Evaluation design of Urban Health Centres Europe (UHCE): preventive integrated health and social care for community-dwelling older persons in five European cities

Both general outcome health measures and specific outcome health measures applicable to each care pathway are applied: healthy life styles, fall risk, appropriate medication use, loneliness, frailty, level of independence and health-related quality of life. Healthy life style is measured with one item on physical activity, two items on smoking, and three items of the AUDIT-C [32] on high-risk alcohol use. Fall risk is measured by two items on (the number of) falls in the previous year, a single item asking whether or not the person is afraid of falling, and fear of falling while performing several daily activities as measured by the 7-item Falls Efficacy Scale International (FES-I) short version [33]. Appropriate medication use is measured with 10 items of the Medication risk questionnaire (MRQ-10) [23], a tool developed for use by older persons to identify who is at increased risk of potentially experiencing a medication-related problem. Loneliness is measured with the short 6-item version of the Jong Gierveld loneliness scale [34], which measures the degree of what one wants and what one has in terms of interpersonal affection and intimacy. Frailty is measured with the 15-item Tilburg Frailty indicator [24, 25], that includes questions on physical, psychological and social components of frailty. Physical frailty is additionally measured with the SHARE-Frailty instrument which is an instrument that was developed and validated in a European population [35, 36], SHARE-frailty includes hand-grip strength measurement, and physical frailty is also measured with a measurement of the mid-upper arm circumference [37], a measure for malnutrition. Level of independence is measured with the Groningen activity restriction scale [38], that includes 18 items on independence of activities of daily living (ADL) and instrumental activities of daily living (IADL) and additionally with the one-item Global Activity Limitation Index (GALI) [39, 40]. Health-related quality of life is measured with the 12-item short-form (SF-12) [41, 42] and the full 5-item mental health scale of the SF-36 [43].

Additionally to health measures, use of care is measured with four questions regarding the use of doctor appointments, household work, help caring (such as washing or dressing) and hospital admissions.

Various socio-demographic characteristics are measured: age, gender, country of birth, educational level, income, marital status, employment situation, household composition and religion. Additionally, several questions on the participant’s general health are asked: self-reported height and weight, use of walking or other aids, whether they ever have been diagnosed with any of fifteen listed health conditions. Any additional remarks can be left in an open box at the end of the questionnaire.

This process element aims at measuring the proportion of the intended target population that is reached by the care approach. In UHCE we calculate which proportion of the participants that we contacted participate in the UHCE approach. If possible reasons for refusal are reported.

Dose delivered measures whether the anticipated care is offered to the participant and dose received measures the extent in which participants actively engage in the care that is offered. For this purpose, data on the delivery of the UHCE approach and reasons for non-participation in care are recorded by the care coordinator. A 1-page logbook is kept for each participant that includes the different stages of the UHCE approach: 1. assessment, 2 shared decision making, and 3. care pathways and monitoring. At least after 6 months, the care coordinator records (if needed telephone contact with the participant or responsible health care provider is sought) whether key elements of the UHCE approach are delivered. In case of loss to follow- up at the T1 measurement, reasons are recorded by the research staff, given they are provided by the participant.

We aim to measure the extent to which the UHCE approach is implemented as planned (fidelity) and the satisfaction of main stakeholders with the UHCE approach. In the T1 questionnaire, three items measure the general satisfaction with professional, social and self-care in the past 12 months, 4 items measure the satisfaction with specific UHCE elements (assessment, shared-decision making and care-pathways) and a final question rates the whole UHCE approach on a scale from 1 to 10. To gain more in-depth knowledge on how the UHCE approach is carried out and which barriers are encountered, focus groups and semi-structured interviews with older persons, caregivers, and social and health professionals involved in UHCE are held 12 months after inclusion of the last group of participants. In each city we organize 1 focus group with 6–8 older persons and caregivers (e.g. family, friends) and 1 group with 6–8 social and health care professionals. All professionals involved with UHCE are invited to participate in the focus groups. The focus group discussions are recorded and translated in English.

As the UHCE approach is implemented in five diverse settings its’ success depends on the context in which it is implemented. With the use of structured forms we make an inventory of relevant contextual factors of each city in which the UHCE approach is embedded; type and experience of health staff, setting, resources and interventions available or newly developed.