Neighbourhoods for Ageing in Place

In their struggle to support growing numbers of community-dwelling older people with complex needs, western governments increasingly rely on ageing in place policies and engagement of the community. However, we remain relatively ignorant about the feasibility and implications of these policy imperatives. This thesis therefore sheds light on a) important neighbourhood characteristics that support ageing in place and b) the effects and processes of an integrated neighbourhood approach (INA) that aims to promote ageing in place. The findings demonstrate that both physical and social neighbourhood characteristics carry great significance for older people’s well-being and ability to age in place. This study further shows that the effectiveness of integrated neighbourhood approaches may be promoted by meso- and macro-level contexts that carefully anticipate needs for innovation and collaboration at the micro-level of care and support provision. Current policy aspirations also ask for careful consideration of normative and relational aspects of integrated care and support. This thesis will be of particular interest to those researching, practicing or governing innovative ways to support community-dwelling older people

How to build an integrated neighborhood approach to support community-dwelling older people?

Background: Although the need for integrated neighborhood approaches (INAs) is widely recognized, we lack insight into strategies like INA. We describe diverse Dutch INA partners’ experiences to provide integrated person- and population-centered support to community-dwelling older people using an adapted version of Valentijn and colleagues’ integrated care model. Our main objective was to explore the experiences with INA participation. We sought to increase our understanding of the challenges facing these partners and identify factors facilitating and inhibiting integration within and among multiple levels. Methods: Twenty-one interviews with INA partners (including local health and social care organizations, older people, municipal officers, and a health insurer) were conducted and subjected to latent content analysis. Results: This study showed that integrated care and support provision through an INA is a complex, dynamic process requiring multilevel alignment of activities. The INA achieved integration at the personal, service, and professional levels only occasionally. Micro-level bottom-up initiatives were not aligned with top-down incentives, forcing community workers to establish integration despite rather than because of meso- and macro-level contexts. Conclusions: Top-down incentives should be better aligned with bottom-up initiatives. This study further demonstrated the importance of community-level engagement in integrated care and support provision

Even Buurten: Een wijkgerichte aanpak voor thuiswonende ouderen in Rotterdam

__Abstract__ Door de dubbele vergrijzing en noodzaak van kostenbesparing in de zorg wordt steeds meer een appèl gedaan op ondersteuning van ouderen door informele netwerken. Vrijwel alle ouderen willen zo lang mogelijk zelfstandig blijven leven in hun eigen buurt. Een sterk ondersteunend netwerk is een belangrijke voorwaarde om dat doel te bereiken. In Rotterdam is sinds mei 2011 het project ‘Even Buurten’ actief waarin professionals uit zorg en welzijn via een integrale wijkaanpak proberen de sociale netwerken rondom thuiswonende ouderen te versterken. Dit met als doel om (vroeg)signalering mogelijk te maken en concrete hulp en ondersteuning te bieden aan kwetsbare ouderen. Uitgangspunt hierbij is de wens van de oudere zelf, wat hij of zij zelf nog kan doen, zonodig met ondersteuning uit het informele netwerk en –pas als dat niet voldoende blijkt te zijn– professionele ondersteuning. Onderzoekers van de Erasmus Universiteit Rotterdam (EUR), instituut Beleid en Management Gezondheidszorg (iBMG) evalueren het Even Buurten project onder leiding van Professor Anna Nieboer. Doel van deze rapportage over de tussentijdse bevindingen van de evaluatie is i) inzicht geven in de relaties tussen kenmerken van ouderen zoals, geslacht, opleidingsniveau, etnische achtergrond, kwetsbaarheid en welzijn en buurtkenmerken zoals sociale cohesie, veiligheid en kwaliteit van de buurt, ii) de behoeften van (kwetsbare) ouderen beschrijven als het gaat om hun fysieke en sociale omgeving, iii) inventariseren in hoeverre een integrale wijkaanpak als Even Buurten bijdraagt aan de kwaliteit van leven van kwetsbare ouderen, iv) nagaan wat de kosten en baten zijn van de inzet van spillen in de buurt, v) beschrijven wat de ervaringen van de spillen zijn in het Even Buurten project en vi) rapporteren welke barrières er zijn bij deze wijkgerichte aanpak

Effects of an integrated neighborhood approach on older people's (health-related) quality of life and well-being

Background: Integrated neighborhood approaches (INAs) are increasingly advocated to reinforce formal and informal community networks and support community-dwelling older people. They aim to augment older people's self-management abilities and engage informal networks before seeking professional support. INAs' effectiveness however remains unknown. We evaluated an INA's effects on older people's (health-related) quality of life (HRQoL) and well-being in Rotterdam. Methods: We used a matched quasi-experimental design comparing INA with "usual" care and support. Community-dwelling frail older (70+ years) people and frailty- and gender-matched control subjects (n = 186 each) were followed over a 1-year period (measurements at baseline and 6 and 12 months). Primary outcomes were HRQoL (EQ-5D-3L, SF-20) and well-being [social production function instrument for the level of well-being (SPF-IL)]. The effect of INA was analysed using an "intention to treat" and an "as treated" approach. Results: The results indicated that pre-intervention participants had lower incomes and were significantly older, more often single, less educated and more likely to have ≥1 disease than control subjects; they had lower well-being, physical functioning, role functioning, and mental health. Generalized linear mixed modelling of repeated measurements revealed no substantial difference in well-being or HRQoL between the intervention and control group after 1 year. The small differences we did find in the intention to treat group though were in favour of the control subjects (SF-20 = 6.98, 95 % confidence interval [CI] = 2.45-11.52; SPF-IL =.09, 95 % CI =.01-.17). However, the difference in well-being (SPF-IL) disappeared in the as treated analysis. Conclusions: The lack of effects of INA highlights the complexity of integrated care and support initiatives. Barriers associated with meeting the complex, varied needs of frail older people, and those related to dynamic political and social climates challenge initiative effectiveness. Trial registration The research was supported with a grant provided by the Netherlands Organisation for Health Research and Development (ZonMw, project number 314030201) as part of the National Care for the Elderly Programme

Even Buurten: De complexiteit van een wijkgerichte aanpak

De inzet van een integrale wijkaanpak wordt steeds vaker aanbevolen als middel om een ondersteunend klimaat te bieden aan het groeiend aantal zelfstandig wonende ouderen met een (complexe) hulpvraag. Binnen een integrale wijkaanpak werken de gemeente(n), zorg- en welzijnsorganisaties en informele zorgverleners samen om de beschikbare zorg in de wijk te coördineren zodat beter kan worden ingespeeld op de specifieke behoeften van de kwetsbare ouderen. Hoewel een integrale wijkaanpak steeds vaker wordt aangeprezen als middel om zelfstandigwonende ouderen te onde

Belang van ondersteunende netwerken voor ouderen

__Abstract__ ‘Even Buurten’ is een Rotterdams initiatief. Hierin proberen professionals uit zorg en welzijn via een integrale wijkaanpak de sociale netwerken rondom thuiswonende ouderen te verstevigen. Doel van dit sociale netwerk is (vroeg) signalering en het bieden van concrete hulp en ondersteuning aan kwetsbare ouderen. Uit onderzoek naar het ‘Even Buurten’-initiatief komt het belang van een sterk sociaal buurtnetwerk duidelijk naar voren. Het succes van een integrale wijkaanpak hangt in sterke mate af van een integraal formeel e´n informeel ondersteunend netwerk in de buurt. Formele en informele netwerken werken echter nog niet goed samen. En ook binnen het formele netwerk (bijv. tussen zorg en welzijn) wordt nog onvoldoende samengewerkt om kwetsbare ouderen optimale ondersteuning te bieden. Deze klinische les beschrijft hoe integrale, wijkgerichte ondersteuning beter tegemoetkomt aan de behoeften en wensen van kwetsbare ouderen

Views of professionals and volunteers in palliative care on patient-centred care: A Q-methodology study in the Netherlands

Background: Patients with palliative care needs, require support with their physical needs, but also with their emotional, spiritual and social needs. Patient-Centred Care (PCC) may help organizations to support these patients according to their needs and so improve the quality of care. PCC has been shown to consist of eight dimensions, including for instance access to care and continuity of care, but these eight dimensions may not be equally important in all care settings and to all patients. Furthermore, the views of those involved in care provision may affect the choices they make concerning care and support to patients. Therefore, insight into how professionals and volunteers involved in palliative care delivery view PCC is important for understanding and improving the quality of care in the palliative sector. Methods: This study was conducted in the palliative care setting (hospices and hospitals) in the Netherlands. Views on palliative care were investigated using the Q-methodology. Participants were asked to rank 35 statements that represented the eight dimensions of PCC in palliative care settings, and to explain their ranking during a follow-up interview. Ranking data were analysed using by-person factor analysis. Interview materials were used to help interpret the resulting factors. Results: The analysis revealed two distinct viewpoints on PCC in palliative care: 'The patient in the driver seat', particularly emphasizing the importance of patient autonomy during the last phase of life, and 'The patient in the passenger seat', focussed on the value of coordination between professionals, volunteers and patients. Conclusions: The most distinguishing aspect between views on PCC in palliative care concerned control; a preference for the patient in the driver's seat versus shared decision-making by a team consisti

To vaccinate or not to vaccinate? Perspectives on HPV vaccination among girls, boys, and parents in the Netherlands: A Q-methodological study

Background: Despite the introduction of Human papillomavirus (HPV) vaccination in national immunization programs (NIPs), vaccination rates in most countries remain relatively low. An understanding of the reasons underlying decisions about whether to vaccinate is essential in order to promote wider spread of HPV vaccination. This is particularly important in relation to policies seeking to address shortfalls in current HPV campaigns. The aim of this study was to explore prevailing perspectives concerning HPV vaccination among girls, boys, and parents, and so to identify potential determinants of HPV vaccination decisions in these groups. Method: Perspectives were explored using Q-methodology. Forty-seven girls, 39 boys, and 107 parents in the Netherlands were asked to rank a comprehensive set of 35 statements, assembled based on the health belief model (HBM), according to their agreement with them. By-person factor analysis was used to identify common patterns in these rankings, which were interpreted as perspectives on HPV vaccination. These perspectives were further interpreted and described using data collected with interviews and open-ended questions. Results: The analysis revealed four perspectives: "prevention is better than cure," "fear of unknown side effects," "lack of information and awareness," and "my body, my choice." The first two perspectives and corresponding determinants of HPV vaccination decisions were coherent and distinct; the third and fourth perspectives were more ambiguous and, to some extent, incoherent, involving doubt and lack of awareness and information (perspective 3), and overconfidence (perspective 4). Conclusions: Given the aim of publically funded vaccination programs to minimize the spread of HPV infection and HPV-related disease and the concerns about current uptake levels, our results indicate that focus should be placed on increasing awareness and knowledge, in particular among those in a modifiable phase

The Natural Sequence in Which Subclinical Inflamed Joint Tissues Subside or Progress to Rheumatoid Arthritis:A Study of Serial MRIs in the TREAT EARLIER Trial

Objective: The natural trajectory of clinical arthritis progression at the tissue level remains elusive. We hypothesized that subclinical inflammation in different joint tissues (synovitis, tenosynovitis, osteitis) increases in a distinct temporal order in patients with clinically suspect arthralgia (CSA) who develop rheumatoid arthritis (RA) and subsides in a different sequence when CSA spontaneously resolves. Methods: We studied 185 serial magnetic resonance images (MRIs) from CSA patients with subclinical joint inflammation from the placebo arm of the TREAT EARLIER trial: 52 MRIs from 21 RA progressors (MRIs conducted at 1 year before, at 4 months before, and upon RA development), and 133 MRIs from 35 patients with spontaneous resolution of pain (MRIs conducted at baseline and at 4, 12, and 24 months). MRIs were scored for osteitis, synovitis, and tenosynovitis. We used cross-lagged models to evaluate 2 types of time patterns between pairs of inflamed tissues: a simultaneous pattern (coinciding changes) and a subsequent pattern (inflammatory changes in 1 tissue preceding changes in another tissue). Results:In patients who developed RA, synovitis, tenosynovitis, and osteitis increased simultaneously. Increasing osteitis occurred in the final 4 months before RA diagnosis, following incremental tenosynovitis and synovitis changes during the 1 year to 4 months before diagnosis (P &lt; 0.01). In anti–citrullinated protein antibody (ACPA)-positive and ACPA-negative patients who progressed to RA, osteitis increased just before RA development. In patients with pain resolution, simultaneous decreases in synovitis, tenosynovitis, and osteitis occurred, with tenosynovitis decreasing in the first 4 months after CSA onset preceding decreasing synovitis and osteitis during 4–12 months (P = 0.02 and P &lt; 0.01). Conclusion:We identified natural sequences of subclinical inflammation in different joint tissues, which deepens our understanding of clinical arthritis and RA development. During RA progression, increasing osteitis followed previous increases in tenosynovitis and synovitis. During pain resolution, tenosynovitis decreased first, followed by decreasing synovitis and osteitis.</p

Interosseous tendon inflammation in the hands of patients with clinically suspect arthralgia:analysis of MRI data from a prospective cohort study

Background: Inflammation around the tendons of interosseous muscles of the hand (interosseous tendon inflammation) was recently observed with MRI for the first time in patients with rheumatoid arthritis and in at-risk individuals with detectable anti-citrullinated protein antibodies, generating the hypothesis that interosseous tendon inflammation precedes clinical arthritis. To better understand the role of interosseous tendon inflammation during the development of rheumatoid arthritis, we studied the frequency of interosseous tendon inflammation in healthy individuals and in those with arthralgia that was suspected of progressing to rheumatoid arthritis (ie, clinically suspect arthralgia) and the association of interosseous tendon inflammation with other symptoms of inflamed joint tissues and with clinical arthritis development. Methods: Adult (age ≥18 years) patients who presented with clinically suspect arthralgia and symptom-free (control) individuals underwent contrast-enhanced hand MRI. MRIs were evaluated for interosseous tendon inflammation on the radial and ulnar sides of the second to fifth metacarpophalangeal joints, and for synovitis, tenosynovitis, and osteitis using the rheumatoid arthritis MRI scoring system. Patients with clinically suspect arthralgia were followed up for clinical arthritis development. The presence of local tenosynovium was examined using immunohistochemistry for anti-CD55 and anti-CD68 on tissue from the hands of three embalmed bodies donated for scientific research. The primary outcome for the cross-sectional part of the study was the presence of interosseous tendon inflammation on MRI. The primary outcome for the longitudinal part of the study was development of clinical arthritis. Findings: Between April 3, 2012, and May 20, 2020, 667 patients with clinically suspect arthralgia (mean age 44 years [SD 13], 504 [76%] were women and 163 [24%] were men) underwent contrast-enhanced hand MRI. Between Nov 1, 2013, and Nov 30, 2014, 193 symptom-free controls were recruited (mean age 50 years [SD 16], 136 [70%] were women and 57 [30%] were men). Two (1%) of 193 symptom-free controls had interosseous tendon inflammation. Immunohistochemistry of cadaveric hand tissues showed no tenosynovium surrounding interosseous tendons. At inclusion, 67 (10%) of 667 patients with clinically suspect arthralgia had interosseous tendon inflammation (p&lt;0·0001 vs symptom-free controls). Interosseous tendon inflammation occurred more frequently if synovitis (odds ratio [OR] 2·2 [95% CI 1·2–4·2]), or tenosynovitis (OR 9·7 [5·5–17·0]), was present at metacarpophalangeal joints. A three-dimensional MRI reconstruction suggested confluency of interosseous tendon inflammation with metacarpophalangeal-flexor-tenosynovitis. 91 (16%) of 558 patients with clinically suspect arthralgia developed clinical arthritis during follow-up (median total follow-up 25·3 months [95% CI 25·1–25·5]). Patients with clinically suspect arthralgia with interosseous tendon inflammation had a higher risk of developing clinical arthritis (hazard ratio [HR] 4·5 [2·8–7·2]), which was attenuated but still significant after adjusting for concomitant synovitis, tenosynovitis, or osteitis (HR 1·7 [1·02–2·8]). Interpretation: Interosseous tendon inflammation is almost absent in symptom-free individuals but occurs in people with clinically suspect arthralgia, in whom it correlates with symptoms and is associated with the development of clinical arthritis. The absence of local tenosynovium suggests that interosseous tendon inflammation arises from expanding local subclinical inflammation in the pre-arthritis phase of rheumatoid arthritis. Funding: European Research Council and the Dutch Arthritis Society.</p