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Resumo Objetivo Compreender dificuldades e emoções no processo de cuidado na perspectiva das pessoas que cuidam de pessoas idosas em processos de fragilização nos seus domicílios. Método Pesquisa qualitativa, ancorada no referencial teórico-metodológico da Antropologia Interpretativa e Médica. Nove cuidadoras e um cuidador foram entrevistados no domicílio da pessoa idosa cuidada. A análise êmica foi guiada pelo modelo dos Signos, Significados e Ações Resultados As dificuldades aparecem na ausência de formação para cuidar, nos constrangimentos das rotinas de higiene, na ausência de cumprimento de direitos trabalhistas, na falta de acessibilidade e de recursos materiais, nas relações familiares e na interpretação das ações da pessoa cuidada como teimosia. As emoções descritas pelas pessoas entrevistadas são de carinho, satisfação, cansaço, estresse, sobrecarga e medo de agravamento e de erro. Conclusão As pessoas que cuidam revelaram um envolvimento intenso e complexo de âmbito moral, mas também ético e emocional. Evidenciam um cenário em que é fundamental reconhecer e enxergar o trabalho de cuidar de as pessoas idosas em processo de fragilização e implementar políticas de cuidado com ações comunitárias e intersetoriais de suporte ao cuidado.
Abstract Objective To comprehend the challenges and emotions within the caregiving process from the perspective of those who care for older adults in situations of frailty within their own homes. Method A qualitative research approach rooted in the theoretical and methodological framework of Interpretative and Medical Anthropology was employed. Nine female caregivers and one male caregiver were interviewed within the homes of the elderly individuals they were caring for. Emic analysis was guided by the model of Signs, Meanings, and Actions. Results Challenges manifest in the absence of caregiver training, constraints related to hygiene routines, the absence of compliance with labor rights, lack of accessibility and material resources, family relationships, and the interpretation of the actions of the care recipients as stubbornness. Emotions described by the interviewees include affection, satisfaction, fatigue, stress, burden, and fear of worsening and making mistakes. Conclusion Caregivers revealed a deep and complex moral, ethical, and emotional involvement in their caregiving roles. They highlight a scenario where it is essential to recognize and acknowledge the work involved in caring for older adults in situations of frailty and to implement caregiving policies with community and cross-sector support actions.
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Humanos , Idoso Fragilizado , Cuidadores/psicologia , Atividades Cotidianas , Envelhecimento , Saúde do Idoso , Cuidadores , Cuidadores/educação , Pacientes DomiciliaresRESUMO
Background: In low and middle-income countries, there is growing interest in managing pressures on health services through community interventions for older people. Evidence on the effects of such interventions is scarce. We draw on qualitative data to examine these effects for a specific scheme, Programa Maior Cuidado (PMC) in the Brazilian city of Belo Horizonte. Methods: Building on quantitative findings reported elsewhere, we use qualitative data to develop and test theories of change. These include data from 50 meetings with policymakers, managers and staff in 30 health centres and social assistance posts. Data collection was embedded in key informant interaction and knowledge coproduction. Data include participant and non-participant observation, focus groups and semi-structured interviews with key informants, as well as older people and carers from seven families. Findings: The data reveal three theories of change. Theory 1 is PMC maintains older people's health which reduces their need for inpatient or outpatient care. We find strong evidence to support this, through effects on use of medication, chronic disease management and risk prevention. Theory 2 is PMC promotes timely intervention by anticipating health problems, thus reducing demand for emergency and acute care. We find some evidence for this, but it was limited by limited availability of timely treatment or referral beyond PMC. Theory 3 is PMC facilitates hospital discharge. We find limited evidence for this, reflecting a lack of formal liaison between PMC and hospitals. Interpretation: Schemes like PMC have potential to reduce pressures on health service utilisation by older people, if they are well articulated with wider health services. Funding: Medical Research Council, Newton Fund and Brazilian Council of State Funding Agencies.
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OBJECTIVE: To understand the perception of different actors involved in the older adults care process in the intersectoral strategy of the Programa Maior Cuidado (PMC - Greater Care Program), aiming at the development of actions that contribute to the improvement of the services provided. METHODS: Eleven qualitative interviews guided by a semi-structured script were conducted in 2020 with key informants directly involved in the PMC: the older adults and their families, caregivers, health professionals and social assistance. In addition, to understand the functioning and proposals of the PMC, a documentary analysis was also carried out with the tracking of existing information on the guidelines, protocols, and management instruments. The content analysis technique was used to classify textual data, and the interpretation process was mediated by the theoretical-methodological framework of hermeneutic anthropology. RESULTS: Two categories were identified: "Repercussions of the care offered by the PMC: the 'little' that makes a difference" and "Problems beyond the PMC: the limits of family care in the face of violence against the older adults". For all interviewees, the perception the PMC is very necessary is unison, being able to minimize the occurrence of health problems and avoid transfers of the older adults to hospitals and Long Stay Institutions for the Elderly (Instituição de Longa Permanência - ILPI in Portuguese). Chronic comorbidities increase the demands of health care and generate situations that can be managed by the PMC caregiver. Population aging requires the planning of strategies and public policies aimed at providing continuous care for the older adults, including those living in communities. The PMC emerges as an intersectoral alternative to assist in this issue. CONCLUSIONS: The PMC can be considered a good practice model to be expanded to other locations, however there are gaps that need to be rediscussed so that its processes are improved and its results enhanced.
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Envelhecimento , Cuidadores , Humanos , Idoso , Brasil , Atenção à Saúde , Pessoal de Saúde , Pesquisa QualitativaRESUMO
The present study sought to understand how frail older adults perceive their therapeutic care itineraries. This qualitative research was based on Critical Medical Anthropology. Data were collected through interviews in the homes of 22 older adults, whose average age was 79. The emic analysis was guided by the model of Signs, Meanings, and Actions. All interviewees expressed access to professional care in their trajectories, which are understood as insufficient, unprepared, prejudiced, uncomfortable, contradictory, (un)accessible, realization, respectful, and excessive. Therapeutic itineraries were also revealed in the psychosocial and cultural spheres. Several day-to-day actions were evaluated and interpreted in the record of self-care and justified by this end: the time they wake up, sleep, what they eat, and how they behave. They face the lack of care policies in their trajectories, labeling their bodies as undesirable due to physical, symbolic, communicational, attitudinal, systematic, cultural, and political barriers. Thus, they bring to light therapeutic pluralism, challenges, confrontations, insistence, and resistance in maintaining care when experiencing old age with frailties.
O trabalho buscou compreender a percepção de pessoas idosas em processo de fragilização sobre seus itinerários terapêuticos de cuidados. Esta pesquisa qualitativa, ancorou-se na antropologia médica crítica. A coleta dos dados ocorreu por meio de entrevistas no domicílio de 22 pessoas idosas, com média etária de 79 anos. A análise êmica foi guiada pelo modelo dos signos, significados e ações. Todos os(as) entrevistados(as) expressam acessar cuidados profissionais em sua trajetória que são interpretados como: insuficientes, despreparados, preconceituosos, incômodos, contraditórios, (in)acessíveis, um achado, respeitosos e excessivos. Os itinerários terapêuticos revelam-se também nos âmbitos psicossociais e culturais. Diversas ações do dia a dia vão sendo avaliadas e interpretadas no registro do cuidado consigo e justificadas por esse fim: o horário que acorda, que dorme, o que come, como se comporta. Em suas trajetórias, deparam-se com a falta de políticas de cuidados, com o enquadramento de seus corpos como indesejáveis, com barreiras físicas, simbólicas, comunicacionais, atitudinais, sistemáticas, culturais e políticas. Desse modo, revelam o pluralismo terapêutico, os desafios, os enfrentamentos, a insistência e a resistência na manutenção de cuidados ao experienciar velhices com fragilidades.
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Idoso Fragilizado , Fragilidade , Humanos , Idoso , Autocuidado , Preconceito , Pesquisa QualitativaRESUMO
Resumo O trabalho buscou compreender a percepção de pessoas idosas em processo de fragilização sobre seus itinerários terapêuticos de cuidados. Esta pesquisa qualitativa, ancorou-se na antropologia médica crítica. A coleta dos dados ocorreu por meio de entrevistas no domicílio de 22 pessoas idosas, com média etária de 79 anos. A análise êmica foi guiada pelo modelo dos signos, significados e ações. Todos os(as) entrevistados(as) expressam acessar cuidados profissionais em sua trajetória que são interpretados como: insuficientes, despreparados, preconceituosos, incômodos, contraditórios, (in)acessíveis, um achado, respeitosos e excessivos. Os itinerários terapêuticos revelam-se também nos âmbitos psicossociais e culturais. Diversas ações do dia a dia vão sendo avaliadas e interpretadas no registro do cuidado consigo e justificadas por esse fim: o horário que acorda, que dorme, o que come, como se comporta. Em suas trajetórias, deparam-se com a falta de políticas de cuidados, com o enquadramento de seus corpos como indesejáveis, com barreiras físicas, simbólicas, comunicacionais, atitudinais, sistemáticas, culturais e políticas. Desse modo, revelam o pluralismo terapêutico, os desafios, os enfrentamentos, a insistência e a resistência na manutenção de cuidados ao experienciar velhices com fragilidades.
Abstract The present study sought to understand how frail older adults perceive their therapeutic care itineraries. This qualitative research was based on Critical Medical Anthropology. Data were collected through interviews in the homes of 22 older adults, whose average age was 79. The emic analysis was guided by the model of Signs, Meanings, and Actions. All interviewees expressed access to professional care in their trajectories, which are understood as insufficient, unprepared, prejudiced, uncomfortable, contradictory, (un)accessible, realization, respectful, and excessive. Therapeutic itineraries were also revealed in the psychosocial and cultural spheres. Several day-to-day actions were evaluated and interpreted in the record of self-care and justified by this end: the time they wake up, sleep, what they eat, and how they behave. They face the lack of care policies in their trajectories, labeling their bodies as undesirable due to physical, symbolic, communicational, attitudinal, systematic, cultural, and political barriers. Thus, they bring to light therapeutic pluralism, challenges, confrontations, insistence, and resistance in maintaining care when experiencing old age with frailties.
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This article aims to evaluate the Brazilian Long-Term Institutions for Older People (LTIE), according to the Integrated Multidimensional Theoretical Model of Quality and Service (MIQA), and compare the performance achieved between the regions of the country. Descriptive ecological study carried out with public secondary data from the LTIE participating in the 2018 Census of the Unified Social Assistance System. An Evaluation Matrix was constructed from the Census variables and the MIQA Theoretical Model. Quality parameters were used to classify the institutions' performance for each indicator as "incipient", "developing" or "desirable". The disparity index was obtained for each indicator. 1,665 institutions were analyzed. Differences were observed in the percentages of LTIE with "desirable" performance between Brazilian regions, and the need for improvement in most LTIE in relation to the proportion of caregivers of older people, the composition of the multidisciplinary team, accessibility and supply of health promotion actions. There was a need for government support for the suppression of exclusionary differentiation criteria and for the expansion of services to overcome overcrowding.
O objetivo deste artigo é avaliar as Instituições de Longa Permanência para Idosos (ILPI) brasileiras, segundo o Modelo Teórico Multidimensional Integrado de Qualidade e Atendimento (MIQA), e comparar o desempenho alcançado entre as regiões do país. Estudo ecológico descritivo realizado com dados secundários públicos das ILPI participantes do Censo do Sistema Único da Assistência Social de 2018. Uma Matriz de Avaliação foi construída a partir das variáveis do Censo e do Modelo Teórico MIQA. Parâmetros de qualidade foram empregados para classificar o desempenho das instituições para cada indicador em "incipiente", "em desenvolvimento" ou "desejável. O índice de disparidade foi obtido para cada indicador. Foram analisadas 1.665 instituições. Observaram-se diferenças nos percentuais de ILPI com desempenho "desejável" entre as regiões brasileiras, e a necessidade de aprimoramento na maioria das ILPI em relação à proporção de cuidadores de pessoas idosas, a composição da equipe multiprofissional, a acessibilidade e a oferta de ações de promoção de saúde. Verificou-se a necessidade de apoio governamental para a supressão dos critérios de diferenciações excludentes e para a expansão dos serviços para superar as superlotações.
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Instituição de Longa Permanência para Idosos , Idoso , Humanos , Brasil , Instituição de Longa Permanência para Idosos/normasRESUMO
Resumo O objetivo deste artigo é avaliar as Instituições de Longa Permanência para Idosos (ILPI) brasileiras, segundo o Modelo Teórico Multidimensional Integrado de Qualidade e Atendimento (MIQA), e comparar o desempenho alcançado entre as regiões do país. Estudo ecológico descritivo realizado com dados secundários públicos das ILPI participantes do Censo do Sistema Único da Assistência Social de 2018. Uma Matriz de Avaliação foi construída a partir das variáveis do Censo e do Modelo Teórico MIQA. Parâmetros de qualidade foram empregados para classificar o desempenho das instituições para cada indicador em "incipiente", "em desenvolvimento" ou "desejável. O índice de disparidade foi obtido para cada indicador. Foram analisadas 1.665 instituições. Observaram-se diferenças nos percentuais de ILPI com desempenho "desejável" entre as regiões brasileiras, e a necessidade de aprimoramento na maioria das ILPI em relação à proporção de cuidadores de pessoas idosas, a composição da equipe multiprofissional, a acessibilidade e a oferta de ações de promoção de saúde. Verificou-se a necessidade de apoio governamental para a supressão dos critérios de diferenciações excludentes e para a expansão dos serviços para superar as superlotações.
Abstract This article aims to evaluate the Brazilian Long-Term Institutions for Older People (LTIE), according to the Integrated Multidimensional Theoretical Model of Quality and Service (MIQA), and compare the performance achieved between the regions of the country. Descriptive ecological study carried out with public secondary data from the LTIE participating in the 2018 Census of the Unified Social Assistance System. An Evaluation Matrix was constructed from the Census variables and the MIQA Theoretical Model. Quality parameters were used to classify the institutions' performance for each indicator as "incipient", "developing" or "desirable". The disparity index was obtained for each indicator. 1,665 institutions were analyzed. Differences were observed in the percentages of LTIE with "desirable" performance between Brazilian regions, and the need for improvement in most LTIE in relation to the proportion of caregivers of older people, the composition of the multidisciplinary team, accessibility and supply of health promotion actions. There was a need for government support for the suppression of exclusionary differentiation criteria and for the expansion of services to overcome overcrowding.
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BACKGROUND: Family caregivers are primarily responsible for the care of older adults with dementia, and the demands of this care increase as the end of life approaches. Experiencing the end of a family member's life can be stressful, and caregivers consider important to know how to identify when their loved one is approaching the end of life in order to prepare for this moment. Thus, as the family is primarily responsible for the older adult with dementia, it is essential to know the meanings of the end of life attributed by family caregivers. OBJECTIVE: To analyze the perceptions of family caregivers of older adults with dementia about the end of life. METHODS: This is a qualitative, descriptive and exploratory study. The convenience sample consisted of family caregivers of older adults with dementia. The inclusion criteria were being a family member directly involved in the care of the older adult with dementia and being 18 years of age or older. Data were collected from individual semi-structured interviews. The number of participants was defined during the interviews using the saturation criterion. Data were analyzed using the thematic analysis technique. RESULTS: A total of 63 family caregivers participated, 74.6% of whom were women, predominantly wives and daughters. Two themes resulted from the data analysis: (i) Different perspectives on the end of life: from death itself to a sad, painful and long grief process; and (ii) End of life in the perspective of transcendence. The meaning of the end of life was perceived in different ways by family caregivers. Understanding how they perceive and experience the end-of-life process of the older adult with dementia helps to clarify the best ways for the health professionals to approach and intervene with these families.
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Cuidadores , Demência , Humanos , Feminino , Adolescente , Adulto , Idoso , Masculino , Pessoal de Saúde , Pesar , Família , Morte , Pesquisa QualitativaRESUMO
ABSTRACT OBJECTIVE To understand the perception of different actors involved in the older adults care process in the intersectoral strategy of the Programa Maior Cuidado (PMC - Greater Care Program), aiming at the development of actions that contribute to the improvement of the services provided. METHODS Eleven qualitative interviews guided by a semi-structured script were conducted in 2020 with key informants directly involved in the PMC: the older adults and their families, caregivers, health professionals and social assistance. In addition, to understand the functioning and proposals of the PMC, a documentary analysis was also carried out with the tracking of existing information on the guidelines, protocols, and management instruments. The content analysis technique was used to classify textual data, and the interpretation process was mediated by the theoretical-methodological framework of hermeneutic anthropology. RESULTS Two categories were identified: "Repercussions of the care offered by the PMC: the 'little' that makes a difference" and "Problems beyond the PMC: the limits of family care in the face of violence against the older adults". For all interviewees, the perception the PMC is very necessary is unison, being able to minimize the occurrence of health problems and avoid transfers of the older adults to hospitals and Long Stay Institutions for the Elderly (Instituição de Longa Permanência - ILPI in Portuguese). Chronic comorbidities increase the demands of health care and generate situations that can be managed by the PMC caregiver. Population aging requires the planning of strategies and public policies aimed at providing continuous care for the older adults, including those living in communities. The PMC emerges as an intersectoral alternative to assist in this issue. CONCLUSIONS The PMC can be considered a good practice model to be expanded to other locations, however there are gaps that need to be rediscussed so that its processes are improved and its results enhanced.
RESUMO OBJETIVO Compreender a percepção de diferentes atores envolvidos no processo de cuidado ao idoso na estratégia intersetorial do Programa Maior Cuidado (PMC), visando o desenvolvimento de ações que contribuam para a melhoria dos serviços prestados. MÉTODOS Foram realizadas 11 entrevistas qualitativas guiadas por roteiro semiestruturado em 2020 junto a informantes-chave diretamente envolvidos no PMC: idosos e seus familiares, cuidadores, profissionais da saúde e da assistência social. Adicionalmente, com o objetivo de compreensão do funcionamento e das propostas do PMC, também foi realizada uma análise documental com o rastreamento de informações existentes sobre as diretrizes, os protocolos e os instrumentos de gestão. Utilizou-se a técnica de análise de conteúdo para classificar os dados textuais, e o processo de interpretação foi mediado pelo referencial teórico-metodológico da antropologia hermenêutica. RESULTADOS Foram identificadas duas categorias: "Repercussões do cuidado ofertado pelo PMC: o 'pouco' que faz diferença" e "Problemas para além do PMC: os limites do cuidado familiar diante da violência contra a pessoa idosa". Para todos os entrevistados é uníssona a percepção de que o PMC é muito necessário, sendo capaz de minimizar a ocorrência de agravos de saúde e evitar transferências dos idosos para hospitais e Instituições de Longa Permanência para Idosos (Ilpi). As comorbidades crônicas aumentam as demandas de cuidado em saúde e geram situações que podem ser manejadas pelo cuidador do PMC. O envelhecimento populacional requer o planejamento de estratégias e políticas públicas voltadas para o provimento de cuidados contínuos para idosos, incluindo aqueles que vivem em comunidades. O PMC surge como alternativa intersetorial para auxiliar nessa questão. CONCLUSÕES O PMC pode ser considerado um modelo de boa prática a ser expandido para outras localidades, entretanto existem lacunas que necessitam ser rediscutidas para que seus processos sejam aprimorados e seus resultados potencializados.
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Humanos , Masculino , Feminino , Envelhecimento , Saúde do Idoso , Cuidadores , Política de Saúde , Pesquisa QualitativaRESUMO
Resumo Introdução Com o envelhecimento populacional faz-se necessário conhecer a percepção e experiência de pessoas idosas em processo de fragilização acerca de seu processo de cuidado. Objetivo Objetivou-se compreender a percepção de pessoas idosas em processo de fragilização sobre a necessidade de ajuda de terceiros para seu próprio cuidado. Método Trata-se de uma pesquisa qualitativa, ancorada na Antropologia Médica. A coleta dos dados ocorreu com participantes do estudo multicêntrico FIBRA (Fragilidade em Idosos Brasileiros), do polo de Belo Horizonte, Minas Gerais. Entrevistaram-se, no domicílio, 22 pessoas idosas em processo de fragilização, que tinham, em média, 79 anos. A análise êmica foi guiada pelo modelo dos Signos, Significados e Ações. Resultados Os signos evidenciam a inevitabilidade de depender dos outros: "não aguentar", "não dar conta", "não poder mais fazer". Como indicativo da necessidade de ajuda surge: "ter que se limitar", "ter que ter ajuda", "ter que ter um acompanhante". Assim, depender do outro aparece como um suporte essencial e se revela algo doloroso, invasivo, controlador, prenunciando a finitude. Diante disso, as pessoas idosas tentam adaptar-se às mudanças para manter certo grau de autonomia e independência, para sentir-se úteis, lançam mão de tratamentos diversos e têm fé. As desigualdades sociais influenciam as ações realizadas por esse público. Conclusão Observa-se a necessidade da solidariedade social e de políticas públicas comprometidas com o cuidado com a pessoa idosa em processo de fragilização, enquanto um sujeito sociocultural.
Abstract Background With the aging population becomes necessary to know the perception and experience of older people in a process of weakening about the care process. Objective This study aims to understand the perception of elderly people in fragility process about needing help from others to maintain their care. Method It is a qualitative research, based on Medical Anthropology. The data were collected from participants in the multicenter study FIBRA (Fragility in Brazilian Elderly), located in Belo Horizonte, Minas Gerais. At home, 22 elderly people in the process of frailty were interviewed, who were, on average, 79 years old. The emic analysis was guided by the Signs, Meanings and Actions model. Results The signs that show the inevitability of care on others: "can't stand it", "can't stand it", "can't do it anymore". As indicative of the need for help: "having to": "having to be limited", "having to have help "," having to have an accompaniment ". To needing help, is as an essential support, but also proves painful, invasive, controlling, revealing of finitude. In the face of this, they try to adapt to changes to maintain a degree of autonomy and independence, feel useful, use various treatments, and have faith. Social inequalities influence the actions. Conclusion There is a need for social solidarity and public policies committed to the care of the elderly in the process of weakening, also considering them as a socio-cultural subject.
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Long-term care facilities for older adults (LTCFs) were directly affected by the COVID-19 pandemic. This study aimed to discuss the perceptions of occupational therapists about deaths and other losses in LTCFs during the pandemic. This qualitative study is anchored in social phenomenology, and conducted in-depth interviews with eight occupational therapists who worked in LTCFs. Thus, two themes were generated after the Thematic Analyses: "The proximity of death" and "Losses associated with living and dying in a LTCF." In the first theme, the interviewees addressed the feeling of imminent death in the daily life of the LTCF, and feelings related to their own death, that of their family members and other older adults. In the second, the professionals highlighted three groups of losses: social, functional, and psychological/cognitive. These results highlighted the challenges faced by occupational therapists and can contribute to improve behavior and care for institutionalized older adults during the pandemic.
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OBJECTIVE: Defining priority vaccination groups is a critical factor to reduce mortality rates. METHODS: We sought to identify priority population groups for covid-19 vaccination, based on in-hospital risk of death, by using Extreme Gradient Boosting Machine Learning (ML) algorithm. We performed a retrospective cohort study comprising 49,197 patients (18 years or older), with RT-PCR-confirmed for covid-19, who were hospitalized in any of the 336 Brazilian hospitals considered in this study, from March 19th, 2020, to March 22nd, 2021. Independent variables encompassed age, sex, and chronic health conditions grouped into 179 large categories. Primary outcome was hospital discharge or in-hospital death. Priority population groups for vaccination were formed based on the different levels of in-hospital risk of death due to covid-19, from the ML model developed by taking into consideration the independent variables. All analysis were carried out in Python programming language (version 3.7) and R programming language (version 4.05). RESULTS: Patients' mean age was of 60.5 ± 16.8 years (mean ± SD), mean in-hospital mortality rate was 17.9%, and the mean number of comorbidities per patient was 1.97 ± 1.85 (mean ± SD). The predictive model of in-hospital death presented area under the Receiver Operating Characteristic Curve (AUC - ROC) equal to 0.80. The investigated population was grouped into eleven (11) different risk categories, based on the variables chosen by the ML model developed in this study. CONCLUSIONS: The use of ML for defining population priorities groups for vaccination, based on risk of in-hospital death, can be easily applied by health system managers.
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Vacinas contra COVID-19 , COVID-19 , Adulto , Idoso , Brasil/epidemiologia , COVID-19/prevenção & controle , Mortalidade Hospitalar , Humanos , Aprendizado de Máquina , Pessoa de Meia-Idade , Estudos Retrospectivos , VacinaçãoRESUMO
BACKGROUND: Since 2011, the Brazilian city of Belo Horizonte has been operating an innovative scheme to support care-dependent older people in disadvantaged communities: Programa Maior Cuidado (PMC - Older Person's Care Program). This paper examines two potential associations between inclusion in PMC on types of outpatient health service utilization by dependent older people. The first is that being in PMC is associated with a higher frequency of outpatient visits for physical rehabilitation. The second is that being in PMC is associated with a higher frequency of planned versus unplanned outpatient visits. METHODS: We apply a quasi-experimental design to a unique set of health administrative data recording visits to outpatient health services. We focus on comparisons of the universe of visits, transformed to ratios of planned/unplanned visits and rehabilitation/other reasons for visiting the outpatient service. First, we preprocess our sample through different matching techniques such as 'coarsened exact matching' (CEM), 'nearest neighbor' based on logit scores (NN), 'optimal pair' (OP) and 'optimal full' (OF) methods. Second, we estimate marginal effects of being in PMC on our outcomes of interest. We use Poisson regressions controlling for individual and community factors and use robust standard errors. Our results are presented as the comparative incidence ratio of PMC on rehabilitation and planned visits. RESULTS: We find significant positive incidence rates for belonging to PMC for both outcomes of interest under all matching specifications. Poisson models using CEM shows a higher incidence rate for planned visits in comparison to unplanned visits, 1.3 (95% CI 1.1-1.4), by PMC patients compared to the non-PMC controls, and a higher proportion of visits for rehabilitation, 3.4 (95% CI 1.7-6.8). Similar positive results are found across other matching methods and models. CONCLUSIONS: Our analysis reveals significant positive associations between older people included in PMC and a matched set of controls for a greater ratio of making outpatient visits that were planned, rather than unplanned. We find similar associations for the proportion of visits made for rehabilitation, as opposed to other reasons. These findings indicate that PMC influences some elements of outpatient health service utilization by dependent older people.
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Assistência Ambulatorial , Prestação Integrada de Cuidados de Saúde , Idoso , Brasil/epidemiologia , Humanos , Incidência , Aceitação pelo Paciente de Cuidados de SaúdeRESUMO
Depending on the fields and actors involved, dignity may involve, signify, and encompass different meanings. This fundamental right can be subjectively experienced and rooted in a person's perception of being treated and cared for. Care refers to a set of specific activities combined in a complex life-sustaining network, including long-term Care, which involves various services designed to meet a person's health or personal care needs. However, older residents' human rights have been disrespected and widened the gaps between theory and practice regarding the precarious protection of their rights and dignity inside long-term facilities and nursing homes. This paper aims to discuss threats to dignity and elucidate some strategies to promote and conserve dignity in care, including the person-centered practice in long-term care. Some barriers to the dignity of older residents involve the organizational culture, restraints of time, heavy workload, burnout, and lack of partnership between the residents, their families, and the long-term care homes' staff. Person-centered integrated care quality frameworks are core components of a good quality of care in these spaces in high-income countries. Unfortunately, the COVID-19 pandemic highlighted how weak long-term care policies were and demonstrated that much progress in the dignity of care in long-term care facilities and nursing homes is needed. In low- and middle-income countries, long-term care policies do not accompany the accelerated and intense aging process, and there are other threats, like their invisibility to the public sector and the prejudices about this service model. It's urgent to create strategies for designing and implementing sustainable and equitable long- term care systems based on a person-centered service with dignity to everyone who needs it.
Assuntos
Assistência de Longa Duração , Pandemias , Humanos , Idoso , Respeito , Casas de Saúde , Esgotamento PsicológicoRESUMO
To catalyze the discussion and implementation of state policies for an integrated continuum of long-term care (LTC), it is imperative to assemble strategic actions involving the public and private sectors, civil society, international agencies, professionals, academia, and the media, considering clear objectives for improving the lives of older adults, their families, and the communities where they live. Care may be provided at home, in the community, or at LTC facilities (LTCFs) for older adults. In this essay, we focused on institutional care. Tensions between advocates of different models of care for older people should include space for dialogue, convergence, and intersectoral actions, regardless of where LTC is provided. Conditions for LTCFs not to be perceived as the "last and undesirable alternative" should exist or be created so that these institutions are seen instead as welcoming, productive, and inclusive environments that are integrated to the community and its social, recreational, and health systems. The aim of this essay was to reflect on the urgency of developing an integrated continuum of LTC for older adults in Brazil that considers care as a right along with its modalities of delivery, flow, services, and activities, as well as sustainable financing alternatives and legal and governance directives. This work was divided into four sections: (1) aging as a social achievement and care as a right; (2) models of LTC and panorama of the sector in Brazil; (3) change in paradigms for conceiving LTCFs and LTC; and (4) framework for achieving an integrated continuum of LTC.
Para catalisar a discussão e a implementação de políticas de Estado para um continuum integrado de cuidados de longa duração (CLDs), é imperativo reunir ações estratégicas envolvendo os poderes público e privado, a sociedade civil, as agências internacionais, os profissionais, a academia e a mídia, considerando metas claras para melhorar a vida das pessoas idosas, de suas famílias e das comunidades em que vivem. Esses cuidados podem ser ofertados no domicílio, na comunidade e em instituições de longa permanência para idosos (ILPIs). Neste ensaio, o foco são os cuidados institucionais. É fundamental as tensões entre defensores de diferentes modelos de organização do cuidado com a pessoa idosa darem lugar a diálogos, aproximações e ações intersetoriais, independentemente de onde os CLDs sejam prestados. Devem existir (ou ser criadas) condições para que as ILPIs não sejam percebidas como "a última e indesejável alternativa", mas sim como ambientes acolhedores, produtivos, inclusivos e integrados à comunidade e aos seus sistemas sociais, recreativos e de saúde. O objetivo deste ensaio é refletir sobre a urgência do desenvolvimento de um continuum integrado de CLDs para idosos no Brasil, que considere o cuidado como direito, suas distintas modalidades de oferta, fluxo, serviços e atividades, bem como alternativas sustentáveis de financiamento e normativas legais e de governança. Está dividido em quatro seções: (1) O envelhecimento como uma conquista social e os cuidados como um direito; (2) Modelos de CLDs e o panorama do setor no Brasil; (3) Mudança de paradigmas na concepção de ILPIs e CLDs; e (4) Estrutura para construir um continuum integrado de CLDs.
Assuntos
Humanos , Idoso , Assistência Integral à Saúde/organização & administração , Serviços de Saúde para Idosos/organização & administração , Instituição de Longa Permanência para Idosos , Fatores de Tempo , BrasilRESUMO
ABSTRACT OBJECTIVE Defining priority vaccination groups is a critical factor to reduce mortality rates. METHODS We sought to identify priority population groups for covid-19 vaccination, based on in-hospital risk of death, by using Extreme Gradient Boosting Machine Learning (ML) algorithm. We performed a retrospective cohort study comprising 49,197 patients (18 years or older), with RT-PCR-confirmed for covid-19, who were hospitalized in any of the 336 Brazilian hospitals considered in this study, from March 19th, 2020, to March 22nd, 2021. Independent variables encompassed age, sex, and chronic health conditions grouped into 179 large categories. Primary outcome was hospital discharge or in-hospital death. Priority population groups for vaccination were formed based on the different levels of in-hospital risk of death due to covid-19, from the ML model developed by taking into consideration the independent variables. All analysis were carried out in Python programming language (version 3.7) and R programming language (version 4.05). RESULTS Patients' mean age was of 60.5 ± 16.8 years (mean ± SD), mean in-hospital mortality rate was 17.9%, and the mean number of comorbidities per patient was 1.97 ± 1.85 (mean ± SD). The predictive model of in-hospital death presented area under the Receiver Operating Characteristic Curve (AUC - ROC) equal to 0.80. The investigated population was grouped into eleven (11) different risk categories, based on the variables chosen by the ML model developed in this study. CONCLUSIONS The use of ML for defining population priorities groups for vaccination, based on risk of in-hospital death, can be easily applied by health system managers
Assuntos
Humanos , Adulto , Pessoa de Meia-Idade , Idoso , Vacinas contra COVID-19 , COVID-19/prevenção & controle , Brasil/epidemiologia , Estudos Retrospectivos , Vacinação , Mortalidade Hospitalar , Aprendizado de MáquinaRESUMO
BACKGROUND: Brazil is seeing rapid population ageing, which is leading to new demands on primary health care services. There is a need to develop and assess the effectiveness of new interventions to build the capacity of staff, including community health workers, to meet the needs of groups such as care-dependent older people and their care-givers. This study examines the feasibility of a small training intervention piloted in the Brazilian city of Fortaleza. METHODS: The study evaluated participants' own assessments of key knowledge and skills related to the needs of care-dependent older people, both before and after the training intervention. It also assessed their capacity to implement a simple screening tool of geriatric risk factors. RESULTS: The participant self-assessments indicate significant improvements in their perceived knowledge and capacity in responding to the health needs of care-dependent older people. Additionally, participants were able to successfully conduct the home visits and screening for risk factors. CONCLUSIONS: The study demonstrates the feasibility of developing interventions to enhance the capacity of community health workers to meet the needs of dependent older people in countries like Brazil. The evidence of effectiveness, though limited and subjective, provides justification for a larger, formally evaluated intervention. The experience of Fortaleza provides valuable lessons for other cities and countries in the region which are facing similar challenges.