Expert Panel Research Articles

Face and content validity of the EMPOWER-UP questionnaire: a generic measure of empowerment in relational decision-making and problem-solving

BackgroundDecision-making and problem-solving processes are powerful activities occurring daily across all healthcare settings. Their empowering potential is seldom fully exploited, and they may even be perceived as disempowering. We developed the EMPOWER-UP questionnaire to enable assessment of healthcare users’ perception of empowerment across health conditions, healthcare settings, and healthcare providers’ professional backgrounds. This article reports the initial development of EMPOWER-UP, including face and content validation.MethodsFour grounded theories explaining barriers and enablers to empowerment in relational decision-making and problem-solving were reviewed to generate a preliminary item pool, which was subsequently reduced using constant comparison. Preliminary items were evaluated for face and content validity using an expert panel of seven researchers and cognitive interviews in Danish and English with 29 adults diagnosed with diabetes, cancer, or schizophrenia.ResultsA preliminary pool of 139 items was reduced to 46. Independent feedback from expert panel members resulted in further item reduction and modifications supporting content validity and strengthening the potential for generic use. Forty-one preliminary items were evaluated through 29 cognitive interviews, resulting in a 36-item draft questionnaire deemed to have good face and content validity and generic potential.ConclusionsFace and content validation using an expert panel and cognitive interviews resulted in a 36-item draft questionnaire with a potential for evaluating empowerment in user-provider interactions regardless of health conditions, healthcare settings, and healthcare providers’ professional backgrounds.

The safety of standardized management of suspected cardiovascular immune-related events in patients treated by immunecheckpoints inhibitors

Abstract Background Immune checkpoint inhibitors (ICIs) treatment carries a risk of immune-related adverse events (irAEs), including cardiovascular (CV) events. Current guidelines recommend troponin testing to detect early CV irAEs, especially myocarditis, prompting hospital admission. However, high volumes might hinder hospital admission for all suspected CV irAEs patients. Purpose To assess the safety of standardized management in outpatients with suspected irAEs. Methods A prospective single-center cohort study was conducted, including all adults referred to our unit for suspected CV irAEs. Patients exhibiting CV symptoms, receiving double ICIs, or showing ECG changes were referred to cardiology or intensive care based on severity. Patients with no CV symptoms or ECG changes, on single ICI therapy, and no other immune disorder were assessed in a day stay within 8 working days. Patients underwent serial serum testing, ECG, transthoracic echocardiogram, and cardiac magnetic resonance imaging (cMRI) and were assessed by a multidisciplinary team (MDT) including cardiology and internal medicine specialists. Coronary artery imaging and endomyocardial biopsy were performed when deemed necessary (Figure 1). The primary endpoint was CV mortality at 30 days after referral. Secondary endpoints included identifying factors associated with the diagnosis of CV irAEs at referral. Events were adjudicated by a panel of experts (FC, MM, SH) who reviewed the MDT's weekly meeting conclusions. Results 175 patients were enrolled from March 2022 to October 2023; 40 (22.89%) were male, median age 61 (IQR 48.0-72.0) years. 146 (83.4%) were seen in the outpatient clinic. No CV deaths occurred within the initial 30 days. 95 patients (54.1%) had CV irAEs at referral, including 72 (41.1%) with myocarditis; 10 (5.7%) with acute coronary syndromes; 9 (5.1%) with pericarditis; 7 (4.0%) with heart failure; 4 (2.3%) with high-degree conduction or ventricular arrhythmias; and 1 (0.6%) with Tako-Tsubo. 8 (4.6%) had a combination of CV irAEs. The majority of patients admitted to the hospital had CV irAEs (24, 82.7%). On multivariable regression analysis(Figure 2), CV or muscle symptoms(OR 2.677 [CI 1.207-5.937], p=0.015), prior CV disease history(OR 3.668 [CI 1.486-9.057], p=0.0048), and abnormal ECG (OR 2.855 [CI 1.074-7.589], p=0.035) remained associated with CV irAEs at referral. Including global longitudinal strain (GLS) in the model, we identified prior CV disease history. (OR 7.011 [CI 2.217-22.167], p=0.0009) and GLS <16% (OR 2.774 [CI 1.07-7.17], p=0.035) as significant. Conclusions We demonstrate the safety of a standardized outpatient management approach for most patients referred for suspected CV irAEs, mainly triggered by asymptomatic elevation of troponin. No patient experienced CV death at 30 days. When suspecting a CV irAEs, CV or muscle symptoms, previous history of CV disease, and abnormal ECG should prompt speedy assessment given the higher likelihood of CV irAEsFigure 1

Development of a systematic referral model to primary care health interventions for patients with atrial fibrillation. a delphi study

Abstract Background The European Society of Cardiology (ESC) guidelines for the management of atrial fibrillation (AF) recommend integrated care in AF, combining medical treatment with lifestyle modifications and psychosocial management in a multi-disciplinary set-up. Research show that patients with AF can benefit from lifestyle interventions and psychosocial management, like patient education. According to World Health Organization recommendations, these health interventions are moving from hospitals to primary healthcare settings. Therefore, patients with AF should be systematically referred to these interventions. Yet, an evidence-based referral model that can support this transition is lacking. Purpose The purpose is to develop a systematic referral model for primary care health interventions for patients with AF. Methods We used the Delphi-technique with three rounds of questionnaires (figure 1). International and national clinical experts in AF across disciplines and health sectors were invited to participate. In the first round, the expert panel evaluated items that could be part of a referral model on relevance, improvability and self-reporting. In the second round, the expert panel evaluated each item as either an inclusion or exclusion criteria, important knowledge to have, or not relevant. In the third round, the expert panel evaluated the items according to data source and outcome status. A final model was drawn based on items reaching consensus. The study was reported according to the guidance on conducting and reporting Delphi studies (CREDES). Results In total, 69 of 139 invited experts accepted to participate (50%). These were mostly academics or clinicians (90%), stemming from primary sector (16%), secondary sector (35%) and research (32%). Most were medical doctors (36%) and nurses (35%). However physiotherapist, psychologists, dieticians, and other disciplines along with six patients with AF were also represented. The expert panel (60% females) had a mean age of 50 years, and 65% were from Denmark. For the final referral model (figure 2), AF symptom burden and impaired health-related quality of life, anxiety and poor medicine compliance combined with a risk factor profile were the main inclusion criteria. Furthermore, it was important to know about the patients’ mental well-being, self-management abilities and comorbidities. Conclusion Consensus was reached for a generic referral model, which can be further adjusted in the appropriate clinical context. The model includes inclusion criteria which closely correlate with guidelines for AF management focusing on reducing the patients’ symptom and risk factor burden. The referral model is expected to increase the number of patients with AF referred to primary care health interventions, which could lead to better quality of life, fewer hospital admissions and lowered health care costs in AF.

Vaccination health literacy: cultural validation and pilot testing of the HLS19-VAC instrument

Abstract Introduction Vaccinаtion health literacy (VHL) is considered an extremely important aspect of health literacy. HLS19-VAC questionnaire is a 14-item ‘subjective’ perception-based instrument used for measuring VHL in the M-POHL Health Literacy Survey 2019-2021, which Serbia was not part of. Aim Translation and cultural validation of the HLS19-VAC questionnaire and using the validated Serbian version (HLS19-VAC_RS) for pilot study research. Materials and methods The English version of HLS19-VAC was translated using a systematic approach; three forward and one back-translations were synthesized and compared by an expert committee. Thereafter, cognitive interviews with 11 participants produced a version that was culturally validated by an expert panel. We conducted a cross-sectional pilot study using a HLS19-VAC_RS, on a convenient sample of the general population in Serbia. VHL was assessed by calculating the score for 4 out of 14 questions. Additional data were collected through a general questionnaire with 30 questions. Descriptive and inferential statistics were used. Results Cognitive interviews showed some problems in wording, and cultural adaptation resulted in minor refinements to eight out of 14 items. The instrument was pretested by 11 experts who adjusted it accordingly to produce culturally validated HLS19 -VAC_RS. Of 439 respondents in a pilot study, 15% had problematic VHL, while the levels of sufficient and excellent VHL were nearly the same (38.5% and 35.1%, respectively). There was difficulty in deciding whether to receive the flu vaccine (15.0%) and to find information about recommended vaccines (12.3%). There was a significant statistical difference in responses to VHL and monthly income and alcohol consumption. Most of the respondents contacted pharmacists as primary sources of information about medication (42.7%). Conclusions HLS19 -VAC_RS could be implemented in a local context as culturally appropriate. Further testing on a population level is needed. Key messages • HLS19-VAC_RS Questionnaire is culturally appropriate for assessing vaccination health literacy in Serbia. • Majority of respodents had sufficient or excellent vaccination health literacy.

3.F. Round table: Legal action & capacity building: essential for climate action to protect and promote public health

Abstract The climate crisis is the single biggest threat to global health, peace and security, a crisis multiplier, and a significant driver of health inequalities within and between countries. In many areas of public health policy, legal action and litigation have delivered significant and long-lasting impacts. Court action is a strong domain of legal policy and practice to address climate change and related air pollution in many countries, and increasingly in international courts and tribunals. Examples include the 2021 landmark UK Coroners Report on the asthma-related death of Ella Kissi-Debrah, the 2023 UN General Assembly Request for an Advisory Opinion from the International Court of Justice on states’ obligations to address climate change, and the 2024 European Court of Human Rights decision in Klimanseniorinnen v. Switzerland. Climate litigation also creates opportunities for public scrutiny and debate by raising awareness of inaction or harm caused by governments or private sector polluters, generating wider community mobilisation for action. Since 2021, the EUPHA Law and Public Health Section, Faculty of Public Health (UK), Aletta Jacobs School of Public Health, Global Network for Academic Public Health, ASPHER and other partners have collaborated to build ethicolegal competence and capacity of public health professionals for climate action. Initiatives have also included research, advocacy, and resource development, and exploring opportunities for legal action and litigation, including at the International Conference on Strategic Litigation and Public Health (Liverpool, 2023). The roundtable will present key findings from an evaluation of the course on climate change organised by the ASPHER and the Global Consortium on Health and Climate Education (GCHCE), and learnings and feedback from the publication ‘From analysis to action: climate change litigation. A guide for public health professionals’, which was launched at the 16th European Public Health Conference. The expert panel will also reflect on whether the nature of current educational materials, means and methods in curriculum and training initiatives are effective, appropriate, adequate, and sufficient. Should climate change be part of One Health and Planetary Health programmes rather than a distinct entity? What is the role of, and what are the opportunities for, public health professionals to be engaged in climate litigation? What are the gaps and opportunities through strategic networking with environmental and legal experts, and affected communities? The roundtable will be interactive and invite input and insights from the participants to explore opportunities to further advance the agenda. Key messages • Public health professionals have a key and increasing role in climate law and litigation: interdisciplinary collaboration is essential. • Public health professionals have multiple avenues for capacity building on opportunities to address climate and environmental impacts on public health through law. Speakers/Panelists David Patterson University of Groningen, Groningen, Netherlands Farhang Tahzib Faculty of Public Health, Haywards heath, UK Liz Green Public Health Wales, Wrexham, UK Ana-Catarina Pinho-Gomes University College London, London, UK

Immune-checkpoint myocarditis phenotype when using systematic troponin surveillance in cancer patients.

Abstract Background ICI myocarditis, often described as potentially fulminant in registries from specialized centers, lacks sufficient data on its subclinical forms. ESC 2022 guidelines advocate systematic troponin measurements for early detection, resulting in numerous suspected cases of ICI myocarditis. Additionally, many patients receive other potentially cardiotoxic cancer drugs (e.g.,anthracyclines), adding complexity to the management. Purpose To identify factors associated with ICI-myocarditis diagnosis in a single-center unselected cohort referred for suspicion of CV immune-related adverse events(irAEs). Patients underwent standardized evaluation, including serum testing, ECG, echocardiogram, cardiac MRI(CMRi) and multidisciplinary team assessment including cardiology and internal medicine specialists. Coronary imaging and myocardial biopsy (EMB) were performed as needed. ICI-myocarditis diagnosis was adjudicated by expert panel (FC, MM, SH) based on Dallas, ESC, and IC-OS criteria. Results We enrolled 175 consecutive patients from March 2022 to October 2023; 40 (22.89%) were male, with a median age of 61 (IQR 48.0-72.0) years. 92(52.57%) were referred for lone asymptomatic troponin raise, 101 (57.7%) had breast cancer; 142 (81.11%) received other cardiotoxic drugs. We identified 95 (61.71%) patients with CV irAEs at referral (8 had >=2 CV irAEs) with a total of 108 CV irAEs after follow up, including 72 (41.14%) with ICI-myocarditis at referall. No CV deaths occurred within 30 days from referall. Characteristics and univariate analysis are depicted in the Table1. Reasons for referral in the ICI-myocarditis population are depicted in the Figure1. On multivariate regression analysis, prior CV disease history (OR 6.232 [CI 1.204-32.260], p=0.029), EMB (OR 24.969 [5.139-121.32], p=<.0001), IC-OS criteria fulfilled (OR 43.108 [9.222-201.510], p=<.0001), and positive Lake Louise criteria on CMRi (OR 6.583[1.416-30.610], p=0.0163) were associated with myocarditis. In a sub-analysis group of breast cancer patients (largely receiving anthracyclines), ICI-myocarditis was associated on multivariate regression with abnormal ECG (OR 14.227 [CI 1.632-124.040], p=< 0.0163) and EMB (OR 8.508 [CI 2.718-26.638], p=0.0002). The same characteristics were significantly associated with other CV irAEs in the group of breast cancer patients. In the group of patients with cancers other than breast, factors significantly associated with ICI myocarditis diagnosis were: EMB (OR 70.656 [CI 5.970-836.161], 0.0007), and no arterial hypertension (OR 9.554 [CI 1.792-50.940], p= 0.0082). Conclusions The FAST TRACK study highlights the high proportion of patients fulfilling ICI-myocarditis criteria despite no or mild symptoms, mainly referred for troponin elevation. However, subclinical ICI-myocarditis appears to bear good prognosis. Endomyocardial biopsy is key to increase the diagnosis rate of ICI-myocarditis across different cancer populations when mildly symptomatic.Table 1Figure 1

4.Y.1. Climate trauma, public protest and the ethics of civil disobedience in our warming world

Abstract Eco-anxiety, defined as “a chronic fear of environmental dooms,” is related to both a direct experience of extreme weather events (e.g., floods, wildfires, hurricanes, droughts) as well as environmental changes. Although it is not yet being addressed as a proper disease, eco-anxiety is being related to symptoms such as obsessive thoughts about the climate and the total destruction of the planet, existential fear and feelings of guilt about one’s own carbon footprint, anger, frustration, depression, and anxiety, among others. Eco-anxiety is increasingly reported among children and young people (Hickman et al, Lancet Planetary Health, 2021). Less studied and understood is climate trauma at a societal level resulting from the ever-present, ever-growing threat of climate change.This session aims to facilitate a better understanding of the mechanisms that lead to this symptomatology as well as the reasons for our apparent collective paralysis as a society to act in accordance with the climate threats we face. This analysis will take into account aspects linked to cultural diversity and structural factors that can rationalise the inaction. Particularly following the COVID-19 pandemic, many states have introduced or strengthened laws restricting the right to protest, with implications for public protest about state inaction on climate change. The workshop also aims to address questions such as: Are public protest and civil disobedience rational responses to the climate crisis? Should health professionals protest publicly? How has eco-anxiety been used as a legal defence to criminal charges? How should professional accreditation bodies respond when a member is convicted in a climate protest? Is deregistration appropriate, or should we instead be hastening to revise professional codes of ethics and public health training curriculums to reflect ‘the single biggest threat facing humanity’? (WHO, 2021). In the United Kingdom, the UK Health Alliance on Climate Change has urged the General Medical Council ‘to be as lenient as the law allows’ with health professionals convicted of offences resulting from their protests against damage to nature, the climate, and health. Three expert panellists in mental health, law and ethics will present their perspectives in Pecha Kucha format. Key messages • Climate trauma at societal level may account for our collective paralysis in the face of climate change: yet political, structural and cultural factors must not be overlooked. • Ethical codes and training curriculums for public health professionals must be updated to reflect the evolving roles of PHP in response to climate change. Speakers/Panelists Jutta Lindert Hochschule Emden-Leer, Emden, Germany David Patterson University of Groningen, Groningen, Netherlands Farhang Tahzib Faculty of Public Health, Haywards Heath, UK

The association of steatotic liver disease with recurrent ischemic events in patients with chronic coronary syndrome: a multicenter cohort study

Abstract Background/introduction A panel of multi-society experts has proposed new subcategories under the term steatotic liver disease (SLD), replacing the exclusive term non-alcoholic fatty liver disease with the new nomenclature metabolic dysfunction-associated steatotic liver disease (MASLD). However, the prognostic impact of SLD subtypes in patients with chronic coronary syndrome (CCS) remains unknown. Purpose We aimed to investigate the associations between SLD subtypes and recurrent event risks in CCS patients. Methods Our analysis included a total of 9,448 patients with CCS from a large multicenter nationwide cohort. Hepatic steatosis was defined as hepatic steatosis index ≥36 and ultrasound evidence. Patients were categorized into four groups based on the evidence of steatosis, cardiometabolic risk factors and alcohol intake: 1) no SLD; 2) MASLD; 3) MASLD with increased alcohol intake (MetALD) and 4) SLD with other causes. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), a composite of all-cause mortality, myocardial infarction, stroke and unplanned revascularization. Results The prevalence of no SLD, MASLD, MetALD and SLD with other causes in our population was 37.3%, 47.7%, 14.7% and 0.3%, respectively. During a median follow-up of 2.0 years, 759 (8.0%) MACCE events occurred. After multivariable adjustment, MASLD (HR 1.25, 95%CI 1.06-1.48), MetALD (HR 1.31, 95%CI 1.04-1.65) and SLD with other causes (HR 2.81, 95%CI 1.04-7.57) were all significantly associated with higher MACCE risks compared to no SLD. Conclusions A significant proportion of SLD was observed in CCS patients. Patients with various SLD subcategories all had higher risks of recurrent events.

Insights from an international clinic survey on CIED patient management practices and perceptions

Abstract Background Remote monitoring (RM) is recommended as standard of care to manage patients with cardiac implantable electronic devices (CIEDs). However, implementation within overall follow-up (FU) practice is challenging with many organizational aspects to consider. While the 2023 HRS/EHRA/APHRS/LAHRS consensus on management of remote device clinics provided guidance, data on current patient management practice is lacking to understand existing gaps. Purpose This survey of device clinic staff characterized the state and perceptions of CIED patient management. Methods A Delphi panel of US and EU clinical experts guided the research objectives, structure, and content of the survey. Once consensus was reached, the online survey (Qualtrics) was deployed in partnership with HRS. An available case analysis was performed to handle missing data. Results A total of 471 responses were received between September 2023-January 2024 (66% US, 19% Europe, 15% other). Overall, performing a combination of in-office visits and RM was the most frequent FU practice for all devices. Remote-only management was only commonly reported for insertable cardiac monitors (ICM). Adoption of RM was lower in EU compared to US for therapeutic devices, especially pacemakers for which in-person only FU remained high (Figure 1). Frequency of routine visits and transmissions is reported in Figure 2. While the majority of respondents (48-67%, depending on device type) expressed that less than 20% routine visits are actionable, adopting a practice of FU visits scheduled every 2 years as suggested in the 2023 consensus was rarely reported for therapeutic devices. However, alert-based RM seems to emerge for ICM without routine FU. In the US, frequency of scheduled transmissions appeared aligned with reimbursement rules (monthly for ICMs; quarterly for therapeutic devices), whereas there was more variability in EU where RM often lacks clear funding. Divided opinion was observed regarding staff sufficiency as 43% found staffing levels somewhat/very sufficient, while 42% rated it as somewhat/very insufficient. Managing disconnected patients, initial transmission review, and patient phone calls were identified as most burdensome tasks and were the ones for which there was most willingness to outsource. Although 60% respondents rated their practice as somewhat/very efficient, the majority (45%) did not report monitoring performance. The minority (29%) assessing patient management performance primarily tracked workload volume rather than quality-related metrics. Conclusion This large international survey characterized contemporary CIED patient management practices. While the 2023 HRS/EHRA/APHRS/LAHRS consensus highlighted the potential for alert-based RM, reducing in-person visits, and third-party resources to streamline patient FU, these practices have yet to be fully implemented. As such, there is opportunity to standardize and optimize workflows to drive efficiency and quality of care.Follow-up paradigm by regionFrequency of routine follow-up

The economic and social burden of congenital thrombotic thrombocytopenic purpura (cTTP) in Italy

Background: Congenital thrombotic thrombocytopenic purpura (cTTP) is a rare genetic disorder characterized by an abnormal clotting process leading to serious health complications such as thrombocytopenia and hemolytic anemia. Despite its clinical significance, the estimated broader economic and social impacts in Italy on patients and society remain underexplored. Methods: A detailed questionnaire, developed and validated by a panel of cTTP experts, was distributed to healthcare professionals and patient associations to gather comprehensive data on the economic and social burden of cTTP in Italy. The study was focused on direct and indirect costs associated with the disease management of 15 patients with cTTP, as well as out-of-pocket expenses incurred by patients. Results: The analysis revealed that of the 15 patients diagnosed with cTTP in Italy, 60% were adults aged 40-55 years. Productivity loss and diminished quality of life dominated the economic burden of cTTP, accounting for 81.05% of total costs. Direct medical costs, while substantial, represented a smaller portion of the overall financial impact. Additionally, out-of-pocket expenses, though constituting the smallest fraction, underscored the financial contributions made by patients towards their own care management. Conclusion: The findings underscore the need for a multidisciplinary and holistic approach to cTTP management that extends beyond the clinical treatment. Addressing the economic and social implications of the disease is crucial for improving patient well-being and ensuring the sustainability of healthcare systems. The study advocates for increased awareness, research, and access to care for cTTP patients, highlighting the importance of comprehensive support networks to mitigate the disease’s broader societal impacts, estimated to be around 2 million euro for 15 patients in 10 years.

Measuring navigational health literacy – an extension of the HLS19-NAV scale

Abstract Background European healthcare systems are characterized by a high complexity and intransparency. Finding one’s way through the multitude of services requires navigational health literacy (NAV-HL). NAV-HL is defined as the ability to maneuver the healthcare system and deal with information necessary to do so at the system, organizational, and interactive levels. Using a newly developed scale, the European health literacy population survey 2019-2021 (HLS19) measured NAV-HL across multiple countries. To better capture the complexity of the construct and enhance scale validity, the aim was to improve it by generating additional items on the interactive level. Methods An international panel of health literacy experts from ten countries generated additional items that specifically covered tasks related to interactions with healthcare professionals. These skills are important for ensuring continuity of healthcare and navigating the healthcare system. The items were generated in an iterative process, translated, and tested in cognitive interviews. Results Four items were generated according to the four cognitive domains of the underlying conceptual model. These items concern the proficiency to: a) obtain information from health-care professionals about further healthcare services, b) understand this information and c) assess it in relation to one’s own preferences, and d) use it to make decisions about further healthcare. Using cognitive interviews, the four new items have been found to be meaningful and comprehensible. Only minor adjustments were made. Conclusions The HLS19-NAV scale has already been successfully applied and validated in eight countries of the HLS19. The new items capturing the interactive level enhance the validity of the existing HLS19-NAV scale. The psychometric properties of the new (sub)scale will be explored.

Ethics in social listening in infodemic management in health emergencies

Abstract Issue During the COVID-19 pandemic and subsequent outbreaks, health organizations have increased the use of social listening to inform infodemic management and outbreak response activities. This demonstrated the need to provide ethical guidance to organizations, and individuals engaging in social listening practices before, during and after public health emergencies, whilst protecting human rights. Description of the problem Social listening as a public health activity draws on analysis of conversations in social media, internet platforms, and feedback from geographically localized communities. Infodemic insights are generated rapidly, to support agile action by health organizations that improves outbreak response, health information delivery, community engagement, or reduction of unintended harm experiences by communities. Social listening involves use of social media and internet trace data, which were traditionally not used in public health for understanding community expressions, WHO convened a panel of experts to develop a framework on ethical considerations for social listening in infodemic management to provide recommendations for health authorities and researchers on practical tools that support setting up new data analysis and use of insights hereto not used in routine. Results The guidance framework has been structured into segments that vary from ethical principles and challenges in social listening and generation of infodemic insights, alignment with human rights, substantive principles, procedural principles, and practical guidance for translating these principles into real-world practice. Lessons This guidance aims to illuminate the intricate ethical dimensions of social listening and stress the urgent need for ethical guidance in this realm. The framework is a comprehensive inquiry of the ethical scope in social listening, providing valuable insights, practical guidance, and case studies to enhance understanding of this critical global health issue. Key messages • While essential, social listening and infodemic insights come with ethical risks, including potential harm to populations in vulnerable situations, erosion of trust, and misuse of data. • This ethical framework will govern social listening practices and ensure responsible and ethical social listening.

Guidance on health promoting and climate-friendly hospitals and health services

Abstract The negative impacts of climate change on health and the healthcare system are becoming increasingly evident. The healthcare sector, which accounts for nearly seven percent of Austria’s CO2 emissions, contributes to the exacerbation of climate change on one hand, but is also affected by its consequences on the other. To meet these challenges, it is necessary for healthcare facilities to both adopt climate-protective measures and adapt to the changed conditions. A project launched in 2023, supported by the Austrian Health Promotion Agenda and in cooperation with the Austrian Network of Health Promoting Hospitals and Health Services, has shown that there is a need for support in implementing climate protection measures in healthcare facilities. In response, the WHO Collaborating Centre for Health Promotion in Hospitals and Healthcare, located at the Competence Centre for Health Promotion and Healthcare at the Austrian National Public Health Institute, will work on the development of standards based on international models to support healthcare facilities in the introduction of climate-friendly practices until 2026. The methodology of the project includes the analysis of existing quality criteria and instruments, as well as a modified Delphi process with two rounds of online questionnaires directed at an international panel of experts. After each round, exchange meetings with a smaller group from the panel take place to achieve consensus. Based on the research findings and the Delphi consultations, a draft of standards and an implementation manual will be created. These drafts will be piloted in various healthcare facilities in Austria and other countries to assess their practicability and effectiveness. Following the pilot tests, the standards and the manual will be revised to integrate the practical insights gained. At the time of the conference, the initial results of the Delphi process will be presented, providing insights for the further development of the standards. Key messages • Integrating climate-friendly practices into all aspects of healthcare can reduce its environmental impact, improve health outcomes, and contribute to the broader sustainable development goals. • Climate-friendly approaches yield significant health, economic, and social co-benefits.

Defining child maltreatment for research and surveillance: a Delphi study in 34 countries

Abstract Background Child maltreatment is a complex public health issue that has consequences across the life-course. Studies to measure child maltreatment and identify interventions and services are constrained by a lack of uniform definitions across sectors and countries. We conducted a Delphi study to reach consensus on types and characteristics of child maltreatment for use in surveillance and research in Europe. Methods Statements were developed following a scoping review and identification of key concepts by an international expert team (n = 19). A multidisciplinary expert panel (n = 70) from 34 countries participated in three rounds of online data collection. We defined consensus as ≥ 70% agreement or disagreement with each statement after the final round. Results Consensus was reached on 26/31 statements, with a participant retention rate of 94%. The definition states that child maltreatment is a subtype of violence against children. The perpetrator can be an adult or minor, but must be in a position of power over the child. To define an act or omission as child maltreatment, it must cause harm or have the potential to cause harm, regardless of intention, severity, chronicity, or the traditional/cultural beliefs of the perpetrator. In addition, the broad umbrella term encompassing emotional, behavioural or cognitive maltreatment should be “psychological”, and psychological maltreatment should be split into sub-types of psychological abuse and psychological neglect. “Neglect” is a broad type of child maltreatment within which there are subtypes that can all be characterised as “failure to provide” or “failure to supervise”. Conclusions This is the first study to demonstrate consensus on the types and key characteristics of child maltreatment across multiple sectors and countries, providing a unified definition of child maltreatment to improve consistency of measurement and surveillance in Europe. This abstract is submitted on behalf of Working Group 1 COST Action 19106. Key messages • A standardised definition is essential for monitoring child maltreatment. • We propose a consensus-based definition that can be used to improve child maltreatment measurement in research and surveillance.

Defining Systemic Change in School Counseling: A Delphi Study

ABSTRACT Systemic change is regarded as a key component of professional school counseling practice for increasing positive, equitable outcomes for PreK-12 students. Although related constructs like leadership and advocacy have been thoughtfully explored, systemic change requires consultation and collaboration with educational and community partners. To date, there has been a lack of clarity around how systemic change looks in practice for school counselors. The purpose of this study was to explore the foundational components of systemic change in school counseling. Using Delphi methodology, an expert panel of 22 participants consisting of professional school counselors, counselor educators, and school counseling supervisors developed a consensus list of 130 items describing the core beliefs, knowledge, dispositions, and skills necessary for school counselors to conduct systemic change. The findings suggest future implications for school counseling research, preparation, and consultation.

The future of public health in Europe

Abstract EuroHealthNet - in collaboration with the Copenhagen Institute for Futures Studies - has conducted a Foresight study to collect insights and identify risks and opportunities. The study investigates the role of public health by 2035 in achieving health equity through health promotion and prevention, in the context of the digital and green transition. The multi-round study ran from June to November 2023. It consisted of a workshop, a kick-off meeting, two rounds of surveys using the Delphi method, and a final back-casting expert panel. The Foresight exercise involved 35 experts across Europe and covered six themes: public health policy and governance; public health financing and spending; sustainability and the green transition; health promotion and disease prevention; equity and society; digitalisation in public health. The presentation will highlight some of the outcomes, recommendations as well as experiences from this Foresight exercise and how it can be applied in practice.

Development of a novel Patient-Reported Outcome Measure (PROM) for adults with an Inherited Cardiac Condition (ICC)

Abstract Background Research on the quality-of-life (QoL) among patients with inherited cardiac conditions (ICC) is limited. Existing evidence from a systematic review indicates that most studies rely on generic measures of health-related QoL, which may not adequately capture ICC-specific factors. The current study aims to develop a disease-specific patient-reported outcome measure to address this gap. Methods Using a qualitative study design, we first conducted focus groups until data saturation was achieved (n=15). Additionally, an expert panel of healthcare professionals was interviewed to ascertain their perspectives on patient-centered care and to evaluate face validity. Transcripts of all focus groups and interviews were analyzed thematically using Atlas.ti, qualitative analysis software, to identify concepts and formulate survey items for the initial instrument. We used the ‘Centre for Health Promotion’ QoL model, consisting of three domains- Being, Belonging, and Becoming- as the theoretical framework for our analysis. Results Our analysis revealed alignment with specific QoL domains of the overarching framework and identified a gap in genetic-specific domains. A novel overarching theme, genetic well-being, was identified, encompassing specific constructs related to future uncertainty, reproductive concerns, and the anticipation of disease development, thus enriching the conceptualization of QoL in the context of inherited cardiac conditions. The discussion will include an exploration of the face validity of the draft instrument. Conclusion Patients diagnosed with an inherited cardiac condition (ICC) face a spectrum of challenges originating from both disease-related stressors and hereditary factors alike. Recognizing that relying solely on objective clinical assessment may fail to capture the full impact of the disease, there has been an increasing focus on incorporating patient-reported measures into disease evaluation. This qualitative study contributes to developing a comprehensive patient-reported outcome measure tailored to individuals with ICC.PROM development study

Adverse Myocardial and vascular side effects of Immune Checkpoint Inhibitors: a prospective multimodal cardiovascular assessment (AMICI study)

Abstract Background Immune checkpoint inhibitors (ICIs) are transformative treatments in oncology, yet they are also associated with a range of cardiovascular (CV) events. Purpose To identify the incidence of CV events (including subclinical) in patients receiving ICIs for solid cancer, either alone or in association with other cancer therapies (e.g., chemotherapies, target therapies). Objectives and methods The Adverse Myocardial and vascular side effects of Immune Checkpoint Inhibitors(AMICI) study prospectively assessed the incidence of CV changes by means of a thorough multimodal assessment. This included repeated CV imaging (transthoracic echocardiograms (TTE), cardiac magnetic resonance imaging (CMR)), serum biomarkers (troponin, brain natriuretic peptides in a single laboratory), and ambulatory ECG monitoring, before and during (at 6 weeks and at 6 months) ICI therapy (Figure). Cardiovascular events included myocarditis, pericarditis, acute coronary syndrome, heart failure (HF), high degree conduction abnormalities (defined as new grade 2 or 3 atrioventricular block) or sustained ventricular arrhythmias (defined as 3 or more ventricular beats at a rate ≥ 120/min), CV death as a composite endpoint, validated by an independent expert panel Results Out of 130 solid cancer patients considered for ICI therapy, 49 patients (38 (77.6%) male; mean age 64.3 (­SD 11.0) years old) were included (June 2020 -December 2021). 22 (55.1%) suffered from kidney or bladder cancer; 7 (14.3%) had CV disease prior to cancer diagnosis; 4 (8.2%) received PD1 and CTLA4 inhibitors. Early CV events were observed in 9 (18.4%) patients at mean 40.1 (SD 5.9) days, with heart failure (HF) in 5 (10.2%), ventricular arrhythmias or new conduction disorders in 4 (8.2%) patients. History of AF (HR 4.49 (CI 1.11-18.14), P=0.035) predicted early CV events at 6 weeks (Table). At 6 months follow-up, 18 CV events were observed in 15/49 (31%) patients, with 6 (12.2%) HF events, 5 (10.2%) significant ventricular arrhythmias or conduction disorders and 4 (8.2%) AF. There was a significant decline in LVEF (P<0.001) in patients even in the absence of CV event (P=0.003) or HF (P=0.003). Higher creatinine at inclusion (HR 0.99 [0.98-1.00], P=0.006) predicted HF. Conclusions Cardiovascular complications arising during cancer treatment with ICIs are primarily due to the exacerbation of pre-existing HF or the onset of non-inflammatory heart rhythm disorders. The majority of these CV changes manifest shortly after starting ICIs and do not need hospital admission. Our results suggest that more close follow-up may be needed in patients with underlying CV conditions when starting ICI therapy, by means of CMR and ambulatory ECG holter monitoring.

Design and Validation of a Health Inequalities Questionnaire for Occupational Health Nurses and Occupational Health Nursing Students in Spain.

This article aims to describe the methodology for the design, validation, reliability, and pilot testing of a questionnaire aimed at exploring the knowledge and training needs on health inequalities of occupational health nurses (OHNs) and occupational health nursing students in Spain. Working and employment conditions are social determinants that influence the health of workers. The unequal distribution of these factors leads to inequalities. The training and competencies of OHNs need to focus on the social determinants of health to reduce social inequalities. The questionnaire was structured in five sections and 24 closed questions, self-administered and online. It was validated by a panel of experts using Moriyama's criteria and achieved an average consensus of 93.85%. Internal reliability reached a Cronbach's alpha coefficient of 0.843 and a McDonald's omega of 0.953. Participation in the pilot test was 92.5% of the sample recruited. Achieving higher levels of health of the working population requires a consensus among different social actors to integrate social determinants, gender and equity perspectives into the overall health policy of the company.

Enhancing Untrained Football Referees’ Strength, Speed, and Endurance through A Mix-training Programme

Given the distance, energy consumption and football referees’ physical challenge during matches, it is crucial that their speed, endurance, and strength should be enhanced. It is in this perspective that this One-Group Pretest-Posttest Design quasi-experimental research, aims to (a) validate a mixed-training program to enhance Primus League football referees’ speed, endurance, and strength. The research also aims to (b) gather evidence on the program reliability and effectiveness. The sample consisted of 15 Primus League football referees (n=15) who attended a five-week training program with sessions held 3 times per week. During an expert panel, eight Fitness and Vitality Enhancement (FVE) professionals validated the program and later the replicability estimation indicated the training program related tests’ high reliability (ICC=0.77). The normality assumption was verified, and the results obtained through paired-sample t test, with related sig.<0.025, indicated that the intervention program effectiveness, except the speed component for which there was not enough evidence of the referees’ improvement. With bigger sample sizes, it is recommended that the relation between the referees’ age, body mass, and speed be established to shed light on the reason of speed component statistical insignificance.