This thesis starts with a literature review on the observation of aggression, then describes the development and implementation of an Observation Checklist in 2 Dutch Juvenile Justice Institutions ... Show moreThis thesis starts with a literature review on the observation of aggression, then describes the development and implementation of an Observation Checklist in 2 Dutch Juvenile Justice Institutions (JJI) and concludes with two papers researching the added value of data harvested with this tool, both for risk assessment and cultural sensitive assessment. Show less
Epileptic seizures are associated with changes in autonomic function. Ictal asystole, when it leads to syncope, can cause severe traumatic falls. We discovered a new indirect method, based on video... Show moreEpileptic seizures are associated with changes in autonomic function. Ictal asystole, when it leads to syncope, can cause severe traumatic falls. We discovered a new indirect method, based on video, EEG and ECG, to disentangle if vasodilatation was the dominant mechanism behind the syncope. In this group of patients, pacemaker implantation is less helpful. Autonomic manifestations of epilepsy can also help to detect seizures. Our literature review discovered that combining different modalities in one detection device provides higher sensitivity, and personalization of detection algorithms can decrease false alarm rate. We validated a wearable multimodal detection system (NightWatch) on children at home. NightWatch showed high sensitivity for the detection of potentially dangerous nocturnal seizures, reduces caregiver stress and saved costs from a societal perspective. Validation of an automated video detection system showed that this could provide a good alternative for children who cannot tolerate a wearable device.From different qualitative user studies, we concluded that caregivers’ needs for seizure detection vary greatly. Also, the success of device implementation is highly dependent on the protective behavior parents developed towards their child with epilepsy. This emphasizes the importance of tailored and user-centered approaches for seizure detection. Show less
Physical Activity (PA) is one of the most important lifestyle factors influencing human health. The general and disease-specific health benefits of PA are well known to the general population and... Show morePhysical Activity (PA) is one of the most important lifestyle factors influencing human health. The general and disease-specific health benefits of PA are well known to the general population and to those people living with rheumatic musculoskeletal diseases (RMDs). The importance of PA as an intervention for the management of RMDs has been endorsed by various stakeholders, e.g. the World Health Organisation and the European Alliance of Associations for Rheumatology/EULAR. The early translation of research evidence into clinical care benefits patients with RMDs greatly.This thesis is focused on the effects and promotion of PA and exercise on people with RMDs, and particularly those with axial Spondyloarthritis (axSpA).The overall aim of this thesis was to document the journey from the development of the EULAR PA recommendations for people with RMDs (including axSpA) to the practical implementation of a concept for group exercise therapy for people with axSpA living in Switzerland that conforms to these recommendations. Show less
Nursing participation in how new working methods for nurses are introduced on the ICU is thought to improve patient outcomes and the autonomy of the nurses. Hard evidence by direct comparison in... Show moreNursing participation in how new working methods for nurses are introduced on the ICU is thought to improve patient outcomes and the autonomy of the nurses. Hard evidence by direct comparison in the presence or absence of IC-nursing participation is not available. The ICU of the St Antonius Hospital offered this opportunity of an experimental and a control group with a minimal chance of mutual influence between the groups. We investigated the differences in care using two different implementation methods: a) a method which does not allow participation in implementation decisions and b) a method which does allow participation. The result differences between the groups show that participation of nurses in the implementation resulted in better patient outcomes and more nursing compliance. It also resulted in more professional clinical autonomy, changes in the personal orientation of nurses towards their activities and in their personal norms and values. The differences suggest that participation led to changing of the protocol while the goals of the protocol were adhered to. The increase in professional clinical autonomy, not connected to the innovation suggests that taking part of the participation was more important than the participation actions. Show less
Chronic respiratory disease (CRD) is a silent, ongoing pandemic. It disproportionally affects low-resource settings. Tobacco smoke and kitchen smoke (caused by the use of solid fuels and... Show moreChronic respiratory disease (CRD) is a silent, ongoing pandemic. It disproportionally affects low-resource settings. Tobacco smoke and kitchen smoke (caused by the use of solid fuels and inefficient stoves) are major risk factors. Evidence-based solutions to CRD often fail to be effective, as they misalign with local needs and then fail to be implemented. This thesis focused on how lung health solutions can be implemented successfully by capitalising on the local needs.Within the Horizon2020 FRESH AIR implementation research project, we first studied local settings in Kyrgyzstan, Uganda, Greece, and Vietnam. For example, we found that COPD in the highlands of Kyrgyzstan occurred three times more frequently than in the lowlands, partly due to higher levels of kitchen smoke. We discovered the high indirect burden of asthma and COPD, by their impact on work- and daily activities. We also found that many communities and their health workers mistook CRD for infectious disease like tuberculosis. Based on these findings and on implementation literature, we then designed several practical tools addressing critical factors for implementation success of lung health interventions. These evidence-based tools can facilitate implementation success, thereby optimising the use of already scarce resources and benefitting health outcomes. Show less
Physical activity is effective in preventing and treating many of these age-related diseases. However, two thirds of Dutch older adults do not reach the recommended level of physical activity.... Show morePhysical activity is effective in preventing and treating many of these age-related diseases. However, two thirds of Dutch older adults do not reach the recommended level of physical activity. Current efforts to increase physical activity with professional led physical activity interventions are effective during the intervention period, but do not manage to have a sustainable effect. In this thesis we studied the possibility of peer coaching to sustainably increase physical activity in older adults. We do this by studying the effectiveness, implementation and organization of peer coach physical activity intervention. The conclusion of this thesis is that older adults can effectively and sustainably increase physical activity of older adults through peer coach physical activity interventions. After a small investment for implementation, a sustainable self-organising exercise intervention can be created which exist for years. The reach of the groups can be increased through an exercise referral scheme in primary care, but the effectivity needs to be improved through research. Nationwide implementation of exercise groups for older adults is possible, but it requires effort from a large (governmental) party. Show less
Stroke is a relatively common condition with a large impact on patients’ lives. Rehabilitation treatment aims to support patients in coping with the physical, mental, cognitive and social... Show moreStroke is a relatively common condition with a large impact on patients’ lives. Rehabilitation treatment aims to support patients in coping with the physical, mental, cognitive and social consequences of stroke. Recently, there is an increasing interest in the application of digital technologies (eRehabilitation) in healthcare in general, including in stroke rehabilitation. ERehabilitation may include physical and cognitive exercise programs, patient information and education, e-consultations, physical activity tracking and serious gaming, preferably all together in one digital environment.Although there is evidence on the effectiveness and feasibility of eRehabilitation, the uptake of eRehabilitation in specialized stroke rehabilitation facilities has been slow, warranting the need for implementation research. The aim of this thesis was to provide insight in the complex interplay between the effectiveness, the implementation strategy and the context of eRehabilitation after stroke, as delivered in a specialized rehabilitation facility, in order to improve future use of eRehabilitation in specialized stroke rehabilitation facilities. Show less
The aim of this dissertation is to enhance understanding of care use by children known to have or be at risk of complex problems (CP). Children with CP have a greater need for health services than... Show moreThe aim of this dissertation is to enhance understanding of care use by children known to have or be at risk of complex problems (CP). Children with CP have a greater need for health services than the average child because their chronic physical, behavioral or emotional conditions interact and enhance their vulnerability. Worldwide, around 5% of children suffer from complex problems. They typically have high levels of care consumption, especially psychosocial care.In our studies we address factors impacting care use of children with CP, its intensity, and barriers to care. We found several risk factors for identification of these children: child’s age, adverse life events, child’s psychosocial problems, and parenting concerns. We also look at care use of multiproblem families, involving a subgroup of these children with the highest level of CP. Finally, we studied professionals to understand the challenges they meet in organizing care for these children when using Wraparound Care. This care-coordination method is used in the Netherlands as the backbone of treatment for children with CP. Further development of Wraparound Care and greater understanding of the factors impacting care use by children with CP will help to make their pathway to care more efficient and effective. Show less
Pharmacogenomics (PGx) utilizes an individual’s germline genetic profile to identify those who are at higher risk for ADRs or lack of efficacy. This information can be used by healthcare... Show morePharmacogenomics (PGx) utilizes an individual’s germline genetic profile to identify those who are at higher risk for ADRs or lack of efficacy. This information can be used by healthcare professionals (HCPs) to guide dose and drug selection before drug initiation in an effort to optimize drug therapy through precision medicine. Despite both the promise of and the progress in the field of PGx to achieve precision medicine, it is still not routinely applied in patient care. As such, a number of barriers preventing implementation have been identified. These include the undetermined model for delivering PGx, the lack of evidence supporting a PGx panel approach and the lack of tools supporting implementation. Therefore, the work of this thesis aims to support the implementation of precision medicine using PGx panel testing. It reports on generating evidence for PGx panel testing (Part I) and the development of tools facilitating implementation (Part II), evaluates the implementation process utilizing these tools (Part III) and quantifies the impact of PGx implementation on patient outcomes and cost-effectiveness (Part IV). Show less
With the issuing of guidance documents the European Commission assists the Member States in the implementation of Union law. This thesis seeks to unravel the process of governance through guidance... Show moreWith the issuing of guidance documents the European Commission assists the Member States in the implementation of Union law. This thesis seeks to unravel the process of governance through guidance by tracing its role and legal implications in the Dutch legal order.The first part explores the use of guidance documents by Dutch authorities and courts. Along the lines of five types of guidance and four perspectives on their binding force, different roles of guidance are discerned. National courts act as counterbalancing or facilitating actors by reinforcing or downplaying the role of guidance documents in implementation processes.The second part assesses the implications in the light of legal principles. To this end, it formulates four ‘promises’, or ideal effects, that outline how the use of guidance documents could contribute to a predictable, consistent and transparent implementation process, whilst respecting the rule of EU hard law. The analysis finds that, in practice, these ‘promises of guidance’ are not always fulfilled: a gap between promise and practice exists.The findings thus show how the issuing and use of guidance risks to challenge the rule of law that is so fundamental to the EU legal order. This thesis therefore invites to rethink governance through guidance. Show less
The aim of this thesis is to investigate the adoption of PGx and the integration of genotype guided dosing in the workflow of physicians and pharmacists in primary care. This thesis is divided into... Show moreThe aim of this thesis is to investigate the adoption of PGx and the integration of genotype guided dosing in the workflow of physicians and pharmacists in primary care. This thesis is divided into five parts. The first part provides an overview of answers to frequently asked questions by clinicians related to the implementation of PGx. The second part of this covers investigates whether genotype guided dosing in primary care is feasible in a pilot study where 200 patients with an incident prescription for a subset of 10 drugs and historical use are genotyped in a panel based approach for 8 pharmacogenes and received genotype guided dosing based on recommendations of the DPWG guidelines and covers an assessment of the clinical impact of PGx in primary care in the Netherlands is provided to predict how many patients that start with a drug currently described in the guidelines of the DPWG require an optimization of therapy. Part III covers the harmonization of PGx-test interpretation and therapeutic recommendations. Part IV investigates the knowledge, experience and attitudes towards PGx among (future) healthcare professionals. The thesis is concluded with a general discussion. Show less
Care for older persons is changing. A new primary health care concept is called ‘person-centred, integrated care’ involving changing roles for General Practitioners (GPs) and other... Show moreCare for older persons is changing. A new primary health care concept is called ‘person-centred, integrated care’ involving changing roles for General Practitioners (GPs) and other professionals. The inclusion of the personal values of the patients in the changing care is essential but vulnerable. This thesis links the process of innovating care and the values of the older persons involved, by studying patient satisfaction as an expression of personal value in two care innovation and implementation projects. Key findings are: The level of patient satisfaction is related to complexity of health problems and is related more to the care organization than to the condition of the patient. Modifiable communicative aspects of GP behavior are related to patient satisfaction. Patients and GPs, show different satisfaction about aspects of care reflecting different values. In a real-life implementation strategy, patient satisfaction and engagement is feasible and valuable. Conclusions are that patient satisfaction can be used in innovating care but must be interpreted with caution. Also older patients need a role in the implementation process in order to assure that their values are expressed in the care innovation. A combination of individual shared decision making, satisfaction investigation and procedural engagement is proposed. Show less
International law relies heavily on the machinery of the state for therealisation of its aims. Often those aims require further implementation inthe legal orders of states. States, in turn, enjoy a... Show moreInternational law relies heavily on the machinery of the state for therealisation of its aims. Often those aims require further implementation inthe legal orders of states. States, in turn, enjoy a wide margin of freedom inthe choice of means and methods to fulfil their obligations under internationallaw. However, implementation sometimes requires the involvement ofthe state body entrusted with the task of adopting legislation: the nationallegislature. This study explores its role in the implementation of internationallaw at home. It analyses the regulation of national implementing legislationunder international law. Does international law provide for requirements tobe observed by national legislatures involved in the adoption of implementinglegislation? If so, is their application in practice sufficient to ensure thequality of national implementing legislation? Can we improve national andinternational practice in this regard? Show less
Childhood obesity remains a major public health concern. To successfully address the childhood obesity epidemic, intersectoral community interventions that take into account the multifactorial... Show moreChildhood obesity remains a major public health concern. To successfully address the childhood obesity epidemic, intersectoral community interventions that take into account the multifactorial aetiology of childhood obesity are needed. However, the implementation of such interventions has proved to be difficult and prone to error. This thesis therefore examines the implementation process of five EPODE-derived intersectoral community approaches targeting childhood obesity in the Netherlands. It focuses on both the level of implementation and determinants of implementation. Quantitative as well as qualitative methods are used, next to novel “in-between” methods such as Quantitative Comparative Analysis and Social Network Analysis. Recommendations are provided on how to design strategies to improve the implementation of intersectoral community approaches, and suggestion for future research initiatives are made. Show less
This dissertation looks into the role of discretion granted by EU directives in EU legislative decision-making and national transposition processes. It applies a qualitative single country-study,... Show moreThis dissertation looks into the role of discretion granted by EU directives in EU legislative decision-making and national transposition processes. It applies a qualitative single country-study, focusing on the transposition of six directives in the Netherlands, from the policy areas of consumer protection, environment and justice and home affairs (migration). In the theoretical part the concept of discretion is explored, using insights from both the legal and political sciences. The empirical analysis then presents both EU and national processes regarding the six directives, addressed individually as well as in a comparative manner. This study contributes to clarifying the reasons and circumstances regarding the granting of different margins of discretion to Member States and the effects of discretion on EU negotiations and national transposition. It confirms that discretion can have facilitating and impeding effects on transposition, explains why, and identifies other factors affecting transposition by interacting with discretion. Additionally, a more fine-grained approach to measuring discretion is proposed than hitherto. Finally, but addressed separately from the empirical analysis, the link between discretion and legitimacy is elaborated. It is argued that discretion in national transposition processes can be used to enhance the directives’ input, throughput and output legitimacy within national law. Show less
This thesis aimed to contribute to the optimal use of non-surgical treatment and timing of surgery among hip and knee OA and sciatica patients in two different ways. First, if guidelines are... Show moreThis thesis aimed to contribute to the optimal use of non-surgical treatment and timing of surgery among hip and knee OA and sciatica patients in two different ways. First, if guidelines are specific on non-surgical and (timing of) surgical treatment, the focus was on implementation strategies to improve guideline uptake in hip and knee OA and sciatica care. Across the different studies carried out in this thesis, knowledge, attitude of health care providers and organization of care seem to be relevant for any implementation of evidence based guideline recommendations in a multidisciplinary setting. Future implementation studies can start focusing on these topics. However, if guidelines are not available or not specific on e.g. optimal timing of total hip or knee arthroplasty (THA/TKA), additional evidence is needed. Therefore, the second part of this thesis focused on studying criteria and determinants to reach the best possible outcomes after THA and TKA, as information in the literature is lacking on optimal timing of surgery. Pooling multiple cohort studies in the Netherlands showed that preoperative status is the most important variable for outcome after both THA and TKA, i.e. patients with better preoperative quality of life, functioning and less pain had better postoperative outcomes. Show less
In this thesis we focussed on so-called 'treat to target' therapy in rheumatoid arthritis (RA). Treat to target relies on repetitive measurements of disease activity using a composite score that... Show moreIn this thesis we focussed on so-called 'treat to target' therapy in rheumatoid arthritis (RA). Treat to target relies on repetitive measurements of disease activity using a composite score that incorporates signs of disease activity such as laboratory results, findings of physical joint assessments, and the opinion of the patient. It is recommended that rheumatologists intensify treatment when a predefined level of disease activity, the target, has not yet been achieved. The implementation of treatment to target in daily practice depends on the faith of the rheumatologist and the patient to rely on a disease activity composite index (for instance the DAS) rather than on some judgemental estimate of disease activity ('the patient is doing well'). It also relies on a consensual opinion that a pre-set treatment target (for instance a DAS=>1.6) meaning clinical remission) is a desirable as well as an achievable target, and especially on the willingness to intensify medication every time the treatment target has not been achieved. Several aspects of treat to target, in particular a plea for the improvement of the rheumatologists' awareness about and the implementation of treat to target recommendations in daily clinical practice, are discussed in the thesis Show less
Tobacco control has been identified as the most urgent and immediate priority intervention to reduce the prevalence of non-communicable disease. Nevertheless, a substantial gap exists between the... Show moreTobacco control has been identified as the most urgent and immediate priority intervention to reduce the prevalence of non-communicable disease. Nevertheless, a substantial gap exists between the evidence-based knowledge on the treatment of tobacco dependence and real-world practices of primary care professionals. The empirical studies in this dissertation provided insight in a variety of methodological approaches that can be used to describe and facilitate the implementation of smoking cessation care in general practice. This resulted in study findings showing that a training programme for GPs including action planning has the potential to facilitate the implementation of smoking cessation care, in particular the degree to which smokers are identified and advised to quit. In addition, full health insurance coverage of stop-smoking programmes increased GP prescription behaviour. Yet, challenges remain to incorporate smoking cessation care as a routine procedure in general practice, with a special focus on arranging follow-up support by GPs. This dissertation provided several new ideas for future research in order to overcome these challenges. Multifaceted strategies, based on a socio-ecological approach to guideline implementation and including behavioural change theories, have the potential to facilitate a successful implementation of smoking cessation care in general practice. Show less
The dissertation examines the application of EU farm animal welfare legislation in 27 member states. It develops a theoretical framework that applies insights from the transposition literature to... Show moreThe dissertation examines the application of EU farm animal welfare legislation in 27 member states. It develops a theoretical framework that applies insights from the transposition literature to the post-transposition phase of implementation and derives hypotheses to explain cross-national variation in implementation success. The hypotheses are centered on the notion that the pressure to adapt to EU requirements makes post-transposition application difficult. Countering adaptation pressure, the presence of discretion, whereby member states have some flexibility to adapt requirements to their national circumstances, helps to alleviate the difficulties brought on by adaptation pressure. Additional hypotheses are derived from the transposition literature concerning the geographic and organizational decentralization of implementation authority and the length of transposition delay prior to application. The hypotheses are tested through a mixed methods design that combines a set of case studies and a quantitative analysis of the implementation of all major requirements applied in 27 member states in the legislation within this policy area. Support is found for the adaptation pressure and discretion hypotheses, while limited support is found for the hypotheses concerning the decentralization of implementation authority Show less
Despite the promising findings related to the efficacy of primary health care-based physical activity interventions and recommendations for primary health care professionals to promote physical... Show moreDespite the promising findings related to the efficacy of primary health care-based physical activity interventions and recommendations for primary health care professionals to promote physical activity, the introduction of physical activity interventions in routine daily primary health care practice does not always happen as desired. Specifically, rates of physical activity promotion by primary health care professionals are far from optimal and physical activity interventions are not delivered as intended by the intervention developers. Knowledge of the factors that determine the success or failure of the introduction of innovations in health care is important for the development of strategies to improve the introduction process. As a first step towards the effective introduction of physical activity interventions in primary health care practice, the main aim of this thesis is to investigate what factors influence the introduction of physical activity interventions in primary health care. Show less
