target the sources of stigma (public perceptions). We also developed two interventions to change public perceptions of leprosy, based on knowledge gaps, misconceptions, beliefs and fears we identified. These two interventions (contextualised posters and community meetings) were effective in increasing knowledge and changing personal and perceived community attitudes. We identified three main drivers of negative attitudes: (1) poor knowledge and misconceptions about leprosy, (2) local beliefs about leprosy, and (3) fear of contagion. Interventions to change the perception of leprosy should target these drivers taking care to adapt these carefully to the local context.
Patient-reported outcome measures (PROMs) can be defined as instruments that measure aspects of a patient’s health condition and/ or treatment that come directly from the patient, thus without external interpretation. PROMs have been implemented in clinical care with wide-ranging intentions: from screening of health problems, monitoring patients’ response to treatment, facilitating patient-provider communication, enhancing shared decision-making, to benchmarking healthcare institutions for quality-of-care improvement.
The overall aim of this dissertation has been to study methodological aspects of the analysis of PROMs such as case-mix adjustment, and to explore the implementation and application of PROMs in clinical care including facilitators and barriers. Our findings suggest that PROMs are outcomes that are influenced by a wider variety of case-mix factors than traditional (clinical) outcomes. We also determined that the collection of PROMs can be challenging due to IT-infrastructure issues, care providers’ lack of experience, and the clinical workflow. The uptake of PROMs in clinical care is more likely to succeed with a multi-disciplinary approach, and by informing patients about the objectives of PROM collection.
An innovative hand hygiene study (RCT) was conducted in 80 nursing homes across the Netherlands. We developed an intervention to improve the compliance of health care workers to hand hygiene rules, including a novel explanation of the WHO’s hand hygiene rules. The intervention included 3 live lessons about hand hygiene, access to an e-learning, posters for the nursing home wards and a hand hygiene photo competition. Policy regarding personal hygiene and hand hygiene materials was also addressed. A randomized study subsequently showed that compliance improved significantly more in the intervention nursing homes (from 12% to 36%) than in the control nursing homes (from 13% to 21%). The intervention was also successful in a Train the Trainer model. The intervention did not lead to a decrease in infectious diseases among the residents of the nursing homes. Materials to carry out the intervention are available at: https://www.zorgvoorbeter.nl/hygiene/handhygiene-verbeteren-verpleeghuis