Background: Sleep problems are increasing among young adults, with those experiencing childhood adversity particularly at risk. This study provides a comprehensive overview of sleep problems in young adults following multifaceted trajectories of childhood adversity, while emphasizing the transdiagnostic nature of sleep problems. Methods: Register data on 1,276,831 individuals were supplemented with nested survey data on 36,873 participants. Childhood adversity (ages 0-16) was operationalized using previously derived trajectories: low adversity, early life material deprivation, persistent material deprivation, loss or threat of loss, and high adversity. Sleep problems (ages 16-30) were assessed through prescriptions, diagnoses, and self-reported data. Survival models were used to estimate associations between childhood adversity and sleep problems. Co-occurrence of sleep and mental health problems were explored, and confirmatory factor analysis was used to model self-reported sleep impairment across adversity groups. Findings: Childhood adversity was associated with sleep problems, with prevalences of 8∙2%, 10∙4%, 10∙8%, 13∙6%, and 20∙1% across the five adversity groups. Risk was highest in the high adversity (HR 2∙37; 95% CI 2∙32–2∙43) and loss or threat of loss (1∙71; 1∙68–1∙74) groups vs. low adversity. Sleep problems most commonly involved sleep medication prescriptions only (49%) but also co-occurred with mental disorders (43%). The high adversity and loss or threat of loss groups showed higher variation in self-reported sleep impairment and higher proportions above the 80th percentile compared with other groups. Interpretation: Sleep problems are common among young adults who experienced childhood adversity; linking early-life stress, disturbed sleep, and mental health conditions from childhood into adult life. These interconnected public health challenges underscore the relevance of multi-sectoral policy approaches, including upstream prevention of childhood adversity and downstream recognition and treatment of sleep problems, while considering variability in how these problems develop, manifest, and persist. Funding: Lundbeck Foundation (grant no. R396-2022-352) and Tryg Foundation (grant no. 157232).

Background. The 9-item Shared Decision Making Questionnaire (SDM-Q-9) is widely used to measure shared decision-making (SDM) across clinical settings, but no study so far has synthesized its psychometric properties. Purpose. We systematically reviewed and synthesized psychometric evidence of the SDM-Q-9. Data Sources. MEDLINE, Web of Science, PsycInfo, and CINAHL. Study Selection. Original studies in English or German, providing any information on psychometric properties of the SDM-Q-9 considering all possible interpretations and constructs measured by the instrument. Data Extraction. Details on study design, sample characteristics, and any information on psychometric evidence were extracted. Data Synthesis. 83 studies were included, with 73 articles contributing evidence on validity, 46 on reliability, and 3 on fairness. We found a high amount of psychometric evidence on validity and reliability of the SDM-Q-9, interpreting the score as SDM perceived by the patient. Evidence is lacking for other interpretations and fairness. Notable is the weak association of the SDM-Q-9 with physician-rated SDM. Conclusions. The SDM-Q-9 is highly reliable and valid for the subjectively experienced level of SDM by the patient. Further research is needed on alternative interpretations, and on fairness of the measure.

Background:The network theory describes mental disorders as a network of interacting symptoms. While most research on the network theory is based on network analyses of symptom data, little is known about mental health professionals´ attitudes towards this theory. Clinical expertise could offer a valuable additional perspective on the validity of the theory and its applications to clinical practice. Method:Mental health professionals rated their agreement with propositions of the network theory regarding the phenomenology, aetiology, and treatment of mental disorders in an online survey. Further, the acceptability and appropriateness of possible applications were evaluated. We calculated descriptive statistics and examined associated factors with regression analyses. Results:The participating psychotherapists (n = 183), specialized physicians (n = 45), and clinical psychologists (n = 29, total n = 257) largely agreed with the network theory's propositions regarding the phenomenology of mental disorders and treatment effects. Appraisal of the network theory regarding the aetiology of mental disorders, regarding important treatment targets, and regarding acceptability and appropriateness of possible applications was mixed. A theoretical background in cognitive behavioural therapy and previous knowledge of the network theory were associated with a stronger agreement in most domains. Conclusions:The fundamental assumptions of the network approach seem to resonate with mental health professionals, while the consequences for the diagnosis and treatment of mental disorders were questioned. Our findings indicate that the general conceptualization of mental disorders as symptom networks seems to align with mental health professionals' perceptions but, at the same time, emphasizes the novelty and limited specificity of the theory's implications for clinical practice.

Introduction Healthcare workers (HCWs) have been disproportionately affected by the COVID-19 pandemic, both as carers and as patients. Many individuals developed persistent symptoms following an acute SARS-CoV-2 infection, known as post-COVID-19 syndrome (PCS). Previous research indicates that a significant proportion of HCWs experience long-lasting and debilitating symptoms of PCS. The aim of this study is to investigate the longitudinal symptom burden as well as the care pathways and treatment experiences of PCS-affected HCWs insured by the German Social Accident Insurance Institution for Health and Welfare. Methods and analysis The study uses a mixed-methods approach. The longitudinal survey will extend a cohort study of n=2436 HCWs (started in 2023) affected by PCS, adding two measurement points, set in 2025 (T 3 ) and 2026 (T 4 ). Additionally, interviews on care pathways and treatment experiences will be conducted with a subsample of n=60 PCS-affected HCWs. Another subsample of n=30 HCWs will be asked to participate in ecological momentary assessments of symptom burden, emotional well-being and coping strategies. Analyses of routinely collected data by the insurance company will complement the study data. The study is supported by an advisory board comprising PCS-affected HCWs who assist with the content of both qualitative and quantitative surveys. Ethics and dissemination This study was approved by the Local Ethics Committee of the University Medical Center Hamburg-Eppendorf, Germany (LPEK-0909, 1 May 2025; amendment: LPEK-0954, 18 September 2025). The results of the study will be presented at conferences and published in peer-reviewed journals. Registration details https://drks.de/search/de/trial/DRKS00035957

OBJECTIVE:This study aimed to evaluate the effectiveness of a needs-based communication skills training designed to foster patient-centered communication among nursing professionals. METHODS:We conducted a randomized controlled trial with a waitlist-control group at three hospitals in Hamburg, Germany. Data were collected at three time points. Primary outcome was self-efficacy in communication with patients directly after training participation. Secondary outcomes included training evaluation (intervention group only), knowledge about patient-centered communication, attitudes towards communication, communication behavior and health- and work-related distress. Data analyses employed mixed-model analyses, Chi²-test, and descriptive statistics. RESULTS:157 nursing professionals participated in the study, with 136 (87%) being female. Regarding the primary outcome, self-efficacy in communication with patients, the intervention group showed statistically significant post-training improvements compared to waitlist-control (Estimated Marginal Mean Difference -10.00, p < .001, d=0.81). Statistically significant post-training improvements were also observed for the secondary outcomes, subjective communication knowledge (p.001) and attitudes toward communication (p < .039). Additionally, participants rated the training as highly positive. CONCLUSION:To our knowledge, this is the first study to develop and evaluate a needs-based patient-centered communication skills training for nursing professionals in Germany. We found that the intervention had statistically significant effects on the participants' self-efficacy, subjective knowledge, and attitudes towards communication, while effects on other secondary outcomes were limited. Further research is needed to assess impact on other outcomes, such as participants' communication behavior and health- and work-related distress. PRACTICE IMPLICATIONS:Participation in a needs-based communication skills training is a promising way to improve patient-centered care by enhancing nursing professionals' communication skills.

Understanding mental health as a complex system has motivated the adoption of time-varying network models to explore how the dynamics of psychological variables change over time. While existing time-varying network models assume gradual change, shifts in symptom dynamics such as transitions between healthy and disordered states may occur rapidly. This could manifest as abrupt, qualitative changes between distinct states, often labelled as regime switches. In this scoping review, we identified and synthesized statistical approaches for modeling such phase transitions in the behavioral sciences that could be applied to network models. Our review yielded 40 studies across different fields, featuring 56 statistical analyses in total. Most analyses (71.4%) were based on Hidden Markov Models, which can be extended flexibly to model unobserved, recurrent states in various scenarios. Other approaches included change point models (14.3%), which identify shifts directly in the observed time series, and threshold models (12.5%), which model regime switches triggered when a dedicated threshold variable is crossed. We describe these approaches, their applications, and their data requirements, and assess their strengths and limitations for modeling shifts in the dynamics of time series. Notably, several approaches already include multilevel or multivariate-extensions, making them promising candidates for modelling changes in network dynamics in mental health. In sum, our review highlights the broad potential of regime-switching models to enrich the understanding of dynamics of mental health processes.

Abstract Background As improvements in anti-cancer treatments have extended survival, patients with advanced cancer and their family caregivers face existential tension between engaging in life and coping with uncertainty about illness trajectory and the course of treatment. For a subgroup, this tension is associated with overwhelming fear and existential distress. Such adjustment difficulties may increase the risk of mental disorders, poor quality of life, and suicidality, and impair prognostic awareness and patient-clinician communication. Despite growing interest in open conversations about end-of-life issues, systematic evidence on effective psychotherapies to best support psychological adaptation in patients with high levels of existential distress is still scarce. We aim to evaluate the effectiveness of a short-term psychodynamic therapy (ORPHYS) to mitigate existential distress compared to usual psycho-oncological treatment (TAU). Methods We conduct a two-arm parallel randomized controlled trial with an active control group. ORPHYS is a manualized individual face-to-face psychotherapy focusing on emotional and relational conflicts specific to cancer patients’ illness situation. Treatment lasts between 5 and 11 months with 15 to 31 weekly sessions (50 min). TAU includes at least one individual session provided by physicians or psychologists with experience in psycho-oncological care. Patients will be assessed pre-intervention and 3, 6, 9, and 12 months after baseline. Target sample size is 160 randomized participants. We recruit patients with stage III/IV solid tumors or advanced hematological cancer and clinically significant existential distress from psycho-oncology clinics and referring oncologists at Hamburg, Düsseldorf, and Würzburg Comprehensive Cancer Centers, Germany. The primary outcome is demoralization (Demoralization Scale-II). Secondary outcomes include diagnoses of affective, anxiety and stress-related disorders, death anxiety, dignity-related distress, and quality of life. Outcome assessments are conducted via self-report questionnaires and diagnostic interviews. Linear mixed models examine outcome differences between trial arms. A confirmatory test of the group contrast at 6-month follow-up after baseline is conducted. Discussion Due to an aging population and prolonged survival, there is a growing demand to help patients deal with existential challenges undergoing palliative cancer care. The study will contribute to knowledge about how clinicians can best help patients with advanced cancer who substantially struggle with uncertainty at the end of life. Trial registration German Clinical Trials Registry, DRKS00038173. Registered October 20th, 2025, https://drks.de/search/en/trial/DRKS00038173 . ClinicalTrials.gov, NCT07312760. Registered December 30, 2025, https://clinicaltrials.gov/study/NCT07312760 .

IntroductionHealth literacy (HL) has been recognized as a central construct in healthcare that contributes to individual health and serves as a predictor of various health outcomes. Recently, vulnerable groups such as older adults have increasingly become the focus of studies examining HL. In this context, various questionnaires have been developed and deployed, including the widely used European Health Literacy Survey Questionnaire (HLS-EU-Q47) and its short form (HLS-EU-Q16). However, it remains unclear whether results from population- and community-based studies can be applied to specific inpatient populations. Furthermore, research focusing on HL among older patients is limited. The aim of this study was therefore to examine distributions of HL across different characteristics and its associations with other health variables and to assess the psychometric properties of the HLS-EU-Q16 in a sample of older inpatients after elective surgery.MethodsWe analyzed a cross-sectional sample of 143 hospital patients aged 65 years or older who underwent elective surgery at a university hospital in northern Germany. Levels of HL, along with various sociodemographic and health-related variables, were examined. Additionally, we conducted a confirmatory factor analysis (CFA) to examine the latent factor structure of the HLS-EU-Q16 in this context.ResultsThe average age of patients was 73.2 years (SD = 5.8), with 52.4% being male. Nearly half (47.6%) of the sample had difficulties in handling health information (i.e., limited HL). Overall, 13.8, 33.8, 40.0, and 12.3% of patients were classified as having inadequate, problematic, sufficient, and excellent HL, respectively. Patients reported the greatest difficulties with items related to mental health and media on the HLS-EU-Q16. No significant differences in HL levels were observed between age groups, genders, or other sociodemographic variables (p > 0.05). Regarding the CFA, we were unable to fully replicate the three-factor structure of the HLS-EU-Q16.ConclusionOur findings align with previous research indicating high rates of limited HL among older adults. However, we were unable to confirm the three-factor model of the HLS-EU-Q16, which adds to the mixed findings across different participant groups and contexts of previous studies. Developing or adapting HL questionnaires for clinical purposes may improve their relevance and usability in future studies.

BACKGROUND:Hospital-wide mortality review processes are increasingly used to analyze inpatient deaths and identify opportunities to improve patient safety. This study evaluated the feasibility of developing and implementing such a mortality review in a German academic medical center. METHODS:We developed a mortality review checklist based on the Harvard Mortality Review and conducted a pilot test to assess its usability and integration into clinical systems (stage 1). Findings from the pilot phase informed revisions to the checklist and review processes. The adapted checklist was then implemented hospital-wide over 12 months (stage 2). Implementation was evaluated using a multifaceted approach that included clinical and administrative data and an assessment of key barriers and facilitators. RESULTS:During implementation, attending physicians (review 1a) and project clinical risk managers (review 1b) were invited to review 1303 inpatient deaths. Physicians completed 482 reviews (36.99%), rating 21 deaths (4.3%) as potentially preventable. Project clinical risk managers completed reviews for all cases and identified 33 deaths (2.5%) as potentially preventable. Nosocomial infections were the most frequent complication identified in both reviews (Review 1a: 35.02%; Review 1b: 32.92%; κ=0.260). Agreement between physician and risk manager assessments ranged from poor to substantial across checklist sections with particularly low agreement for preventability ratings. Twenty interviews with physicians and project staff identified key barriers to implementing the mortality review, including limited physician resources, redundant documentation, lack of automation, and liability concerns, while perceived usefulness and usability of the review were rated high. CONCLUSIONS:Implementation of a hospital-wide mortality review checklist and associated processes was feasible but constraint by organizational barriers. Although physicians and clinical risk managers identified potentially preventable deaths, inter-rater agreement was low. Sustainable integration into routine care will require substantial adaptations to clinical workflows and organizational structures. As part of a broader patient safety efforts, structured mortality review processes may support learning from inpatient deaths.

Abstract: The 9-item Shared Decision Making Questionnaire (SDM-Q-9) is widely used to measure shared decision-making (SDM) across clinical settings, but no study so far has synthesized its psychometric properties. In the present study, we systematically reviewed and synthesized psychometric evidence on the SDM-Q-9. The MEDLINE, Web of Science, PsycInfo, and CINAHL databases were searched for original studies in English or German, providing any information on psychometric properties of the SDM-Q-9 considering all possible interpretations and constructs measured by the instrument. Details on study design, sample characteristics, and information on psychometric evidence were extracted. We included 101 studies, with 49 articles contributing evidence on reliability, 91 on validity (87 on interrelations with other variables and 68 on the internal structure), and three on fairness. We found a high amount of psychometric evidence on the validity and reliability of the SDM-Q-9 as a measure of SDM perceived by the patient. Evidence is lacking for other interpretations and fairness. Notable is the weak association of the SDM-Q-9 with physician-rated SDM. In summary, substantial evidence supports reliability and validity of the SDM-Q-9 for assessing the subjectively experienced level of SDM by the patient, but further research is needed on alternative interpretations and on fairness of the measure.

BACKGROUND:Cross-sectional studies have already investigated associations between coping (i.e., strategies for dealing with stressors) and depressive and anxiety symptoms during the COVID-19 pandemic. However, these studies often lack considerations of temporal dynamics. Understanding these dynamics is crucial for addressing mental health challenges and preparing for future crises. This five-wave cohort study aimed to explore the relationship between coping, depressive and anxiety symptoms. METHODS:We included self-report data from n = 1289 German adults participating in a European cohort study ('ADJUST'). Individuals were surveyed at five timepoints between June 2020 and March 2024. Depressive and anxiety symptoms (anhedonia, depressed mood, anxious arousal, worrying) were measured using the Patient Health Questionnaire-4. Coping was assessed using the Brief-COPE, which incorporates 14 subscales (e.g., positive reframing, humor, behavioral disengagement, denial, self-blame). Cross-lagged panel network analysis was conducted to evaluate the relationship between coping and symptoms. We estimated three networks (temporal, contemporaneous, between-person) to quantify associations. RESULTS:We found several temporal associations. For example, increased worrying was linked to heightened denial and self-blame. Increased depressed mood was associated with stronger behavioral disengagement, which in turn was linked to decreased depressed mood and anhedonia. Humor was related to decreased anxious arousal, while positive reframing was linked to reduced anhedonia. CONCLUSIONS:The findings showed cross-lagged associations in which coping strategies and symptoms influenced each other over time. Future preventive, psychotherapeutic, or policy interventions could focus on addressing worrying and strengthening adaptive coping strategies such as positive reframing and humor to improve mental health.

The network approach to psychopathology conceptualizes mental disorders as systems of interacting symptoms rather than consequences of a latent factor. Recent developments have focused on modeling changes in symptom networks over time, where most approaches assume that these changes occur continuously. We propose an alternative by modelling discrete shifts between network states using hidden Markov models (HMMs). We conducted a secondary analysis of a multicenter randomized trial comparing disorder-specific and non-specific psychotherapy for chronic depression (n = 254). We identified two distinct states with the HMM: a low-symptom level state showing weaker symptom connectivity and a high-symptom level state with stronger positive connections. While participants typically remained in the same state across consecutive time points (80-88% of the time), transition probabilities differed between treatment groups. In particular, participants receiving disorder-specific psychotherapy showed higher probability of transitioning from the high-symptom to low-symptom state compared to the non-specific psychotherapy (19.5% vs. 12.0%). The regime-switching approach to analysis proved feasible and theoretically plausible, offering practical advantages for treatment evaluation within the network framework. By examining differences in network structure during healthy versus disordered states, this method provides insights into symptom dynamics that could inform both research and clinical applications.

Understanding mental health as a complex system has motivated the adoption of time-varying network models to explore how the dynamics of psychological variables change over time. While existing time-varying network models assume gradual change, shifts in symptom dynamics such as transitions between healthy and disordered states may occur rapidly. This could manifest as abrupt, qualitative changes between distinct states, often labelled as regime switches. In this scoping review, we identified and synthesized statistical approaches for modeling such phase transitions in the behavioral sciences that could be applied to network models. Our review yielded 40 studies across different fields, featuring 56 statistical analyses in total. Most analyses (71.4%) were based on Hidden Markov Models, which can be extended flexibly to model unobserved, recurrent states in various scenarios. Other approaches included change point models (14.3%), which identify shifts directly in the observed time series, and threshold models (12.5%), which model regime switches triggered when a dedicated threshold variable is crossed. We describe these approaches, their applications, and their data requirements, and assess their strengths and limitations for modeling shifts in the dynamics of time series. Notably, several approaches already include multilevel or multivariate-extensions, making them promising candidates for modelling changes in network dynamics in mental health. In sum, our review highlights the broad potential of regime-switching models to enrich the understanding of dynamics of mental health processes.

OBJECTIVE:Establishing robust evidence for psychotherapeutic treatment efficacy is crucial in evidence-based medicine for mental disorders. Randomized controlled trials (RCTs) are key to minimizing biases such as selection effects and baseline imbalances between study groups. However, another challenge to robust evidence in psychotherapy research is heterogeneity in treatment outcomes due to therapists and clinical sites. While this has been frequently observed in naturalistic settings, therapist- and site-related heterogeneity in treatment outcomes has been understudied in RCTs. METHOD:The present study addresses this gap in a secondary data analysis, examining how therapists and clinical sites differ in treatment outcomes and differential/average treatment effect (i.e., outcome differences between treatment groups) within a large, multicentre RCT. We analysed data from 255 patients with chronic depression treated by 79 therapists in nine study sites, that received two different active psychotherapeutic interventions. RESULTS:Therapist- and site-related variances in treatment outcomes appeared relatively small, accounting for 1.1% [0.0%, 8.1%] and 1.7% [0.0%, 9.9%] of the total variance, respectively. Notably, site-related variance in differential treatment effects appeared relatively larger at 12.5% [0.1%, 44.4%]. These variances were only partially explained by patient or therapist characteristics. CONCLUSION:While the sample size only allowed to estimate the variance contributions of therapists and sites with high uncertainty, the relative size comparison points to the importance of considering site heterogeneity in evaluating RCTs' differential treatment effects. Further research on site characteristics' impact could enhance understanding of psychotherapeutic treatment efficacy across diverse contexts.

OBJECTIVES:Geriatric patients are at increased risk of developing postoperative neurocognitive disorders, including delirium. Existing evidence-based perioperative interventions need to be implemented into routine care to improve postoperative outcomes. In this qualitative interview study, we wanted to collect stakeholder experiences to understand the implementation process of a multi-component intervention to prospectively facilitate future implementation. DESIGN:Descriptive qualitative evaluation research. SETTING:Single-centre at a German major urban academic hospital. PARTICIPANTS:22 interviews were conducted with n = 7 geriatric patients after surgery who had received a comprehensive geriatric assessment and an individualised perioperative multi-component intervention, and n = 15 healthcare professionals, including nurses, physicians and medical assistants working in the perioperative care. INTERVENTIONS:Semi-structured interviews were conducted, addressing the implementation procedure of the multicomponent intervention and the experience with it within the routine setting. MAIN OUTCOME MEASURES:The implementation outcomes were adoption, acceptance, appropriateness, feasibility and sustainability. RESULTS:Transcribed audio recordings were analysed with directed content analysis. Most intervention components could be adopted during the pilot trial. Implementation barriers were identified. Limited resources and logistic constraints threatened feasibility and sustainability. Acceptance of patients and healthcare providers regarding an intervention depended on its perceived appropriateness, which varied per intervention component, workspace and duration of the implementation. CONCLUSIONS:We were able to replicate and extend previous findings on the implementation of improved perioperative care. To facilitate the implementation success and motivation to implement evidence-based measures, resource allocation needs to be adjusted and standard operational procedures, as well as the cross-sectional collaboration, must be simplified. TRIAL REGISTRATION NUMBER:NCT03325413.

Background: We aimed to assess impairments on health-related quality of life, and mental health resulting from Retinal artery occlusion (RAO) with monocular visual field loss and posterior circulation ischemic stroke (PCIS) with full or partial hemianopia using patient-reported outcome measures (PROMs). Methods: In a prospective study, consecutive patients with acute RAO on fundoscopy and PCIS on imaging were recruited during their surveillance on a stroke unit over a period of 15 months. Baseline characteristics were determined from medical records and interviews. Health-related quality of life (PROM Information System 10-Question-Short-Form, PROMIS-10), and mental health symptoms (Patient-Health-Questionnaire-4, PHQ-4) were assessed 3 and 12 months after admission postally and via phone. Results: Ffity-seven patients with RAO and 19 with isolated full or partial hemianopia determined by the NIHSS (median = 2; IQR:0/2) according to PCIS were included. Characteristics of cardiovascular risk factors, and functional status pre-stroke were comparable between the groups. At 3 months, mean +/- standard deviation T-scores of PROMIS physical and mental health were 47.1 +/- 8.8 and 46.7 +/- 8.8 for patients with RAO, and 43.4 +/- 9.8 and 43.2 +/- 6.2 for PCIS. Compared to 50 +/- 10 in the general population, scores after RAO (p = 0.04; p = 0.02) and PCIS (p = 0.01; p < 0.001) were lower in both domains after 3 months. Concerning PCIS, scores in the mental health domain remained decreased at 12 months (p = 0.04). On the PHQ-4, 25% of patients with RAO, and 62% with PCIS scored indicative for anxious and/or depressive syndromes at 3 months. Conclusions: RAO led only to partial and to less persistent mental impairments than PCIS. This suggests that a different approach involving complex visual and neuropsychological treatment over a longer period of time needs to be considered for post-stroke care of PCIS. Trial Registration Information: The trial was submitted at http://www.clinicaltrials.gov, under NCT03795948.

Stroke survivors experience physical and psychological symptoms. However, long-term symptom prevalence and symptom associations have not been extensively studied. The current study aimed to assess the prevalence of physical and psychological symptoms across four years after stroke and to evaluate the relationship between these symptoms. We conducted a secondary analysis of a prospective, clinical, observational study. Physical (pain, fatigue, and physical impairment) and psychological (loss of interest, depressed mood, anxiety, and worry) symptoms were assessed using the International Consortium for Health Outcomes Measurement Standard Set for Stroke and the Patient Health Questionnaire for Depression and Anxiety three months, one year, two years, three years, and four years after hospital admission. We evaluated the prevalence of these symptoms across time and conducted a network analysis using panel vector autoregressive modeling. Physical impairment and fatigue had the highest prevalence in the sample. Psychological symptoms were also consistently observed, however, at a lower prevalence. There was no reduction in any symptom's prevalence across the course of four years after stroke. Furthermore, psychological and physical symptoms were associated with each other. Physical impairment was most strongly associated with the other symptoms, and anxiety symptoms preceded depressive symptoms. Thus, despite established follow-up care in Germany, symptoms persisted for years after stroke. Further, the observed symptom associations suggest the need to investigate the impact of physical symptoms on psychological distress. Our findings emphasize the need to prevent and treat persisting physical and psychological symptoms after stroke.

BACKGROUND:Implementation of interventions to improve follow-up stroke care is complex due to the involvement of various stakeholders and challenges of health care coordination. The aim of this study was to evaluate the process of implementing a cross-sectoral, coordinated follow-up care for stroke patients (the StroCare intervention). METHODS:As part of a multicenter interventional trial, this qualitative study was performed in a pre-post design with semi-structured interviews conducted with patients and health care employees. The multicomponent intervention was implemented in eight participating acute care and rehabilitation clinics. The interviews were analyzed using qualitative content analysis. Contents were coded using eight a priori defined categories (acceptability, adoption, appropriateness, feasibility, fidelity, sustainability, patient-centeredness, satisfaction with treatment, and pandemic-related effects) with the possibility of inductively developed categories. RESULTS:Interviews with 21 patients and 34 interviews with 23 employees were conducted. In addition to the deductive categories, three inductive categories (psychosocial implications, interconnectedness, and potential for improvement) emerged. Acceptability, adoption, and appropriateness were assessed positively before the intervention. However, poor feasibility had a negative impact on adoption and appropriateness. In contrast, outcomes related to patient care (patient-centeredness and psychosocial implications) were independent from this effect. CONCLUSIONS:Similar to other implementation studies of stroke care interventions, implementation of eHealth Services in the StroCare project met barriers in usability and adaptability of new software. However, high adoption and appropriateness in regard to patient-centeredness, psychosocial implications, and an overall benefit for the patients supported continuation of the remaining intervention components. Trial registration The trial is registered at ClinicalTrials.gov (NCT04159324), registration date 12/11/19.