[Insight on how to assess and improve the response to the COVID-19 pandemic]. / Reflexiones sobre cómo evaluar y mejorar la respuesta a la pandemia de COVID-19.

The COVID-19 pandemic has hit Spain particularly hard, despite being a country with a developed economy and being praised for the robustness of its national health system. In order to understand what happened and to identify how to improve the response, we believe that an independent multi-disciplinary evaluation of the health, political and socio-economic spheres is essential. In this piece we propose objectives, principles, methodology and dimensions to be evaluated, as well as outlining the type of results and conclusions expected. Inspired by the requirements formulated by the WHO Independent Panel for Pandemic Preparedness and Response and by experiences in other countries, we detail the multidimensional aspects to be evaluated. The goal is to understand key aspects in the studied areas and their scope for improvement in terms of preparedness, governance, regulatory framework, national health system structures (primary care, hospital, and public health), education sector, social protection schemes, minimization of economic impact, and labour framework and reforms for a more resilient society. We seek to ensure that this exercise serves not only at present, but also that in the future we are better prepared and more agile in terms of our ability to recover from any pandemic threats that may arise.

[Communication, participation and leadership in the perception of the emotional climate in a university hospital in Andalusia, Spain]. / Comunicación, participación y liderazgo en la percepción del clima emocional en un hospital universitario de Andalucía, España.

The aim of this study was to identify and analyze perceptions and opinions among health professionals in a university hospital in Andalusia, Spain, regarding the emotional climate, leadership style, quality of information, and internal communication. The study also aimed to collect health professionals' suggestions for improving these workplace characteristics. The study included 730 participants and used a quantitative and qualitative methodology. The results reflect a medium-to-low level of emotional climate, correlated with the leadership style and information and internal communication. Statistically significant differences appeared when comparing professional categories and hospital units. The health professionals provided a positive assessment of the administrators' work, although requiring more task-oriented, participative, and affiliative leadership skills.

Comunicación, participación y liderazgo en la percepción del clima emocional en un hospital universitario de Andalucía, España / Communication, participation and leadership in the perception of the emotional climate in a university hospital in Andalusia, Spain / Comunicação, participação e liderança na percepção do clima emocional em um hospital universitário da Andaluzia, Espanha

El objetivo de este artículo es conocer y analizar la valoración del personal de un hospital universitario de Andalucía, España, sobre el clima emocional, el tipo de liderazgo ejercido y la calidad de la información y comunicación interna, así como recoger sus propuestas de mejora. El estudio realizado con 730 profesionales facultativos, enfermeros y auxiliares, usa metodología cuantitativa y cualitativa. Los resultados reflejan la existencia de un clima emocional medio-bajo, que se correlaciona con el estilo de liderazgo y la percepción sobre el grado de información y comunicación. Se observan diferencias estadísticamente significativas en los resultados, en función de las categorías profesionales, así como de la unidad o servicio hospitalario. Las demandas de los y las profesionales reflejan una valoración positiva de sus responsables, aunque se evidencia la necesidad de más habilidades propias de un estilo de liderazgo orientador, participativo y afiliativo.

The aim of this study was to identify and analyze perceptions and opinions among health professionals in a university hospital in Andalusia, Spain, regarding the emotional climate, leadership style, quality of information, and internal communication. The study also aimed to collect health professionals' suggestions for improving these workplace characteristics. The study included 730 participants and used a quantitative and qualitative methodology. The results reflect a medium-to-low level of emotional climate, correlated with the leadership style and information and internal communication. Statistically significant differences appeared when comparing professional categories and hospital units. The health professionals provided a positive assessment of the administrators' work, although requiring more task-oriented, participative, and affiliative leadership skills.

O objetivo deste artigo foi identificar e analisar a percepção e a opinião de profissionais de um hospital universitário na Andaluzia, Espanha, sobre clima emocional, tipo de liderança e qualidade da informação e comunicação interna, assim como identificar propostas de melhoria. O estudo foi realizado com 730 profissionais de saúde e utilizou metodologia quantitativa e qualitativa. Os resultados refletem a existência de um clima emocional médio-baixo, relacionado com o estilo de liderança e com a percepção sobre o grau de informação e comunicação interna. São observadas diferenças estatisticamente significativas nos resultados, em função das categorias profissionais e unidades ou serviço hospitalar. As demandas dos profissionais refletem uma valoração positiva de seus líderes, apesar de evidenciar a necessidade de habilidades próprias de um estilo de liderança orientador, participativo e afiliativo.

Inconsistent condom use among socially excluded heroin users.

The study focused in sexual behaviour among socially excluded heroin users, identifying factors associated with inconsistent condom use. Data was collected in the cities of Granada and Seville between July and October 2000, through a structured questionnaire, to 391 participants. Twenty two and 15% of participants have made consistent use of condoms in vaginal sex in the last year with occasional and regular partners respectively. There is a greater likelihood of inconsistent condom use with occasional partners among users who had had oral sex, and who does not know if their partner(s) inject or injected drugs. For regular partners those who have an injecting partner and do not speak with their sexual partners about AIDS have a higher probability to do not use always a condom. For both groups, when always the partner is who propose the use of condoms (when used) and not themselves, the risk not to use it is near 4 times more than when themselves propose to use it. Speaking about condoms and AIDS with mate, partners and family, and learning to negotiate the use of condoms seems to be the most important strategies to be approached for this sample, from the social and health care system in order to promote a protected sex.

Factors associated with reported hepatitis C and HIV among injecting drug users in ten European cities.

BACKGROUND: To analyze self-reported prevalence of HCV and HIV in a sample of socially excluded injecting drug users, as well as factors associated with the presence of these diseases. METHODS: Cross-sectional study. Data were collected with a structured, face-to-face questionnaire by outreach workers and privileged access interviewers in 1131 participants who had injected heroin and/or cocaine over the past year (71.5% men; mean age, 30 years) from Seville and Granada, Spain; Cologne, Germany; Vienna, Austria; Brussels, Belgium; Athens, Greece; Dublin, Ireland; London, England; Lisbon, Portugal and Perugia, Italy. RESULTS: Among the total sample, 595 (52.6%) participants reported HCV-positive status and 143 (12.6%) HIV-positive status. Multivariate analysis for HCV showed that women are at less risk than men, and that longer drug use, injecting while in prison, sharing needles, and reported positive status for tuberculosis, HBV, HIV or sexually-transmitted disease are positively associated with HCV. Participants reporting positive HIV status were generally older, had injected drugs while in prison, had completed less than 8 years of schooling, were divorced, had no regular employment, and declared infection with tuberculosis, sexually-transmitted disease and HCV. CONCLUSIONS: The highest incidences of HCV and HIV were reported by participants in a poorer social and health situation. Drug addicts must cope not only with their addiction but also with the process of social exclusion they are immersed in. To the greatest extent possible, any course of action for this group should be built into integrated, coordinated plans that take a broad approach to the main issues involved.

Controlled trial of prescribed heroin in the treatment of opioid addiction.

AIM: This study aimed to assess the efficacy of the prescription of intravenous diacetylmorphine (DAM) versus oral methadone with medical and psychosocial support, with a view of improving physical and mental health as well as social integration among socially excluded, opioid-dependent individuals for whom standard treatments have failed. DESIGN: This study used an open, randomized controlled trial. SETTING: This study took place in Granada, Spain. PARTICIPANTS: Sixty-two opioid-dependent participants were randomized, 31 in each treatment group, and 50 of them were analyzed. The participants were recruited directly from the streets, through peer outreach, in well-known meeting places for drug-addicted individuals. INTERVENTIONS: Participants in the experimental group received injected DAM, twice a day, plus oral methadone, once a day, for 9 months. The control group received only oral methadone, once a day. The two groups received an equivalent opioid dosage. The average DAM dosage was 274.5 mg/day (range: 15-600 mg), and an average methadone dosage was 42.6 mg/day (range: 18-124 mg). The daily methadone dosage in the control group was 105 mg/day (range: 40-180 mg). Comprehensive clinical, psychological, social, and legal support was given to both groups. MEASUREMENTS: The following were measured in this study: general health, quality of life, drug-addiction-related problems, nonmedical use of heroin, risk behavior for HIV and HCV, and psychological, family, and social status. FINDINGS: Both groups improved with respect to the total domain assessed. Those in the experimental group showed greater improvement in terms of physical health (the improvement was 2.5 times higher; p = .034) and risk behavior for HIV infection (the improvement was 1.6 times higher; p = .012). In addition, this group decreased its street heroin use from 25 days/month to 8 days/month as seen on the Addiction Severity Index (p = .020), as well as the number of days free from drug-related problems (the improvement was 2.1 times higher; p = .004) or involvement in crime (from 11 days/month to <1 day/month; p = .096 between groups). CONCLUSIONS: These findings support the hypothesis that, under the same conditions, DAM could be safely delivered, in our context. Also, in physical health, HIV risk behavior, street heroin use, and days involved in crime, DAM plus methadone was more efficacious than methadone alone. This implies that this treatment could provide an effective alternative for the treatment of socially excluded, opioid-dependent patients with severe physical and mental health problems because of drug addiction, when all available previous treatments have failed.

Drugs and social exclusion in ten European cities.

AIM: To describe social characteristics seen among socially excluded drug users in 10 cities from 9 European countries, and identify which social exclusion indicators (i.e. housing, employment, education) are most closely linked to intravenous drug use. DESIGN: Cross-sectional survey. SETTING: Interviews were held in social services centers, town halls, streets, squares and other usual meeting points of the target population. PARTICIPANTS: The sample comprises 1,879 participants who have used heroin and/or cocaine and certain derivatives (92.3%) over the last year. Males accounted for 69.7% of the sample, and the mean age was 30.19 years. Participants were recruited in 10 cities: Seville and Granada, Spain; Cologne, Germany; Vienna, Austria; Brussels, Belgium; Athens, Greece; Dublin, Ireland; London, England; Lisbon, Portugal, and Perugia, Italy. MEASUREMENTS: Structured face-to-face questionnaire, conducted by privileged access interviewers. RESULTS: Cannabis, heroin and cocaine are the most widely used substances. In the total sample, 60.2% injected drugs during the last year, 45.9% reported having hepatitis C; 54.9% have been in prison; 14.2% are homeless; 11.3% have a regular job, and 35.2% are involved in illegal activities. Hierarchical logistic regression analysis (injectors and non-injectors) showed that older participants have a greater likelihood of injecting than younger ones. Social exclusion variables associated with intravenous drug use are incarceration, homelessness, irregular employment, and delinquency. Participants who abandoned or were expelled from a drug treatment program are at greater risk of injecting drugs than participants who have never had treatment, are currently in treatment or have been released. CONCLUSION: Personal, social, and economic conditions are all linked in a process of social exclusion that compounds problem drug misuse. Given the findings of this study, we believe that there is a clear need for specific programs targeting specific groups, i.e., distinct strategies must be set in place, in line with the profile and needs of the patient in each context.

[The experimental drug prescription program in Andalusia [PEPSA]: procedure for recruiting participants]. / Captación de participantes en el programa experimental de prescripción de estupefacientes en Andalucía (PEPSA).

In this field note we describe the steps followed in the process of recruiting participants for the experimental drug prescription program in Andalusia (PEPSA). This trial is a comparative, randomized, open study of the difference between intravenous heroin treatment and oral methadone for socially excluded, opiate-dependent patients, in whom other available treatments have been unsuccessful. Because this is a hidden and hard-to-reach population, a specific approach was planned to put as many patients as possible in touch with the program. A previous study of the target population's distribution in the City of Granada was performed and the city was divided into three areas. Potential participants were interviewed in squares, soup kitchens and methadone dispensaries by outreach workers and peers, who suggested they make an appointment with a PEPSA physician. Peer-driven intervention was a crucial instrument in this recruitment procedure, allowing greater access to the target population. Furthermore, this approach allowed contact with drug users who do not attend health and social services. The work of the outreach team involved educating these users in harm reduction and offering them health and social alternatives beyond the clinical trial.