Boosting large-scale river connectivity restoration by planning for the presence of unrecorded barriers.

Conservation decisions are invariably made with incomplete data on species' distributions, habitats, and threats, but frameworks for allocating conservation investments rarely account for missing data. We examined how explicit consideration of missing data can boost return on investment in ecosystem restoration, focusing on the challenge of restoring aquatic ecosystem connectivity by removing dams and road crossings from rivers. A novel way of integrating the presence of unmapped barriers into a barrier optimization model was developed and applied to the U.S. state of Maine to maximize expected habitat gain for migratory fish. Failing to account for unmapped barriers during prioritization led to nearly 50% lower habitat gain than was anticipated using a conventional barrier optimization approach. Explicitly acknowledging that data are incomplete during project selection, however, boosted expected habitat gains by 20-273% on average, depending on the true number of unmapped barriers. Importantly, these gains occurred without additional data. Simply acknowledging that some barriers were unmapped, regardless of their precise number and location, improved conservation outcomes. Given incomplete data on ecosystems worldwide, our results demonstrate the value of accounting for data shortcomings during project selection.

Incremento de la restauración de la conectividad a gran escala de los ríos mediantze la planeación de la presencia de barreras sin registro Resumen Las decisiones de conservación se toman con datos incompletos de la distribución, hábitat y amenazas de las especies, pero los marcos para asignar fondos de conservación rara veces lo consideran. Analizamos cómo la consideración explícita de los datos faltantes puede incrementar la rentabilidad de la inversión en la restauración de ecosistemas. Nos enfocamos en el reto que es la restauración de la conectividad entre ecosistemas acuáticos mediante la eliminación de presas y cruces de carreteras en los ríos. Desarrollamos y aplicamos una forma novedosa de integrar la presencia de las barreras sin registro dentro de un modelo de optimización de barreras en el estado de Maine (Estados Unidos) para maximizar la ganancia esperada de hábitat para los peces migratorios. La omisión de las barreras sin registro durante la priorización resultó en una ganancia de hábitat casi 50% menor a la anticipada cuando se usó una estrategia convencional de optimización de barreras. Sin embargo, el reconocimiento explícito de los datos incompletos durante la selección del proyecto incrementó la ganancia esperada de hábitat en un promedio del 20-273%, dependiendo del número real de barreras sin registro. Estas ganancias ocurrieron sin datos adicionales. Los resultados de conservación aumentaron con tan sólo el reconocimiento de que algunas barreras no estaban registradas, sin importar el número y ubicación precisos, Ya que hay datos incompletos para todos los ecosistemas a nivel mundial, nuestros resultados demuestran lo importante que es considerar la carencia de datos durante la selección de proyectos.

Parental substance use and home visiting programs: Implementation considerations for relationship-based treatment.

Home visiting programs can provide critical support to mothers in recovery from substance use disorders (SUDs) and young children prenatally exposed to substances. However, families impacted by maternal SUDs may not benefit from traditional child-focused developmental home visiting services as much as families not impacted by SUDs, suggesting the need to adjust service provision for this population. Given the need to implement tailored services within home visiting programs for families impacted by SUDs, we sought to investigate the implementation barriers and facilitators to inform future integration of a relationship-based parenting intervention developed specifically for parents with SUDs (Mothering from the Inside Out) into home visiting programs. We conducted nine interviews and five focus groups with a racially diverse sample (N = 38) of parents and providers delivering services for families affected by SUDs in the USA. Qualitative content analysis yielded three most prominent themes related to separate implementation domains and their associated barriers and facilitators: (1) engagement, (2) training, and (3) sustainability. We concluded that the home visiting setting may mitigate the logistical barriers to access for families affected by SUDs, whereas relationship-based services may mitigate the emotional barriers that parents with SUDs experience when referred to home visiting programs.

Los programas de visita a casa pueden ofrecer un apoyo clave a madres en recuperación de trastornos por abusos de sustancias (SUD) y los niños pequeños expuestos a sustancia prenatalmente. Sin embargo, las familias que recibieron el impacto de SUD materno pudieran no beneficiarse de los servicios tradicionales de visita a casa en cuanto al desarrollo enfocados en el niño tanto como las familias que no sufren el impacto de SDU, lo cual sugiere la necesidad de ajustar el ofrecimiento de servicios para este grupo de población. Dada la necesidad de implementar servicios amoldados dentro de los programas de visita a casa para familias que sufren el impacto de SUD, nos propusimos investigar las barreras y los aspectos que facilitan la implementación a manera de informar la futura integración de una intervención de crianza con base en la relación, específicamente desarrollada para progenitores con SUD (Cuidados Maternales Desde Dentro) en los programas de visita a casa. Llevamos a cabo nueve entrevistas y cinco grupos de enfoque con un grupo muestra racialmente diverso (N = 38) de progenitores y proveedores que ofrecen los servicios a familias que sufren el impacto de SUD en los Estados Unidos. Los análisis de contenido cualitativo arrojaron tres temas más prominentes relacionados con dominios de implementación separados y las asociadas barreras y aspectos que la facilitan: (1) involucramiento, (2) entrenamiento, y (3) sostenibilidad. Concluimos que el escenario de visita a casa pudiera mitigar las barreras logísticas de acceso para familias afectadas por SUD, mientras que los servicios con base en la relación pudieran mitigar las barreras emocionales que los progenitores con SUD experimentan cuando se les refiere a programas de visita a casa.

Les programmes de visite à domicile peuvent offrir un soutien critique aux mères qui se rétablissent d'un trouble lié à l'usage d'une substance (TUS) et aux jeunes enfants exposés à des substances avant leur naissance. Cependant les familles impactées par des TUS maternels ne bénéficient pas de services de visite à domicile traditionnels autant que des familles non impactées par un TUS, suggérant le besoin d'ajuster des prestations de service pour cette population. Vu le besoin de mettre en place des services adaptés au sein des programmes de visite à domicile pour les familles impactées par des TUS, nous avons décidé d'étudier les barrières et les facteurs de facilitation de mise en place afin d'éclairer l'intégration future d'une intervention de parentage basée sur une relation développée spécifiquement pour des parents avec des TUS (le maternage de l'intérieur suivant l'anglais Mothering from the Inside Out) dans des programmes de visite à domicile. Nous avons procédé à neuf entretiens et cinq groupes d'étude avec un échantille variés du point de vue racial (N = 38) de parents et de prestataires offrant des services pour des familles affectées par des TUS aux Etats-Unis d'Amérique. Une analyse qualitative de contenu a donné trois groupes importants lié à des domaines de mise en place séparés et les barrières et facteurs de facilitation y étant liés: (1) l'engagement, (2) la formation, et (3) la durabilité. Nous concluons que le contexte de visite à domicile peut mitiger les barrières logistiques à l'accès pour les familles affectées par des TUS, alors que les services relationnels peuvent mitiger les barrières émotionnelles dont les parents avec des TUS font l'expérience lorsqu'on leur recommande des programmes de visite à domicile.

[Barriers and facilitators of the EfiKroniK exercise program for people with chronic diseases in Primary Care]. / Barreras y facilitadores del programa de ejercicio EfiKroniK para pacientes con enfermedad crónica en atención primaria.

OBJECTIVE: Explore patients' perceptions during a supervised exercise program and detect the barriers and facilitators that influence exercise adherence after the supervision period. DESIGN: A qualitative observational study with three focus groups as the main data collection technique was conducted. SITE: Primary Health centers of Bizkaia. PARTICIPANTS: Out of the 175 randomized patients in the hybrid effectiveness-implementation trial, a sample of 19 patients from the intervention group were included in the qualitative study (12 advanced-stage onco-haematological patients and seven with severe mental disorders). METHODS: Content analysis of the generated transcripts was performed by combining a deductive approach, based on the domains of the PRACTIS theoretical framework, and an inductive one, based on the postulates of the Grounded Theory. RESULTS: The data analysis showed that participants were satisfied with the EfiKroniK program and that the main identified benefits were discovery of the benefits of physical exercise, the psychological and emotional management of the disease, the benefits from peer communication and emotional support, and the break from routine of their illness. Participants decreased the levels of physical exercise at the end of the supervision6 due to the confluence of several barriers. CONCLUSION: A supervised exercise program carried out in Primary Care contributed to the improvement of the quality of life as well as the emotional and social well-being of patients with advanced-stage diseases. Our study identified potential barriers and facilitators associated with exercise participation and its continuity, however, it is necessary to encourage inter-sectoral coordination within the socio-health system to promote integrated and continuous care for chronic patients.

The Crying Clinic: Increasing accessibility to Infant Mental Health services for immigrant parents at risk for peripartum depression.

Peripartum depression (PPD) is considered a major public health concern due to its profound impact on families, including infants. In this paper, we report on a pilot initiative designed to reduce barriers and stigma related to the use of traditional infant mental health services for immigrant parents deemed at high risk of PPD. The Crying Clinic (CC) is an innovative walk-in service offered in a culturally diverse Canadian community to support maternal well-being and healthy parent-infant relationships. The CC was designed to be a gateway to existing infant mental health services, through its emphasis on accessibility and cultural sensitivity. Support for concrete concerns, such as anxiety about normative infant behaviors like crying, is underscored in this approach to attract vulnerable families who would otherwise not access mental health support. A review of 44 users, utilization, plans for the use of additional services, and client evaluations suggests that the CC accomplished most of its goals. We conclude that gateway service models such as the CC have the potential to enhance traditional infant mental health programs by creatively addressing the challenge of engaging highly vulnerable parents from culturally diverse backgrounds.

La depresión durante el período inmediatamente antes, durante e inmediatamente después del parto, o peri-parto (PPD) es considerada una preocupación seria de la salud pública debido a su profundo impacto en las familias, incluyendo los infantes (v.g., Howard, Piot y Stein, 2014). En este ensayo, reportamos acerca de una iniciativa experimental diseñada para reducir barreras y el estigma relacionado con el uso de los servicios tradicionales de salud mental infantil por parte de progenitores inmigrantes a quienes se les considera como de alto riesgo con respecto al PPD. La Clínica del Llanto -The Crying Clinic - (CC) en un innovador servicio al que se puede recurrir sin cita previa y que se ofrece en una comunidad canadiense culturalmente diversa con el fin de apoyar el bienestar materno y las saludables relaciones progenitor-infante. La CC fue diseñada para ser una puerta de entrada a los servicios de salud mental infantil existentes, por medio de enfatizar la accesibilidad y la sensibilidad cultural. El apoyo a preocupaciones concretas, tales como la ansiedad acerca de las conductas normativas del infante -el llanto, por ejemplo- es recalcado por medio de este acercamiento para atraer a familias vulnerables que de otra manera no buscarían acceso al apoyo de salud mental. Una revisión de 44 usuarios, la utilización, planes para el uso de servicios adicionales, así como las evaluaciones de los clientes sugieren que la CC alcanzó la mayoría de sus metas. Concluimos con que los modelos de servicios que sirven de puerta de entrada tales como la CC cuentan con el potencial para mejorar los programas tradicionales de salud mental infantil por medio de responder creativamente al reto de atraer a progenitores altamente vulnerables de trasfondos culturales diversos.

La dépression périnatale (PPD) est considérée comme étant un problème de santé publique extrêmement important du fait de son impact profond sur les familles, y compris les nourrissons (par exemple Hoard, Piot, & Stein, 2014). Dans cet article nous faisons part d'une initiative pilote conçue afin de réduire les barrières et le sigma lié à l'utilisation de services de santé mentale traditionnels pour des parents immigrés à risque élevé de PPD. La Clinique Pleurs (en anglais Crying Clinic, soit ici CC) est un service clinique sans rendez-vous innovateur disponible dans une communauté canadienne culturellement diverse pour soutenir le bien-être maternel et des relations parent-nourrisson saines. La CC a été conçue afin d'être une porte d'entrée à des services de santé mentale du nourrisson existants, à travers son accent sur l'accessibilité et la sensibilité culturelle. Le soutien pour des problèmes concrets, comme par exemple l'anxiété à propos de comportements normatifs du nourrisson comme les pleurs, est souligné dans cette approche afin d'attirer des familles vulnérables qui autrement n'accèderaient pas à un soutien de santé mentale. Une étude de 44 utilisateurs, de l'utilisation, des projets pour l'utilisation de services supplémentaires et des évaluations de clients suggère que la CC a rempli la plupart de ses buts. Nous concluons que des modèles de service d'entrée tels que la CC ont le potentiel de mettre en valeur des programmes traditionnels de santé mentale du nourrisson en répondant au défi qu'il y a d'engager des parents extrêmement vulnérables issus de milieux culturellement divers de manière créative.

Rethinking assessment of success of mitigation strategies for elephant-induced crop damage.

Crop damage is the most common impact of negative interactions between people and elephants and poses a significant threat to rural livelihoods and conservation efforts. Numerous approaches to mitigate and prevent crop damage have been implemented throughout Africa and Asia. Despite the documented high efficacy of many approaches, losses remain common, and in many areas, damage is intensifying. We examined the literature on effectiveness of crop-damage-mitigation strategies and identified key gaps in evaluations. We determined there is a need to better understand existing solutions within affected communities and to extend evaluations of effectiveness beyond measurement of efficacy to include rates of and barriers to adoption. We devised a conceptual framework for evaluating effectiveness that incorporates the need for increased emphasis on adoption and can be used to inform the design of future crop-damage mitigation assessments for elephants and conflict species more widely. The ability to prevent crop loss in practice is affected by both the efficacy of a given approach and rates of uptake among target users. We identified the primary factors that influence uptake as local attitudes, sustainability, and scalability and examined each of these factors in detail. We argue that even moderately efficacious interventions may make significant progress in preventing damage if widely employed and recommend that wherever possible scientists and practitioners engage with communities to build on and strengthen existing solutions and expertise. When new approaches are required, they should align with local attitudes and fit within limitations on labor, financial requirements, and technical capacity.

Replanteamiento de la Evaluación del Éxito de las Estrategias de Mitigación del Daño a Cultivos Causado por Elefantes Resumen El daño a los cultivos es el impacto más común generado por las interacciones negativas entre las personas y los elefantes. Actualmente representa una amenaza significativa para el sustento rural y los esfuerzos de conservación. Se han implementado numerosas estrategias para mitigar y prevenir el daño a los cultivos en toda África y Asia. A pesar de la documentación de la eficiencia de las estrategias, las pérdidas todavía son comunes y, en muchas áreas, el daño se está intensificando. Examinamos la literatura sobre la efectividad de las estrategias de mitigación del daño a cultivos e identificamos vacíos importantes en su evaluación. Determinamos que existe una necesidad por entender de mejor manera las soluciones existentes en las comunidades afectadas y por extender las evaluaciones de eficiencia más allá de las medidas de eficacia para que incluyan las tasas y barreras de la adopción. Diseñamos un marco de trabajo conceptual para la evaluación de la eficiencia, el cual incorpora la necesidad de un incremento en el énfasis de la adopción y puede usarse para informar a los diseñadores de las futuras evaluaciones de la mitigación de daños a cultivos causados por elefantes u otras especies conflictivas de manera más amplia. La capacidad de poder prevenir la pérdida de cultivos en práctica está afectada tanto por la eficiencia de una estrategia dada como por las tasas de aceptación entre los usuarios diana. Identificamos como los factores primarios que influyen sobre la aceptación a las actitudes locales, la sustentabilidad y la adaptabilidad, y examinamos cada uno de estos factores a detalle. Argumentamos que incluso las intervenciones moderadamente eficientes pueden llevar a cabo un progreso significativo en la prevención del daño si se emplean ampliamente. También recomendamos que, en donde sea posible, los científicos y los practicantes de la conservación participen con las comunidades para construir y fortalecer las soluciones y el conocimiento existentes. Cuando se requieran nuevas estrategias, éstas deberán alinearse con las actitudes locales y deberán encajar dentro de las limitaciones de la labor, los requisitos financieros y la capacidad técnica.

Practitioner insights as a means of setting a context for conservation.

A key obstacle to conservation success is the tendency of conservation professionals to tackle each challenge individually rather than collectively and in context. We sought to prioritize barriers to conservation previously described in the conservation literature. We undertook an online survey of 154 practitioners from over 70 countries to ascertain the most important barriers to conservation they faced. We used statistical analyses to identify the key impediments to conservation success and to examine whether these were affected by organizational attributes. Twenty-one barriers were identified. The importance ascribed to those was influenced by continent of operation and organization size, but not by organization age or autonomy (from larger parent organizations). We found the most important barriers to consider when undertaking conservation action were wider issues (e.g., population growth, consumerism, favoring development, and industrial-scale activity), operating environment (e.g., lack of political will, ineffective law enforcement, weak governments, corruption, safety and security), community attributes (e.g., dynamics, conflicts, and education levels), and the way conservation is undertaken (overconfidence, lack of funding, and externally set agendas). However, we advise against applying a one-size-fits-all approach. We propose that conservationists account for the complex socioecological systems they operate in if they are to achieve success.

Percepciones de los Profesionales Como Medio para Establecer un Contexto Para la Conservación Resumen Un obstáculo clave para el éxito de la conservación es la tendencia de los profesionales de la conservación a abordar cada desafío individualmente en lugar de colectivamente y en contexto. Buscamos priorizar las barreras a la conservación descritas anteriormente en la literatura de conservación. Realizamos una encuesta en línea a 154 profesionales de más de 70 países para determinar las barreras más importantes para la conservación a las que se enfrentaban. Utilizamos análisis estadísticos para identificar los principales impedimentos para el éxito de la conservación y para examinar si estos se vieron afectados por atributos organizativos. Se identificaron veintiún barreras. La importancia que se les atribuye fue influenciada por el continente donde operan y el tamaño de la organización, pero no por la edad o la autonomía de la organización (de las organizaciones más grandes). Encontramos que los obstáculos más importantes a tener en cuenta al emprender acciones de conservación eran cuestiones más amplias (e. g., crecimiento de la población, consumismo, fomento del desarrollo y actividad a escala industrial), medio ambiente (e. g., falta de voluntad política, ineficacia en la aplicación de la ley, gobiernos débiles, corrupción, seguridad y protección), atributos comunitarios (e. g., dinámicas, conflictos y niveles educativos) y la forma en que se lleva a cabo la conservación (exceso de confianza, falta de financiamiento y agendas establecidas externamente). Sin embargo, aconsejamos no aplicar un enfoque "un tamaño se ajusta a todo". Para lograr el éxito, proponemos que los conservacionistas tengan en cuenta los complejos sistemas socioecológicos en los que operan.

Circuit-theory applications to connectivity science and conservation.

Conservation practitioners have long recognized ecological connectivity as a global priority for preserving biodiversity and ecosystem function. In the early years of conservation science, ecologists extended principles of island biogeography to assess connectivity based on source patch proximity and other metrics derived from binary maps of habitat. From 2006 to 2008, the late Brad McRae introduced circuit theory as an alternative approach to model gene flow and the dispersal or movement routes of organisms. He posited concepts and metrics from electrical circuit theory as a robust way to quantify movement across multiple possible paths in a landscape, not just a single least-cost path or corridor. Circuit theory offers many theoretical, conceptual, and practical linkages to conservation science. We reviewed 459 recent studies citing circuit theory or the open-source software Circuitscape. We focused on applications of circuit theory to the science and practice of connectivity conservation, including topics in landscape and population genetics, movement and dispersal paths of organisms, anthropogenic barriers to connectivity, fire behavior, water flow, and ecosystem services. Circuit theory is likely to have an effect on conservation science and practitioners through improved insights into landscape dynamics, animal movement, and habitat-use studies and through the development of new software tools for data analysis and visualization. The influence of circuit theory on conservation comes from the theoretical basis and elegance of the approach and the powerful collaborations and active user community that have emerged. Circuit theory provides a springboard for ecological understanding and will remain an important conservation tool for researchers and practitioners around the globe.

Aplicaciones de la Teoría de Circuitos a la Conservación y a la Ciencia de la Conectividad Resumen Quienes practican la conservación han reconocido durante mucho tiempo que la conectividad ecológica es una prioridad mundial para la preservación de la biodiversidad y el funcionamiento del ecosistema. Durante los primeros años de la ciencia de la conservación los ecólogos difundieron los principios de la biografía de islas para evaluar la conectividad con base en la proximidad entre el origen y el fragmento, así como otras medidas derivadas de los mapas binarios de los hábitats. Entre 2006 y 2008 el fallecido Brad McRae introdujo la teoría de circuitos como una estrategia alternativa para modelar el flujo génico y la dispersión o las rutas de movimiento de los organismos. McRae propuso conceptos y medidas de la teoría de circuitos eléctricos como una manera robusta para cuantificar el movimiento a lo largo de múltiples caminos posibles en un paisaje, no solamente a lo largo de un camino o corredor de menor costo. La teoría de circuitos ofrece muchos enlaces teóricos, conceptuales y prácticos con la ciencia de la conservación. Revisamos 459 estudios recientes que citan la teoría de circuitos o el software de fuente abierta Circuitscape. Nos enfocamos en las aplicaciones de la teoría de circuitos a la ciencia y a la práctica de la conservación de la conectividad, incluyendo temas como la genética poblacional y del paisaje, movimiento y caminos de dispersión de los organismos, barreras antropogénicas de la conectividad, comportamiento ante incendios, flujo del agua, y servicios ambientales. La teoría de circuitos probablemente tenga un efecto sobre la ciencia de la conservación y quienes la practican por medio de una percepción mejorada de las dinámicas del paisaje, el movimiento animal, y los estudios de uso de hábitat, y por medio del desarrollo de nuevas herramientas de software para el análisis de datos y su visualización. La influencia de la teoría de circuitos sobre la conservación viene de la base teórica y la elegancia de la estrategia y de las colaboraciones fuertes y la comunidad activa de usuarios que han surgido recientemente. La teoría de circuitos proporciona un trampolín para el entendimiento ecológico y seguirá siendo una importante herramienta de conservación para los investigadores y practicantes en todo el mundo.

Inercia clínica en el tratamiento con insulina en el primer nivel de atención.

INTRODUCTION: Refusal of physicians to prescribe insulin to their patients has been scarcely evaluated; the delay in treatment intensification hinders adequate and quality care. OBJECTIVE: To identify the perception of primary care physicians about barriers to initiate insulin treatment in patients with diabetes. METHOD: Using the Smith Index and multivariate analysis, the relevance and grouping of concepts related to barriers to insulin prescription were assessed in 81 family doctors. RESULTS: Only 35.8% of physicians showed confidence for prescribing insulin; almost half of them rated treatment intensification between moderately and little important (39.5% and 6.2%). Barriers were related to the physician (39.5%), the patient (37%), insulin treatment (11.1%) and the institution (6.2%); 6.2 % of physicians did not perceive any barrier. The barriers were grouped in 5 factors that explained 62.48% of the variance: patient cultural level, lack of medical skills, fear of adverse events, insecurity and lack of training. CONCLUSION: Clinical inertia was not the result of a complex medical condition or patient comorbidities, but of doctor's perception and confidence in his/her clinical and communication skills.

INTRODUCCIÓN: Poco se ha evaluado el rechazo de los médicos a prescribir insulina a sus pacientes; el retraso en intensificar el tratamiento impide una atención adecuada y de calidad. OBJETIVO: Identificar la percepción de los médicos acerca de las barreras para iniciar la insulina en los pacientes con diabetes. MÉTODO: Por Índice Smith y análisis multivariado, en 81 médicos familiares se evaluó la relevancia y agrupación de los conceptos relacionados con las barreras para la prescripción de insulina. RESULTADOS: 35.8 % de los médicos mostró confianza en prescribir insulina; casi la mitad calificó la intensificación del tratamiento entre moderadamente y poco importante (39.5 y 6.2 %). Las barreras se relacionaron con el médico (39.5 %), el paciente (37 %), el tratamiento con insulina (11.1 %) y la institución (6.2 %); 6.2 % de los médicos no percibió ninguna barrera. Las barreras se agruparon en cinco factores, que explicaron 62.48 % de la varianza: cultura de los pacientes, falta de habilidades, miedo a los eventos adversos, inseguridad y falta de capacitación. CONCLUSIÓN: La inercia clínica no resultó de una condición clínica compleja o comorbilidades del paciente, sino de la percepción del médico y de su confianza en sus habilidades clínicas y comunicativas.

Validación de Belief Medicines Questionnaire y Self-efficacy for Appropriate Medication Use Scale para medir adherencia al tratamiento farmacológico en pacientes con enfermedad inflamatoria intestinal.

INTRODUCTION: Treatment adherence is crucial in inflammatory bowel disease (IBD) to prevent relapses and complications. In Mexico, there is not a validated tool to assess adherence in patients with IBD. OBJECTIVE: To translate the beliefs about medicines questionnaire (BMQ) and self-efficacy for appropriate medication use scale (SEAMS) instruments, as well as to determine their validity, reliability and sensitivity in IBD-diagnosed Mexican patients. METHOD: After informed consent was obtained, 149 IBD-diagnosed patients were included. The instruments were translated into Spanish and were subsequently applied during medical consultation. For SEAMS, exploratory factorial analysis and ROC curve analysis were carried out and Cronbach's alpha was determined; for the BMQ, Cohen's kappa coefficient and its predictive capacity were employed. RESULTS: Seventy-five women (50.3%) were included, with an average age of 44 years. The SEAMS scale showed a single factor that was highly reliable (Cronbach's alpha = 0.92) and a cutoff point of 33 to identify adherent patients. The "adherence" and "recall barrier" dimensions of the BMQ were adequate adherence predictors. CONCLUSIONS: The SEAMS and BMQ Spanish versions are valid for measuring self-efficacy and barriers to pharmacological treatment adherence in Mexican patients with IBD.

INTRODUCCIÓN: La adherencia terapéutica es crucial en la enfermedad inflamatoria intestinal (EII) para evitar recaídas y complicaciones. En México no se dispone de una herramienta validada para evaluar adherencia en pacientes con EII. OBJETIVO: Traducir los instrumentos Belief Medicines Questionnaire (BMQ) y Self-Efficacy for Appropriate Medication Use Scale (SEAMS), y determinar su validez, fiabilidad y sensibilidad en pacientes mexicanos con diagnóstico de EII. MÉTODO: Se incluyeron 149 pacientes con diagnóstico de EII, previo consentimiento informado. Se tradujeron los instrumentos al español y posteriormente fueron aplicados durante la consulta médica. Para la SEAMS se realizó análisis factorial exploratorio, análisis de curva ROC y determinación del alpha de Cronbach; para el BMQ se empleó el coeficiente kappa de Cohen y su capacidad predictiva. RESULTADOS: Se incluyeron 75 mujeres (50.3 %) con edad promedio de 44 años. La escala SEAMS mostró un único factor altamente confiable (alfa de Cronbach = 0.92) y un punto de corte de 33 para identificar a los pacientes adherentes. Las dimensiones "adherencia" y "barrera de recuerdo" del BMQ fueron adecuados predictores de adherencia. CONCLUSIONES: Las versiones en español SEAMS y BMQ son válidas para medir autoeficacia y barreras para la adherencia al tratamiento farmacológico en pacientes mexicanos con EII.

Barriers to obstetric fistula treatment in low-income countries: a systematic review.

OBJECTIVE: To identify the barriers faced by women living with obstetric fistula in low-income countries that prevent them from seeking care, reaching medical centres and receiving appropriate care. METHODS: Bibliographic databases, grey literature, journals, and network and organisation websites were searched in English and French from June to July 2014 and again from August to November 2016 using key search terms and specific inclusion and exclusion criteria for discussion of barriers to fistula treatment. Experts provided recommendations for additional sources. RESULTS: Of 5829 articles screened, 139 were included in the review. Nine groups of barriers to treatment were identified: psychosocial, cultural, awareness, social, financial, transportation, facility shortages, quality of care and political leadership. Interventions to address barriers primarily focused on awareness, facility shortages, transportation, financial and social barriers. At present, outcome data, though promising, are sparse and the success of interventions in providing long-term alleviation of barriers is unclear. CONCLUSION: Results from the review indicate that there are many barriers to fistula treatment, which operate at the individual, community and national levels. The successful treatment of obstetric fistula may thus require targeting several barriers, including depression, stigma and shame, lack of community-based referral mechanisms, financial cost of the procedure, transportation difficulties, gender power imbalances, the availability of facilities that offer fistula repair, community reintegration and the competing priorities of political leadership.

Situational analysis of lymphatic filariasis morbidity in Ahanta West District of Ghana.

OBJECTIVES: Situational analysis of lymphatic filariasis (LF) morbidity and its management in Ahanta West, Ghana, to identify potential barrier to healthcare for LF patients. METHODS: Lymphoedema and hydrocoele patients were identified by community health workers from a subset of villages, and were interviewed and participated in focus group discussions to determine their attitudes and practices towards managing their morbidity, and their perceived barriers to accessing care. Local health professionals were also interviewed to obtain their views on the availability of morbidity management services in the district. RESULTS: Sixty-two patients (34 lymphoedema and 28 hydrocoeles) and 13 local health professionals were included in the study. Lymphoedema patients predominantly self-managed their conditions, which included washing with soap and water (61.8%), and exercising the affected area (52.9%). Almost 65% of patients had sought medical assistance at some stage, but support was generally limited to receiving tablets (91%). Local health professionals reported rarely seeing lymphoedema patients, citing stigma and lack of provisions to assist patients as a reason for this. Almost half of hydrocoele patients (44%) chose not to seek medical assistance despite the negative impact it had on their lives. Whilst surgery itself is free with national health insurance, 63% those who had not sought treatment stated that indirect costs of surgery (travel costs, loss of earnings, etc.) were the most prohibitive factor to seeking treatment. CONCLUSIONS: The information obtained from this study should now be used to guide future morbidity strategies in building a stronger relationship between the local health services and LF patients, to ultimately improve patients' physical, psychological and economic wellbeing.

[Barriers and motivations of nurses for conducting research in Intensive Care Units and Emergency Medical Service]. / Barreras y motivaciones de los profesionales de enfermería para la utilización de la investigación en Unidades de Cuidados Intensivos y en el Servicio de Emergencias Médicas.

BACKGROUND: The implementation of evidence based practice is essential in clinical practice. However, it is still a challenge in critical care patients. AIM: To identify the barriers for conducting research that nursing professionals perceive in intensive care and medical emergency departments, as well as to investigate the areas of interest and motivations to carry out research projects. METHOD: Cross-sectional and multicentre study carried out in 4 intensive care units and in one Medical Emergency Department emergency pre-hospital carein Catalonia on 2014. The instrument used was The Barriers to Research Utilization Scale which had been previously validated into Spanish. A descriptive and bivariate analysis was performed. A statistical significance of P<.05 was assumed. RESULTS: One hundred seventy-two questionnaires were obtained (69.9% response). Of the total, 135 were from critical care, 27 to pre-hospital care, and 10 from both. Just over half (57.3%) had research experience, although 44.4% had related training. The questionnaire dimension considered most relevant was organisational characteristics. The most important barriers were: there is not enough time at work [3.11 (SD 1.21)], physicians do not collaborate in its implementation [2.99 (SD 1.22)], and nurses are isolated with respect to other professionals [2.86 (SD 1.32)]. Significant differences were observed in the barriers according to research experience and work place. The main motivation was to be updated in critical patient care. CONCLUSIONS: The main barriers perceived are related to the organisation. There are differences in the barriers according to research experience and work place.

'I was thinking too much': experiences of HIV-positive adults with common mental disorders and poor adherence to antiretroviral therapy in Zimbabwe.

OBJECTIVE: To document the lived experiences of people with both poor mental health and suboptimal adherence to antiretroviral therapy in high HIV prevalence settings. METHODS: In-depth qualitative interviews were conducted with 47 (female = 31) HIV-positive adults who scored above the cut-point on a locally validated scale for common mental disorders (CMDs). Purposive sampling was used to recruit participants with evidence of poor adherence. Six additional key informant interviews (female = 6) were conducted with healthcare workers. Data were collected and analysed inductively by an interdisciplinary coding team. RESULTS: The major challenges faced by participants were stressors (poverty, stigma, marital problems) and symptoms of CMDs ('thinking too much', changes to appetite and sleep, 'burdened heart' and low energy levels). Thinking too much, which appears closely related to rumination, was the symptom with the greatest negative impact on adherence to antiretroviral therapy among HIV-positive adults with CMDs. In turn, thinking too much was commonly triggered by the stressors faced by people living with HIV/AIDS, especially poverty. Finally, participants desired private counselling, access to income-generating activities and family engagement in mental health care. CONCLUSIONS: Better understanding of the local expression of mental disorders and of underlying stressors can inform the development of culturally sensitive interventions to reduce CMDs and poor adherence to antiretroviral therapy.

Explaining low rates of sustained use of siphon water filter: evidence from follow-up of a randomised controlled trial in Bangladesh.

OBJECTIVE: To assess sustained siphon filter usage among a low-income population in Bangladesh and study relevant motivators and barriers. METHODS: After a randomised control trial in Bangladesh during 2009, 191 households received a siphon water filter along with educational messages. Researchers revisited households after 3 and 6 months to assess filter usage and determine relevant motivators and barriers. Regular users were defined as those who reported using the filter most of the time and were observed to be using the filter at follow-up visits. Integrated behavioural model for water, sanitation and hygiene (IBM-WASH) was used to explain factors associated with regular filter use. RESULTS: Regular filter usage was 28% at the 3-month follow-up and 21% at the 6-month follow-up. Regular filter users had better quality water at the 6-month, but not at the 3-month visit. Positive predictors of regular filter usage explained through IBM-WASH at both times were willingness to pay >US$1 for filters, and positive attitude towards filter use (technology dimension at individual level); reporting boiling drinking water at baseline (psychosocial dimension at habitual level); and Bengali ethnicity (contextual dimension at individual level). Frequently reported barriers to regular filter use were as follows: considering filter use an additional task, filter breakage and time required for water filtering (technology dimension at individual level). CONCLUSION: The technological, psychosocial and contextual dimensions of IBM-WASH contributed to understanding the factors related to sustained use of siphon filter. Given the low regular usage rate and the hardware-related problems reported, the contribution of siphon filters to improving water quality in low-income urban communities in Bangladesh is likely to be minimal.

[Barriers to ART initiation in HIV infected subjects and with treatment indication in Spain. Why don't they start their treatment? Bridgap Study]. / Barreras para el inicio del tratamiento antirretroviral en pacientes con virus de la inmunodeficiencia humana e indicación de tratamiento en España. ¿Por qué no inician tratamiento quienes lo tienen indicado? Estudio Bridgap.

INTRODUCTION: In Spain, HIV treatment guidelines are well known and generally followed. However, in some patients there are no plans to initiate ART despite having treatment indications. The current barriers to ART initiation are presented. METHODS: A cross-sectional survey including every HIV infected patient in care in 19 hospitals across Spain in 2012, with ≥1 indication to start ART according to 2011 national treatment guidelines, who had not been scheduled for ART initiation. Reasons for deferring treatment were categorized as follows (non-exclusive categories): a) The physician thinks the indication is not absolute and prefers to defer it; b) The patient does not want to start it; c) The physician thinks ART must be started, but there is some limitation to starting it, and d) The patient has undetectable viral load in absence of ART. RESULTS: A total of 256 patients, out of 784 originally planned, were included. The large majority (84%) were male, median age 39 years, 57% MSM, 24% heterosexuals, and 16% IDUs. Median time since HIV diagnosis was 3 years, median CD4 count, 501 cells/mm3, median viral load 4.4 log copies/ml. Main ART indications were: CD4 count <500 cells/mm(3), 48%; having an uninfected sexual partner, 28%, and hepatitis C coinfection, 23%. Barriers due to, the physician, 55%; the patient, 28%; other limitations, 23%; and undetectable viral load, 6%. CONCLUSIONS: The majority of subjects with ART indication were on it. The most frequent barriers among those who did not receive it were physician-related, suggesting that the relevance of the conditions that indicate ART may need reinforcing.

[Limitations and opportunities for the appropriation of the Mediterranean diet in Chilean adults with diagnostic elements of metabolic syndrome]. / Limitaciones y oportunidades para la adopción de la dieta mediterránea en adultos chilenos con elementos diagnósticos del síndrome metabólico.

Introduction: Background: a healthy food intake pattern, specifically the Mediterranean diet (MedDiet), is a factor associated with reduced risk, lower prevalence, and better management of chronic diseases. However, there is limited information regarding how patients integrate proposals for adherence to this food pattern in their daily lives. Objective: to identify factors and conditions that influence adherence to the MedDiet in Chile. Methods: an exploratory qualitative study was applied in 35 to 65-year-old patients of both sexes who presented at least one diagnostic criterion of metabolic syndrome (MetS). Through in-depth interviews and focal groups, knowledge, assessment, attitudes, and practices associated with changes and maintenance of healthy eating habits, with emphasis on the MedDiet, were investigated. Information analysis was carried out under the grounded theory approach using the ATLAS.ti software. Results: participants recognized the value of healthy eating, including the MedDiet, but declared low knowledge (identification of single foods items) together with facilitators (variety of ingredients) and limiting factors (taste, availability/cost of some items, family dynamics) for its routine adoption. In addition, change in eating habits generates a high initial cognitive and emotional load that requires not only individual but also relational effort as it implies modifications of family and collective practices. Conclusions: information obtained on barriers and opportunities to adhere to healthy eating such as the MedDiet is key to design and implement nutritional interventions based on this food pattern and that can be sustainable in time for chronic disease management in Chile.

Introducción: Antecedentes: un estilo de alimentación saludable, específicamente la dieta mediterránea (DMed), es un factor asociado a bajo riesgo, menor prevalencia y mejor manejo de las enfermedades crónicas. Sin embargo, existe información limitada respecto a cómo los pacientes incorporan propuestas de este patrón alimentario en su vida cotidiana. Objetivo: identificar factores y condiciones que pueden influir en la adherencia a la DMed en Chile. Métodos: estudio cualitativo exploratorio en 17 pacientes de ambos sexos de entre 35 y 65 años que presentaban algún criterio diagnóstico de síndrome metabólico (SMet). Mediante entrevistas en profundidad y grupos focales se indagaron el conocimiento, la valoración, las actitudes y las prácticas asociadas a cambios y mantenimiento de alimentación con énfasis en la DMed. El análisis de la información se realizó bajo el enfoque de teoría fundada usando el software ATLAS.ti. Resultados: los participantes reconocieron el valor de una alimentación saludable tipo DMed, pero declararon bajo conocimiento (identificación de algunos alimentos aislados, dinámica familiar) de ella, junto con facilitadores (variedad de ingredientes) y limitantes (sabor, disponibilidad/costo de algunos alimentos) para su adopción rutinaria. Además, el cambio de hábitos alimentarios genera alta carga cognitiva y emocional inicial que requiere esfuerzo no solo individual sino también relacional, pues implica modificaciones de prácticas familiares y colectivas. Conclusiones: la información obtenida sobre barreras y oportunidades para adherir a una alimentación saludable como la DMed resulta clave para diseñar e implementar intervenciones nutricionales basadas en este patrón alimentario y que puedan ser sostenibles en el tiempo para el enfrentamiento de las enfermedades crónicas en Chile.

[Communication with a culturally and linguistically diverse population from Primary Care]. / La comunicación con población cultural y lingüísticamente diversa desde la Atención Primaria.

The care of a culturally and linguistically diverse population is a challenge in primary health care due to language barriers and cultural differences. For this reason, good communication and cultural competence of health personnel is key within medical consultation. Thus, during consultations with this group of people, it is the doctor's duty to identify the patient's culture, their perception of the concept of health, in what way and to what extent they want to be informed, and the role they want to assign to the members of their family before the treatment process begins. For this reason, there are interventions that seek to optimize the care provided to these patients and mitigate the cultural barrier, including the use of multimodal digital tools, the use of translators or interpreters, and training of health personnel in communication and intercultural skills.

Critical appraisal of the Colombian clinical practice guide for the prevention, diagnosis and treatment of suicidal ideation and/or behaviour (adoption).

INTRODUCTION: Suicide is a complex, global public health problem. The Colombian clinical practice guideline provides relevant input for its prevention, diagnosis and treatment. The objective was to evaluate the methodological quality, credibility and applicability of the Colombian clinical practice guideline for suicidal behaviour. METHODS: An academic group of 12 evaluators was established to assess the guide and its recommendations in a standardised way, using the AGREE-II and AGREE-REX instruments. The evaluations were given in the range of 0.0-1.0 with 0.7 as a cut-off point for appropriate quality. RESULTS: The global assessment of the AGREE-II was greater than 0.7 in the dimensions: "scope and objective" (0.86), "clarity of presentation" (0.89), "applicability" (0.73) and "editorial independence" (0.89). The lowest scores were for "participation of those involved" (0.67) and "rigour in preparation" (0.69). With the AGREE-REX, the results in all dimensions were below 0.70, which indicates lower quality and suitability for use. CONCLUSIONS: The adoption process of the Colombian guideline for suicidal behaviour was a rigorous methodological process, while the practice recommendations were valued as of low applicability due to low support in local evidence. It is necessary to strengthen the generation and synthesis of evidence at the national level to give greater support and applicability to the practice recommendations.

Effects of climate change, invasive species, and disease on the distribution of native European crayfishes.

Climate change will require species to adapt to new conditions or follow preferred climates to higher latitudes or elevations, but many dispersal-limited freshwater species may be unable to move due to barriers imposed by watershed boundaries. In addition, invasive nonnative species may expand into new regions under future climate conditions and contribute to the decline of native species. We evaluated future distributions for the threatened European crayfish fauna in response to climate change, watershed boundaries, and the spread of invasive crayfishes, which transmit the crayfish plague, a lethal disease for native European crayfishes. We used climate projections from general circulation models and statistical models based on Mahalanobis distance to predict climate-suitable regions for native and invasive crayfishes in the middle and at the end of the 21st century. We identified these suitable regions as accessible or inaccessible on the basis of major watershed boundaries and present occurrences and evaluated potential future overlap with 3 invasive North American crayfishes. Climate-suitable areas decreased for native crayfishes by 19% to 72%, and the majority of future suitable areas for most of these species were inaccessible relative to native and current distributions. Overlap with invasive crayfish plague-transmitting species was predicted to increase. Some native crayfish species (e.g., noble crayfish [Astacus astacus]) had no future refugia that were unsuitable for the modeled nonnative species. Our results emphasize the importance of preventing additional introductions and spread of invasive crayfishes in Europe to minimize interactions between the multiple stressors of climate change and invasive species, while suggesting candidate regions for the debatable management option of assisted colonization.

[Overcoming the barriers in the approach of the chronic patient]. / Superando las barreras en el abordaje del paciente crónico.

At least one in three adults has multiple chronic conditions. The assistance of patients with chronic conditions is mandatory. This is one of the main tasks of the primary care physicians. The approach in these patients is challenging, as there are many barriers at different levels (sanitary system, healthcare professionals and patients). In addition, COVID-19 pandemic has worsened this situation even more. Therefore, it is necessary to take actions that try to improve this state. For this purpose, with the aim to find solutions/recommendations that may be helpful to attain a better diagnosis, treatment and follow-up of patients with chronic diseases, a group of experts of SEMERGEN have tried to identify the problems in the attention to these patients, searching for potential solutions and areas of improvement. The present document has specifically focused on four prevalent chronic conditions in primary care: dyslipidemia, arterial hypertension, chronic venous disease and depression.