Perceptions and evaluations of front-line health workers regarding the Brazilian National Program for Improving Access and Quality to Primary Care (PMAQ): a mixed-method approach.

Although it is well known that a successful implementation depends on the front-liners' knowledge and participation, as well as on the organizational capacity of the institutions involved, we still know little about how front-line health workers have been involved in the implementation of the Brazilian National Program for Improving Access and Quality to Primary Care (PMAQ). This paper develops a contingent mixed-method approach to explore the perceptions of front-line health workers - managers, nurses, community health workers, and doctors - regarding the PMAQ (2nd round), and their evaluations concerning health unit organizational capacity. The research is guided by three relevant inter-related concepts from implementation theory: policy knowledge, participation, and organizational capacity. One hundred and twenty-seven health workers from 12 primary health care units in Goiânia, Goiás State, Brazil, answered semi-structured questionnaires, seeking to collect data on reasons for adherence, forms of participation, perceived impact (open-ended questions), and evaluation of organizational capacity (score between 0-10). Content analyses of qualitative data enabled us to categorize the variables "level of perceived impact of PMAQ" and "reasons for adhering to PMAQ". The calculation and aggregation of the means for the scores given for organizational capacity enabled us to classify distinct levels of organizational capacity. We finally integrated both variables (Perceived-Impact and Organizational-Capacity) through cross-tabulation and the narrative. Results show that nurses are the main type of professional participating. The low organizational capacity and little policy knowledge affected workers participation in and their perceptions of the PMAQ.

Perceptions and evaluations of front-line health workers regarding the Brazilian National Program for Improving Access and Quality to Primary Care (PMAQ): a mixed-method approach / As percepções e avaliações dos profissionais de saúde que trabalham na ponta em relação ao Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ): uma abordagem com métodos mistos / Percepciones y evaluaciones de los trabajadores de salud de primera línea, en relación con el Programa Nacional de Mejora del Acceso y Calidad de la Atención Básica (PMAQ): un enfoque metodológico mixto

Abstract: Although it is well known that a successful implementation depends on the front-liners' knowledge and participation, as well as on the organizational capacity of the institutions involved, we still know little about how front-line health workers have been involved in the implementation of the Brazilian National Program for Improving Access and Quality to Primary Care (PMAQ). This paper develops a contingent mixed-method approach to explore the perceptions of front-line health workers - managers, nurses, community health workers, and doctors - regarding the PMAQ (2nd round), and their evaluations concerning health unit organizational capacity. The research is guided by three relevant inter-related concepts from implementation theory: policy knowledge, participation, and organizational capacity. One hundred and twenty-seven health workers from 12 primary health care units in Goiânia, Goiás State, Brazil, answered semi-structured questionnaires, seeking to collect data on reasons for adherence, forms of participation, perceived impact (open-ended questions), and evaluation of organizational capacity (score between 0-10). Content analyses of qualitative data enabled us to categorize the variables "level of perceived impact of PMAQ" and "reasons for adhering to PMAQ". The calculation and aggregation of the means for the scores given for organizational capacity enabled us to classify distinct levels of organizational capacity. We finally integrated both variables (Perceived-Impact and Organizational-Capacity) through cross-tabulation and the narrative. Results show that nurses are the main type of professional participating. The low organizational capacity and little policy knowledge affected workers participation in and their perceptions of the PMAQ.

Resumo: Sabe-se que a implementação bem-sucedida de um programa depende do conhecimento e da participação dos profissionais que trabalham na ponta, além da capacidade organizacional das instituições envolvidas. No entanto, ainda sabemos pouco sobre o envolvimento desses profissionais na implementação do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ). O artigo desenvolve uma abordagem de métodos mistos de tipo contingente para explorar as percepções dos profissionais de saúde na ponta - gestores locais, enfermeiros, agentes comunitários de saúde e médicos - sobre o segundo ciclo do PMAQ, além de relacionar essas percepções às avaliações a respeito da capacidade organizacional da unidade de saúde. O estudo é orientado por três conceitos inter-relacionados e relevantes da teoria da implementação: conhecimento das políticas, participação e capacidade organizacional. Cento e vinte e sete profissionais de saúde de 12 unidades de atenção primária em Goiânia, Goiás, Brasil, responderam questionários semiestruturados, buscando coletar dados sobre os motivos pela adesão, formas de participação, impacto percebido (perguntas abertas) e avaliação da capacidade organizacional (pontuações de 0 a 10). As análises de conteúdo dos dados qualitativos permitiram categorizar as variáveis "nível percebido de impacto do PMAQ" e "motivos pela adesão ao PMAQ". Os cálculos e agregação da média das pontuações para capacidade organizacional permitiram classificar os diferentes níveis dessa capacidade. Finalmente, foram integradas as duas variáveis (Impacto Percebido e Capacidade Organizacional) através da tabulação cruzada e da narrativa. Os resultados mostram que os enfermeiros são o principal tipo de profissional que participa no programa. A baixa capacidade organizacional e o conhecimento limitado da política afetaram a participação dos professionais de saúde e suas percepções em relação ao PMAQ.

Resumen: Pese a que es bien sabido que una implementación exitosa depende del conocimiento y participación de los trabajadores de salud de primera línea, así como la capacidad organizativa de las instituciones involucradas, todavía sabemos poco sobre cómo los trabajadores de salud en primera línea de atención han sido involucrados en la implementación del Programa Nacional de Mejora del Acceso y Calidad de la Atención Básica (PMAQ) brasileño. Este trabajo desarrolla un enfoque metodológico mixto aleatorio para investigar las percepciones de los trabajadores de primera línea de la salud -gestores, enfermeras, trabajadores comunitarios de cuidados de salud, y doctores- en relación con el PMAQ (segunda fase), y asociarlos con sus evaluaciones respecto a la capacidad organizativa de las unidades de salud. La investigación está guiada por tres conceptos relevantes interrelacionados, provenientes de la teoría de la implementación: política de conocimiento, participación, y capacidad organizativa. Ciento veintisiete trabajadores de salud, procedentes de 12 unidades de atención primaria de salud en Goiânia, respondieron a cuestionarios semiestructurados, buscando recoger datos sobre: adherencia, formas de participación, impacto percibido (preguntas de final abierto), y evaluación de la capacidad organizativa (notas entre 0-10). El contenido de los análisis cualitativos de datos nos permitió categorizar las variables "nivel del impacto percibido de PMAQ" y "razones de adherencia al PMAQ". El cálculo y agregación de medios para los marcadores proporcionados, respecto a la capacidad organizativa, nos permitieron clasificar los distintos niveles de la misma. Integramos, finalmente, ambas variables (Impacto Percibido y Capacidad Organizativa) mediante tabulación cruzada y narrativa. Los resultados muestran que las enfermeras son la mayor parte de las profesionales que participan. La baja capacidad organizativa y el escaso conocimiento sobre las políticas que deben ser implementadas afectó a la participación y sus percepciones sobre el PMAQ.

Anti-diarrhoeal therapeutic potential and safety assessment of sulphated polysaccharide fraction from Gracilaria intermedia seaweed in mice.

Sulphated polysaccharides extracted from algae have been extensively studied for their diverse biological activities. Thus, the purpose of this study was to evaluate the chemical composition, the anti-diarrhoeal effect and acute toxicity of a sulphated polysaccharide fraction obtained from Gracilaria intermedia (SP-Gi). Initially, the FT-IR of SP-Gi revealed to be an agaran with sulphation at C-6 of the l-galactosyl residues. The anti-diarrhoeal activity of SP-Gi was evaluated in a castor oil-induced diarrhoea model. The effects of SP-Gi on enteropooling, Na +-K +-ATPase activity, gastrointestinal transit, and gastric emptying were then examined. Subsequently, the effect of SP-Gi on diarrhoea induced by cholera toxin (CT) and Escherichia coli was examined. In addition, an acute toxicity test was conducted in accordance with OECD guideline 423. Pre-treatment with SP-Gi reduces the total faeces, total diarrhoeal faeces, and enteropooling. SP-Gi (30mg/kg p.o.) increased Na+/K+-ATPase activity and reduced gastrointestinal transit through anticholinergic mechanisms. ELISA demonstrated that SP-Gi can interact with GM1 receptors and CT. SP-Gi reduced diarrhoea induced by E. coli and prevented weight loss in the animals. Moreover, SP-Gi did not induce any toxicity signs. These results suggest that SP-Gi is a possible candidate for the treatment of diarrhoeal illnesses.

Diminazene aceturate, an angiotensin-converting enzyme II activator, prevents gastric mucosal damage in mice: Role of the angiotensin-(1-7)/Mas receptor axis.

The angiotensin (Ang) II converting enzyme (ACE II) pathway has recently been shown to be associated with several beneficial effects in various organisms, including gastroprotection. ACE II is responsible for converting Ang II into an active peptide, Ang-(1-7), which in turn binds the Mas receptor. Recent studies have shown that diminazene aceturate (Dize) a trypanocidal used in animals, activates ACE II. Thus, in this study, we aimed to evaluate the gastroprotective effects of Dize via the ACE II/Ang-(1-7)/Mas receptor pathway against gastric lesions induced by ethanol and acetic acid in mice. The results showed that Dize could promote gastric protection via several mechanisms, including increased levels of antioxidants and anti-inflammatory factors (e.g., decreasing tumor necrosis factor and interleukin-6 expression and reducing myeloperoxidase activity), maturation of collagen fibers, and promotion of re-epithelialization and regeneration of gastric tissue in different injury models. Thus, Dize represents a novel potential gastroprotective agent.

The efficacy of a sulphated polysaccharide fraction from Hypnea musciformis against diarrhea in rodents.

Seaweeds are sources of diverse bioactive compounds, such as sulphated polysaccharides. This study was designed to evaluate the chemical composition and anti-diarrheal activity of a fraction of sulphated polysaccharide (PLS) obtained from the red seaweed Hypnea musciformis in different animal models, and to elucidate the underlying mechanisms. PLS was obtained by aqueous extraction, with a yield of 31.8% of the seaweed dry weight. The total carbohydrate content accounted for 99% of the sample. The sulfate content of the polysaccharide was 5.08% and the percentage of carbon was 25.98%. Pretreatment with all doses of PLS inhibited castor oil-induced diarrhea, with reduction of the total amount of stool, diarrheal stools, and the severity of diarrhea. PLS (90 mg/Kg) decreased castor oil- and PGE2-induced enteropooling. In addition, PLS (90 mg/Kg) increased the Na(+)/K(+)-ATPase activity in the small intestine and reduced gastrointestinal transit, possibly via activation of cholinergic receptors. Interestingly, the cholera toxin-induced fluid secretion and Cl(-) ion levels decreased in the intestinal contents of the animals pretreated with PLS (90 mg/kg), probably via reduction of toxin-GM1 receptor binding. In conclusion, PLS exerts anti-diarrheal activity by increasing Na(+)/K(+)-ATPase activity, inhibiting gastrointestinal motility, and blocking the toxin-GM1 receptor binding.

Sulphated Polysaccharide Isolated from the Seaweed Gracilaria caudata Exerts an Antidiarrhoeal Effect in Rodents.

Diarrhoea is a significant health problem for children in developing countries that causes more than 1 million deaths annually. This study aimed to evaluate the antidiarrhoeal effect of sulphated polysaccharide (PLS) from the alga Gracilaria caudata in rodents. For the evaluation, acute diarrhoea was induced in Wistar rats (150-200 g) by administration of castor oil (10 mg/kg). Then, different parameters, including enteropooling and gastrointestinal transit and its pharmacological modulation by opioid and cholinergic pathways, were assessed using activated charcoal in Swiss Mice (25-30 g). Secretory diarrhoea was examined using cholera toxin (CT) (1 mg/loop)-treated, isolated intestinal loops from Swiss mice (25-30 g), which were also used to examine fluid secretion, loss of chloride ions into the intestinal lumen and absorption. In addition, a GM1-dependent ELISA was used to evaluate the interaction between PLS, CT and the GM1 receptor. Pre-treatment with PLS (10, 30 and 90 mg/kg) reduced faecal mass, diarrhoeal faeces and enteropooling. However, 90 mg/kg more effectively reduced these symptoms; therefore, it was used as the standard dose in subsequent experiments. Gastrointestinal transit was also reduced by PLS treatment via a cholinergic mechanism. Regarding the diarrhoea caused by CT, PLS reduced all study parameters, and the ELISA showed that PLS can interact with both the GM1 receptor and CT. These results show that PLS from G. caudata effectively improved the parameters observed in acute and secretory diarrhoea, which affects millions of people, and may lead to the development of a new alternative therapy for this disease.

Protective Effects of Simvastatin Against Alendronate-Induced Gastric Mucosal Injury in Rats.

BACKGROUND: It has been reported that simvastatin, a statin commonly prescribed for its anti-inflammatory and antioxidant effects, has gastroprotective effects in indomethacin and ethanol-induced gastric ulcers. However, the effects of simvastatin on alendronate-induced gastric mucosal injury remain unexplored. AIM: This study investigated the use of simvastatin for the treatment of alendronate-induced gastric ulcers in rats. METHODS: Female rats were pretreated with vehicle or simvastatin (20 and 60 mg/kg p.o.). After 1 h, the rats received alendronate (50 mg/kg p.o.). Simvastatin was administered once daily for 7 days, and from the fourth day of simvastatin treatment, alendronate was administered once daily for 4 days. On the final day of treatment, 4 h after alendronate administration, animals were euthanized, their stomachs were removed, and gastric damage was measured. Samples of the stomach were fixed in 10 % formalin immediately after their removal for subsequent histopathological assessment. Unfixed samples were weighed, frozen at -80 °C until assayed for glutathione (GSH), malondialdehyde (MDA), and cytokine levels and myeloperoxidase (MPO) activity. A third group was used to measure mucus and gastric secretion. RESULTS: Pretreatment with simvastatin prevented alendronate-induced macroscopic gastric damage and reduced the levels of MDA and GSH, TNF-α and IL-1ß, MPO activity, and mucus levels, in the stomach. CONCLUSIONS: This study demonstrates the protective effects of simvastatin against alendronate-induced gastric ulceration. Maintenance of mucosal integrity, inhibition of neutrophil activity, and reduced oxidative stress associated with decreased gastric acidity may explain the gastroprotective effects of simvastatin.

Antidiarrheal activity of cashew GUM, a complex heteropolysaccharide extracted from exudate of Anacardium occidentale L. in rodents.

ETHNOPHARMACOLOGICAL RELEVANCE: Anacardium occidentale L. (Anacardiaceae) is commonly known as the cashew tree. It is native to tropical America and extracts of the leaves, bark, roots, chestnut net and exudate have been traditionally used in northeast Brazil for the treatment of various diseases. The exudate of the cashew tree (cashew gum) has been exploited by locals since ancient times for multiple applications, including the treatment of diarrheal diseases. AIM OF THE STUDY: The primary aim of the present study is to evaluate the antidiarrheal activity of cashew gum (CG), a complex heteropolysaccharide from the exudate of the cashew tree, using various models. MATERIALS AND METHODS: The antidiarrheal activity of cashew gum (CG) against acute diarrhea was investigated using the castor oil-induced diarrhea model. The effects of CG on gastrointestinal transit and castor oil- and PGE2- induced enteropooling were also examined in rodents. In addition, the effect of CG against secretory diarrhea was investigated using a model of fluid secretion in cholera toxin-treated intestinal closed loops in live mice. RESULTS: Cashew gum (30, 60, and 90 mg/kg, p.o.) showed a significant (P<0.05-0.01) antidiarrheal effect in rats with castor oil-induced diarrhea, inhibiting the total amount of stool and diarrheal stools. The 60 mg/kg dose of CG exhibited excellent antidiarrheal activity and significantly reduced the severity of diarrhea (diarrhea scores) in rats. CG (60 mg/kg) significantly (P<0.05) decreased the volume of castor oil- and PGE2-induced intestinal fluid secretion (enteropooling). In addition, similar to loperamide (standard drug, 5 mg/kg, p.o.), CG treatment reduced the distance traveled by a charcoal meal in the 30-min gastrointestinal transit model by interacting with opioid receptors. In cholera toxin-induced secretory diarrhea, CG (60 mg/kg) significantly inhibited the intestinal fluid secretion and decreased Cl(-) ion loss in the cholera toxin(-)treated isolated loops model of live mice by competitively binding to cholera toxin-GM1 receptors. CONCLUSIONS: In conclusion, our results indicate that a complex heteropolysaccharide extracted from the exudate of A. occidentale L. has antidiarrheal activity in acute, inflammatory, and secretory diarrhea models, which could justify its traditional use in the treatment of diarrhea in northeast Brazil. The antidiarrheal activity might be explained by the capacity of CG to inhibit gastrointestinal motility and thereby reduce the accumulation of intestinal fluid and the secretion of water and chloride ions in the lumen of the intestine.