Cooperation between general practitioners, occupational health physicians, and rehabilitation physicians in Germany: what are barriers to cooperation and how can these be overcome? A qualitative study

Introduction: Rehabilitation measures for patients in the working age primarily aim at maintaining employability, restoring fitness for work and timely return to work. General practitioners (GPs), occupational health physicians (OPs), and rehabilitation physicians (RPs) fulfill different functions in the rehabilitation process, which need to be interlinked effectively to achieve a successful medical and occupational rehabilitation. In Germany, this cooperation at the interfaces is regarded as often working suboptimal. On this background, this qualitative study had two main aims: the first was to record the experiences and attitudes of OPs, RPs and GPs, as well as of rehabilitation patients, to indicate barriers to and obstacles in the cooperation and communication between medical professionals at the intersection of workplace and rehabilitation institutions. The second aim of the publication was to identify, present and discuss suggestions proposed by physicians and patients on how these barriers and obstacles can be overcome and thereby how communication and cooperation between the medical protagonists may be improved. A special focus of the study was a supposed exclusion of OPs from the rehabilitation process, as reported in the literature. Methods and analysis: As previous literature reviews have shown, insufficient data on the experiences and attitudes of the stakeholders are available. Therefore, an exploratory qualitative approach was chosen. In total, 8 Focus Group Discussions with occupational physicians, rehabilitation physicians, general practitioners and rehabilitation patients (2 Focus Groups with 4–10 interviewees per category) were conducted. Qualitative content analysis was used to analyze the data. Results: A number of barriers to and obstacles in cooperation and communication were reported by the participants, including: (1) organizational (e.g. missing contact details, low reachability, schedule restrictions), (2) interpersonal (e.g. rehabilitants level of trust in OPs, low perceived need to cooperate with OPs, low motivation to cooperate), and (3) structural barriers (e.g. data privacy regulations, regulations concerning rehabilitation reports). In regards to these barriers, options for improvement were identified and characterized by the author in the following categories: (1) regulatory interventions (e.g. formalized role and obligatory input of occupational physicians), (2) financial interventions (e.g. financial incentives for physicians based on the quality of the application), (3) technological interventions (e.g. communication by E-Mail), (4) changes in organizational procedures (e.g. provision of workplace descriptions to RPs on a routine basis), (5) educational and informational interventions (e.g. joint educational programs, measures to improve the image of OPs), and (6) the promotion of cooperation (e.g. between OPs and GPs in regards to the application process). Ethics and dissemination: The research was undertaken with the approval of the ethics committee of the medical faculty and university hospital of Tübingen. The study participants’ gave their written consent prior to participating in the interviews. As set out in the study protocol, the results were published in international, peer-reviewed medical journals. Conclusion: The data on barriers as well as on options for improvements presented in this study are in line with studies and expert opinions from Germany and other countries in Western Europe. While some of the proposed solutions could be implemented by the participants themselves by changing behavior and practice in the everyday routine, a multi-level stakeholder approach might be necessary for implementing others. The evidence for the proposed suggestion is limited and mostly based on studies not conducted in the context of the German health care setting. Future quantitative research is needed to assess the relative weight of the findings and controlled interventional studies are necessary to assess feasibility and effectiveness of the proposed suggestions

WICID framework version 1.0: criteria and considerations to guide evidence-informed decision-making on non-pharmacological interventions targeting COVID-19

Introduction: Public health decision-making requires the balancing of numerous, often conflicting factors. However, participatory, evidence-informed decision-making processes to identify and weigh these factors are often not possible- especially, in the context of the SARS-CoV-2 pandemic. While evidence-to-decision frameworks are not able or intended to replace stakeholder participation, they can serve as a tool to approach relevancy and comprehensiveness of the criteria considered. Objective: To develop a decision-making framework adapted to the challenges of decision-making on non-pharmacological interventions to contain the global SARS-CoV-2 pandemic. Methods We employed the 'best fit' framework synthesis technique and used the WHO-INTEGRATE framework as a starting point. First, we adapted the framework through brainstorming exercises and application to case studies. Next, we conducted a content analysis of comprehensive strategy documents intended to guide policymakers on the phasing out of applied lockdown measures in Germany. Based on factors and criteria identified in this process, we developed the WICID (WHO-INTEGRATE COVID-19) framework version 1.0. Results: Twelve comprehensive strategy documents were analysed. The revised framework consists of 11+1 criteria, supported by 48 aspects, and embraces a complex systems perspective. The criteria cover implications for the health of individuals and populations due to and beyond COVID-19, infringement on liberties and fundamental human rights, acceptability and equity considerations, societal, environmental and economic implications, as well as implementation, resource and feasibility considerations. Discussion: The proposed framework will be expanded through a comprehensive document analysis focusing on key stakeholder groups across the society. The WICID framework can be a tool to support comprehensive evidence-informed decision-making processes

Quantifying changes in global health inequality: the Gini and Slope Inequality Indices applied to the Global Burden of Disease data, 1990-2017

Background The major shifts in the global burden of disease over the past decades are well documented, but how these shifts have affected global inequalities in health remains an underexplored topic. We applied comprehensive inequality measures to data from the Global Burden of Disease (GBD) study. Methods Between-country relative inequality was measured by the population-weighted Gini Index, between-country absolute inequality was calculated using the population-weighted Slope Inequality Index (SII). Both were applied to country-level GBD data on age-standardised disability-adjusted life years. Findings Absolute global health inequality measured by the SII fell notably between 1990 (0.68) and 2017 (0.42), mainly driven by a decrease of disease burden due to communicable, maternal, neonatal and nutritional diseases (CMNN). By contrast, relative inequality remained essentially unchanged from 0.21 to 0.19 (1990-2017), with a peak of 0.23 (2000-2008). The main driver for the increase of relative inequality 1990-2008 was the HIV epidemic in Sub-Saharan Africa. Relative inequality increased 1990-2017 within each of the three main cause groups: CMNNs; non-communicable diseases (NCDs); and injuries. Conclusions Despite considerable reductions in disease burden in 1990-2017 and absolute health inequality between countries, absolute and relative international health inequality remain high. The limited reduction of relative inequality has been largely due to shifts in disease burden from CMNNs and injuries to NCDs. If progress in the reduction of health inequalities is to be sustained beyond the global epidemiological transition, the fight against CMNNs and injuries must be joined by increased efforts for NCDs

Representation of social determinants of health in German medical education: protocol of a content analysis study

Introduction: Action on the social determinants of health has been key for improving health and prolonging life in the past, and remains so today. Against this background, WHO's Commission on Social Determinants of Health has called for increased efforts to create health workforces trained in recognising, understanding and acting on the social determinants of health. However, little is known about the extent to which current medical education systems prepare graduates for this challenge. We, therefore, aim to analyse the extent to which the medical curriculum in Germany incorporates content on the social determinants of health. Methods and analysis: We will conduct a qualitative and quantitative content analysis of four key document groups which influence medical education in Germany: the national medical catalogue of learning objectives; examination content outlines provided by the German Institute for Medical and Pharmaceutical Examination Questions; the online textbook most widely used for final examination preparation and the full set of questions from two national medical licensing examinations. We will analyse these documents based on a coding system, which we derived deductively from the report of WHO's Commission on Social Determinants of Health as well as other key publications of WHO. We will report quantitative indicators, such as the percentage of text related to social determinants of health for each document type. Moreover, we will conduct a semiqualitative analysis of relevant content. Ethics and dissemination: This study is based on the analysis of existing documents which do not contain personal or otherwise sensitive information. Results from the study will be published in a scientific peer-reviewed journal

Environmental Interventions to Reduce the Consumption of Sugar-Sweetened Beverages: Abridged Cochrane Systematic Review

BACKGROUND Regular consumption of sugar-sweetened beverages (SSB) can increase the risk for obesity, type 2 diabetes, cardiovascular disease, and dental caries. Interventions that alter the physical or social environment in which individuals make beverage choices have been proposed to reduce the consumption of SSB. METHODS We included randomised controlled, non-randomised controlled, and interrupted time series studies on environmental interventions, with or without behavioural co-interventions, implemented in real-world settings, lasting at least 12 weeks, and including at least 40 individuals. Studies on the taxation of SSB were not included, as these are subject of a separate Cochrane review. We used standard Cochrane methods for data extraction, risk of bias assessment, and evidence grading and synthesis. Searches were updated to January 24, 2018. RESULTS We identified 14,488 unique records and assessed 1,030 full texts for eligibility. We included 58 studies comprising a total of 1,180,096 participants and a median length of follow-up of 10 months. We found moderate-certainty evidence for consistent associations with decreases in SSB consumption or sales for the following interventions: traffic light labelling, price increases on SSB, in-store promotion of healthier beverages in supermarkets, government food benefit programs with incentives for purchasing fruits and vegetables and restrictions on SSB purchases, multi-component community campaigns focused on SSB, and interventions improving the availability of low-calorie beverages in the home environment. For the remaining interventions we found low- to very-low-certainty evidence for associations showing varying degrees of consistency. CONCLUSIONS With observed benefits outweighing observed harms, we suggest that environmental interventions to reduce the consumption of SSB be considered as part of a wider set of measures to improve population-level nutrition. Implementation should be accompanied by evaluations using appropriate methods. Future studies should examine population-level effects of interventions suitable for large-scale implementation, and interventions and settings not yet studied thoroughly

Adverse effects of non-steroidal anti-inflammatory drugs in patients with viral respiratory infections: rapid systematic review

Objectives: To assess the effects of non-steroidal anti-inflammatory drugs (NSAIDs) in patients with viral respiratory infections on acute severe adverse outcomes, healthcare utilisation, quality of life and long-term survival. Design: Rapid systematic review. Participants: Humans with viral respiratory infections, exposed to systemic NSAIDs. Primary outcomes: Acute severe adverse outcomes, healthcare utilisation, quality of life and long-term survival. Results: We screened 10 999 titles and abstracts and 738 full texts, including 87 studies. No studies addressed COVID-19, Severe Acute Respiratory Syndrome or Middle East Respiratory Syndrome; none examined inpatient healthcare utilisation, quality of life or long-term survival. Effects of NSAIDs on mortality and cardiovascular events in adults with viral respiratory infections are unclear (three observational studies; very low certainty). Children with empyema and gastrointestinal bleeding may be more likely to have taken NSAIDs than children without these conditions (two observational studies; very low certainty). In patients aged 3 years and older with acute respiratory infections, ibuprofen is associated with a higher rate of reconsultations with general practitioners than paracetamol (one randomised controlled trial (RCT); low certainty). The difference in death from all causes and hospitalisation for renal failure and anaphylaxis between children with fever receiving ibuprofen versus paracetamol is likely to be less than 1 per 10 000 (1 RCT; moderate/high certainty). Twenty-eight studies in adults and 42 studies in children report adverse event counts. Most report that no severe adverse events occurred. Due to methodological limitations of adverse event counts, this evidence should be interpreted with caution

Searching two or more databases decreased the risk of missing relevant studies: a metaresearch study

BACKGROUND AND OBJECTIVES: Assessing changes in coverage, recall, review, conclusions and references not found when searching fewer databases. METHODS: In randomly selected 60 Cochrane reviews, we checked included study publications' coverage (indexation) and recall (findability) using different search approaches with MEDLINE, Embase, and CENTRAL and related them to authors' conclusions and certainty. We assessed characteristics of unfound references. RESULTS: Overall 1989/2080 included references, were indexed in ≥1 database (coverage = 96%). In reviews where using one of our search approaches would not change conclusions and certainty (n = 44-54), median coverage and recall were highest (range 87.9%-100.0% and 78.2%-93.3%, respectively). Here, searching ≥2 databases reached >95% coverage and ≥87.9% recall. In reviews with unchanged conclusions but less certainty (n = 2-8): 63.3%-79.3% coverage and 45.0%-75.0% recall. In reviews with opposite conclusions (n = 1-3): 63.3%-96.6% and 52.1%-78.7%. In reviews where a conclusion was no longer possible (n = 3-7): 60.6%-86.0% and 20.0%-53.8%. The 265 references that were indexed but unfound were more often abstractless (30% vs. 11%) and older (28% vs. 17% published before 1991) than found references. CONCLUSION: Searching ≥2 databases improves coverage and recall and decreases the risk of missing eligible studies. If researchers suspect that relevant articles are difficult to find, supplementary search methods should be used

Unintended health and societal consequences of international travel measures during the COVID-19 pandemic: A scoping review

RATIONALE FOR REVIEW International travel measures to contain the COVID-19 pandemic represent a relatively intrusive form of non-pharmaceutical intervention. To inform decision-making on the (re)implementation, adaptation, relaxation or suspension of such measures, it is essential to not only assess their effectiveness but also their unintended effects. This scoping review maps existing empirical studies on the unintended consequences, both predicted and unforeseen, and beneficial or harmful, of international travel measures. We searched multiple health, non-health and COVID-19-specific databases. The evidence was charted in a map in relation to the study design, intervention and outcome categories identified and discussed narratively. KEY FINDINGS Twenty-three studies met our inclusion criteria-nine quasi-experimental, two observational, two mathematical modelling, six qualitative, and four mixed-methods studies. Studies addressed different population groups across various countries worldwide. Seven studies provided information on unintended consequences of the closure of national borders, six looked at international travel restrictions, and three investigated mandatory quarantine of international travelers. No studies looked at entry and/or exit screening at national borders exclusively, however six studies considered this intervention in combination with other international travel measures. In total, eleven studies assessed various combinations of the aforementioned interventions. The outcomes were mostly referred to by the authors as harmful. Fifteen studies identified a variety of economic consequences, six reported on aspects related to quality of life, well-being, and mental health, and five on social consequences. One study each provided information on equity, equality, and the fair distribution of benefits and burdens, environmental consequences and health system consequences. CONCLUSIONS/RECOMMENDATIONS This scoping review represents the first step towards a systematic assessment of the unintended benefits and harms of international travel measures during COVID-19. The key research gaps identified might be filled with targeted primary research, as well as the additional consideration of gray literature and non-empirical studies

Use of the GRADE approach in health policymaking and evaluation: a scoping review of nutrition and physical activity policies

BACKGROUND Nutrition and physical activity policies have the potential to influence lifestyle patterns and reduce the burden of non-communicable diseases. In the world of health-related guidelines, GRADE (Grading of Recommendations, Assessment, Development and Evaluation) is the most widely used approach for assessing the certainty of evidence and determining the strength of recommendations. Thus, it is relevant to explore its usefulness also in the process of nutrition and physical activity policymaking and evaluation. The purpose of this scoping review was (i) to generate an exemplary overview of documents using the GRADE approach in the process of nutrition and physical activity policymaking and evaluation, (ii) to find out how the GRADE approach has been applied, and (iii) to explore which facilitators of and barriers to the use of GRADE have been described on the basis of the identified documents. The overarching aim of this work is to work towards improving the process of evidence-informed policymaking in the areas of dietary behavior, physical activity, and sedentary behavior. METHODS A scoping review was conducted according to current reporting standards. MEDLINE via Ovid, the Cochrane Library, and Web of Science were systematically searched up until 4 July 2019. Documents describing a body of evidence which was assessed for the development or evaluation of a policy, including documents labeled as \textquotedblguidelines,\textquotedbl or systematic reviews used to inform policymaking were included. RESULTS Thirty-six documents were included. Overall, 313 GRADE certainty of evidence ratings were identified in systematic reviews and guidelines; the strength of recommendations/policies was assessed in four documents, and six documents mentioned facilitators or barriers for the use of GRADE. The major reported barrier was the initial low starting level of a body of evidence from non-randomized studies when assessing the certainty of evidence. CONCLUSION This scoping review found that the GRADE approach has been used for policy evaluations, in the evaluation of the effectiveness of policy-relevant interventions (policymaking), as well as in the development of guidelines intended to guide policymaking. Several areas for future research were identified to explore the use of GRADE in health policymaking and evaluation