Qualidade da atenção as pessoas com hanseníase na rede pública de saúde / Quality of assistance provided to people with leprosy in the public health network

O estudo avaliou os serviços de saúde na assistência à Hanseníase a partir da percepção de todos os pacientes diagnosticados em um biênio em um município com baixa prevalência e incidência da doença de acordo com parâmetros da Organização Mundial de Saúde. Os entrevistados responderam a um questionário validado para o Brasil sobre a organização e o desempenho desses serviços. Destacam-se como fatores facilitadores: porta de entrada do serviço; vínculo com os profissionais e atuação profissional. Domínios que mesclaram pontos de satisfação e insatisfação entre os entrevistados: serviços prestados durante as consultas; falta de interesse pelas condições socioeconômicas do doente e de sua família; e participação da família no tratamento. Aspectos que foram consideradas dificultadores: iniciar o acesso ao diagnóstico e ao tratamento, falta de resolutividade dos profissionais quanto aos problemas gerais de saúde, que não relacionados à hanseníase e dificuldade no acesso às especialidades médicas, ausência de visitas domiciliares e orientação à comunidade com ações de educação em saúde.

This study evaluated leprosy care services from the view point of all patients diagnosed during one bienniumin a city with a low prevalence and incidence of the disease according to World Health Organization parameters. Leprosy patients answered a questionnaire validated in Brazil on the organization and performance of services provided. Access to services,relationship with professionals and performance of professionals were considered facilitating factors. Domains of mixed satisfaction and dissatisfaction among those interviewed were the service provided during consultations, lack of interest in the socioeconomic conditions of the patient and their family and family participation in treatment. The factors considered problematic were initial access to diagnosis and treatment, lack of determination of professional sin respect to general health problems not related to leprosy, difficulties to access medical specialties, and lack of home visits and community guidance with health education initiatives.

Calidad de la ejecución del Programa de Lepra en el Policlínico Universitario José Martí / Quality of the implementation of the Leprosy Program in José Martí Pérez University Polyclinic

Se realizó una investigación en Servicios y Sistemas de Salud, a fin de evaluar la calidad de la ejecución del Programa de Lepra en el Policlínico Universitario José Martí Pérez de Santiago de Cuba, desde febrero del 2010 hasta igual mes del 2011, para lo cual se empleó la Propuesta Metodológica para la Evaluación de la Calidad en Instituciones de Atención Primaria de Salud, diseñada por la Facultad de Salud Pública del Instituto Superior de Ciencias Médicas de La Habana, en tanto, las dimensiones evaluadas fueron la estructura, el proceso y los resultados. Se contó con la participación de los 65 profesionales que laboraron en el programa y de los 39 pacientes afectados. Se halló que dicho programa no se ejecutaba con la calidad requerida y que existían dificultades en el proceso y los resultados debido a la insuficiente competencia de los profesionales de la salud, así como la insatisfacción que ellos sentían.

An investigation on health services and systems was carried out in order to evaluate the quality of the implementation of the Leprosy Program in José Martí Pérez University Polyclinic in Santiago de Cuba, from February, 2010 to the same month of 2011, for which the Methodological Proposal for the Evaluation of Quality in Institutions of Primary Health Care was used, designed by the Public Health Faculty of the Higher Institute of Medical Sciences in Havana, while the evaluated dimensions were structure, process and results. There was participation of the 65 professionals who worked in the program and of the 39 affected patients. It was found that this Program was not implemented with the required quality and that there were difficulties in the process and the results due to the insufficient competence of the health professionals, as well as to the dissatisfaction they felt.

Calidad de la ejecución del Programa de Lepra en el Policlínico Universitario José Martí / Quality of the implementation of the Leprosy Program in José Martí Pérez University Polyclinic

Se realizó una investigación en Servicios y Sistemas de Salud, a fin de evaluar la calidad de la ejecución del Programa de Lepra en el Policlínico Universitario José Martí Pérez de Santiago de Cuba, desde febrero del 2010 hasta igual mes del 2011, para lo cual se empleó la Propuesta Metodológica para la Evaluación de la Calidad en Instituciones de Atención Primaria de Salud, diseñada por la Facultad de Salud Pública del Instituto Superior de Ciencias Médicas de La Habana, en tanto, las dimensiones evaluadas fueron la estructura, el proceso y los resultados. Se contó con la participación de los 65 profesionales que laboraron en el programa y de los 39 pacientes afectados. Se halló que dicho programa no se ejecutaba con la calidad requerida y que existían dificultades en el proceso y los resultados debido a la insuficiente competencia de los profesionales de la salud, así como la insatisfacción que ellos sentían(AU)

An investigation on health services and systems was carried out in order to evaluate the quality of the implementation of the Leprosy Program in José Martí Pérez University Polyclinic in Santiago de Cuba, from February, 2010 to the same month of 2011, for which the Methodological Proposal for the Evaluation of Quality in Institutions of Primary Health Care was used, designed by the Public Health Faculty of the Higher Institute of Medical Sciences in Havana, while the evaluated dimensions were structure, process and results. There was participation of the 65 professionals who worked in the program and of the 39 affected patients. It was found that this Program was not implemented with the required quality and that there were difficulties in the process and the results due to the insufficient competence of the health professionals, as well as to the dissatisfaction they felt(AU)

Avaliação da qualidade da assistência aos estados reacionais em Hanseníase na Atenção Primária: o caso da AP 5.3 no município do Rio de Janeiro / Assessment of quality of care for reactional states in leprosy in Primary Care: the case of AP 5.3 in the municipality of Rio de Janeiro

A Hanseníase é considerada um importante problema de saúde pública. Os estados reacionais, descritos como fenômenos agudos sobrepostos à evolução crônica e insidiosa desta doença, são os principais responsáveis por perda funcional de nervos periféricos gerando asincapacidades físicas. Os episódios reacionais mantêm-se como um dos grandes desafios para osProgramas de Controle de Hanseníase em países endêmicos, a exemplo do Brasil. O objetivo desse estudo éavaliar o grau de implementação das ações de assistência aos estados reacionais em Hanseníase em serviços de atenção integral a hanseníase tipo I e II, a partir da qualidade do cuidado. O trabalho se inicia com uma revisão da literatura sobre os estados reacionais e suas ações de controle, avaliação das ações de controle da hanseníase e qualidade da assistência aos mesmos na atenção primária a saúde. A descrição do problema foi feita através da árvorede problemas, enquanto a intervenção foi descrita a partir da construção de um modelo lógico do programa (MLP), que permitiu apresentar a racionalidade existente entre os componentes da intervenção: insumos, atividades, produtos, resultados e impactos. A partir do MLP foi desenvolvido o Modelo Teórico da Avaliação com a definição da abordagem e foco da avaliação, das matrizes de informação, de análise e julgamento, onde foram definidas asdimensões e sub-dimensões para análise do contexto e da intervenção.

Além da definição de critérios e indicadores e as pontuações que objetivaram os parâmetros da avaliação. A abordagem metodológica adotada foi à pesquisa avaliativa, de caráter normativo e formativo,utilizando métodos qualitativos e quantitativos. Os dados primários foram obtidos através de entrevistas com profissionais de saúde envolvidos com a intervenção e observação direta nosserviços. E os dados secundários através da análise de documentos e prontuários. O estudo configurou-se como um estudo de casos múltiplos com vários níveis de análise imbricados.Os três casos foram unidades de saúde da AP 5.3 no município do Rio de Janeiro, visto que esta apresentou nos últimos anos os maiores coeficientes de detecção de casos. Os resultadosmostraram que as ações de assistência aos estados reacionais encontram-se parcialmente implantadas nos três casos. Enquanto o componente estrutural insumos avaliado a partir dasub-dimensão disponibilidade está implantado nos casos, o componente atividades avaliado quanto a qualidade técnico-ciêntifica encontra-se parcialmente implantado em todos eles. O contexto externo influencia diretamente no acesso as referências aos serviços de atenção tipo III, enquanto o contexto organizacional possibilitou a ampliação dos serviços tipo I e organizou as referências na área na lógica da territorialização e construção de redes assistenciais em saúde.

International Federation of Antileprosy Associations and National Leprosy Eradication Programme--an alliance that accelerated quality leprosy services.

One of the main objectives of National Leprosy Eradication Programme in India is to achieve elimination of leprosy at national level (1 per 10,000 population). There will still remain a considerable number of cured leprosy cases with some disabilities and they require physical, socio-economic and phychological rehabilitation. Therefore, leprosy services need to be continued in a sustained manner. There are some major challenges which are to be confronted in a comprehensive and systemic manner. ILEP has come out to work together with the government to reach a common goal of a world without leprosy. It has a long history of providing quality leprosy services. The activities of ILEP support have been mentioned in this article. While considering the further scope of ILEP support to NLEP in India some guiding principles were identified. The support will be planned in line with global leprosy strategy and its operational guidelines.

Application of lot quality assurance sampling for leprosy elimination monitoring--examination of some critical factors.

BACKGROUND: The concept of elimination of an infectious disease is different from eradication and in a way from control as well. In disease elimination programmes the desired reduced level of prevalence is set up as the target to be achieved in a practical time frame. Elimination can be considered in the context of national or regional levels. Prevalence levels depend on occurrence of new cases and thus could remain fluctuating. There are no ready pragmatic methods to monitor the progress of leprosy elimination programmes. We therefore tried to explore newer methods to answer these demands. With the lowering of prevalence of leprosy to the desired level of 1 case per 10000 population at the global level, the programme administrators' concern will be shifted to smaller areas e.g. national and sub-national levels. For monitoring this situation, we earlier observed that lot quality assurance sampling (LQAS), a quality control tool in industry was useful in the initially high endemic areas. However, critical factors such as geographical distribution of cases and adoption of cluster sampling design instead of simple random sampling design deserve attention before LQAS could generally be recommended. The present exercise was aimed at validating applicability of LQAS, and adopting these modifications for monitoring leprosy elimination in Tamil Nadu state, which was highly endemic for leprosy. METHODS: A representative sample of 64000 people drawn from eight districts of Tamil Nadu state, India, with maximum allowable number of 25 cases was considered, using LQAS methodology to test whether leprosy prevalence was at or below 7 per 10000 population. Expected number of cases for each district was obtained assuming Poisson distribution. Goodness of fit for the observed and expected cases (closeness of the expected number of cases to those observed) was tested through chi(2). Enhancing factor (design effect) for sample size was obtained by computing the intraclass correlation. RESULTS: The survey actually covered a population of 62157 individuals, of whom 56469 (90.8%) were examined. Ninety-six cases were detected and this number far exceeded the critical value of 25. The number of cases for each district and the number of cases in the entire surveyed area both followed Poisson distribution. The intraclass correlation coefficients were close to zero and the design effect was observed to be close to one. CONCLUSIONS: Based on the LQAS exercises leprosy prevalence in the state of Tamil Nadu in India was above 7 per 10000. LQAS method using clusters was validated for monitoring leprosy elimination in high endemic areas. Use of cluster sampling makes this method further useful as a rapid assessment procedure. This method needs to be tested for its applicability in moderate and low endemic areas, where the sample size may need increasing. It is further possible to consider LQAS as a monitoring tool for elimination programmes with respect to other disease conditions.

Use of a standardised checklist to assess peripheral sputum smear microscopy laboratories for tuberculosis diagnosis in Uganda.

SETTING: TB diagnostic units in Uganda. OBJECTIVES: To assess and improve the supervision and performance of sputum smear microscopy in the peripheral diagnostic units in Uganda using a standardised laboratory checklist. DESIGN: A standardised checklist was developed and used during the quarterly supervisory visits of the District TB and Leprosy Supervisors for five quarters from the fourth quarter of 1997 until the last quarter of 1998. Individual peripheral laboratory performance was monitored during the study period. RESULTS: Forty-eight of 304 TB diagnostic units in six of the 45 Ugandan Districts were supervised using the checklist. A total of 208 checklists were analysed. The situational analysis of the peripheral diagnostic units at the beginning and at the end of the study showed a marked improvement in laboratory performance in all aspects related to sputum smear microscopy. Individual laboratory performance was monitored over five quarters, and timely response to shortcomings was provided. CONCLUSION: The systematic use of a standardised laboratory checklist can be considered an important step forward in improving the performance of the peripheral laboratories in Uganda through on-the-spot correction of any identified shortcomings.

Lot quality assurance sampling (LQAS) for monitoring leprosy elimination in an endemic district in Tamilnadu.

This paper examines whether the health administration can use lot quality assurance sampling (LQAS) for identifying high prevalence areas for leprosy for initiating necessary corrective measures. The null hypothesis was that leprosy prevalence in the district was at or above ten per 10,000 and the alternative hypothesis was that it was at or below five per 10,000. A total of 25,500 individuals were to be examined with 17 as an acceptable maximum number of cases (critical value). Two-stage cluster sample design was adopted. The sample size need not be escalated as the estimated design effect was 1. During the first phase, the survey covered a population of 4,837 individuals out of whom 4,329 (89.5%) were examined. Thirty-five cases were detected and this number far exceeded the critical value. It was concluded that leprosy prevalence in the district should be regarded as having prevalence of more than ten per 10,000 and further examination of the population in the sample was discontinued. LQAS may be used as a tool by which one can identify high prevalence districts and target them for necessary strengthening of the programme. It may also be considered for certifying elimination achievement for a given area.

Lot quality assurance sampling (LQAS) for monitoring a leprosy elimination program.

In a statistical sense, prevalences of leprosy in different geographical areas can be called very low or rare. Conventional survey methods to monitor leprosy control programs, therefore, need large sample sizes, are expensive, and are time-consuming. Further, with the lowering of prevalence to the near-desired target level, 1 case per 10,000 population at national or subnational levels, the program administrator's concern will be shifted to smaller areas, e.g., districts, for assessment and, if needed, for necessary interventions. In this paper, Lot Quality Assurance Sampling (LQAS), a quality control tool in industry, is proposed to identify districts/regions having a prevalence of leprosy at or above a certain target level, e.g., 1 in 10,000. This technique can also be considered for identifying districts/regions at or below the target level of 1 per 10,000, i.e., areas where the elimination level is attained. For simulating various situations and strategies, a hypothetical computerized population of 10 million persons was created. This population mimics the actual population in terms of the empirical information on rural/urban distributions and the distribution of households by size for the state of Tamil Nadu, India. Various levels with respect to leprosy prevalence are created using this population. The distribution of the number of cases in the population was expected to follow the Poisson process, and this was also confirmed by examination. Sample sizes and corresponding critical values were computed using Poisson approximation. Initially, villages/towns are selected from the population and from each selected village/town households are selected using systematic sampling. Households instead of individuals are used as sampling units. This sampling procedure was simulated 1000 times in the computer from the base population. The results in four different prevalence situations meet the required limits of Type I error of 5% and 90% Power. It is concluded that after validation under field conditions, this method can be considered for a rapid assessment of the leprosy situation.

Health information systems for leprosy control programmes: a case for quality assessment.

A qualitative study was carried out aimed at checking the level of understanding and the actual use of the indicators recommended in leprosy control programmes by either the World Health Organization or the International Federation of Anti-Leprosy Associations. Two successive questionnaires were sent to 268 leprosy control programme managers. The first one concerned information about the main characteristics of the programme, the information system in operation, and the data regarded as indispensable or useful for programme monitoring. The respondents to the first questionnaire (n = 64) proposed an extraordinarily wide range of indicators, mainly ill-defined. The respondents to the second questionnaire (n = 37) to whom a limited list of precisely defined indicators was submitted did not succeed in reaching a complete agreement on any of these indicators. Although the question of programme monitoring has been dealt with at an international level for years, there is an urgent need for a real agreement of international agencies and managers of leprosy control programmes on the indicators to be used. Programme managers in the field are obviously open to the idea of greater intervention by international organizations to improve data collection and to encourage standardization of computerized information systems.

Perfil da prescrição e de uso de medicamentos no Hospital Evandro Chagas, Rio de Janeiro / Profile of prescriptions and drugs use at the Hospital Evandro Chagas, Rio de Janeiro

Revisão de uso de medicamentos, proposta como metodologia de avaliação de qualidade do sistema de distribuição de medicamentos por dose unitária em uma unidade hospitalar de pequeno porte, especializada em pesquisa na área das doenças infecto parasitárias (DIP). A partir da revisão retrospectiva de 983 prescriçoes em 83 internaçoes eleitas proporcionalmente dentre grupos de diagnóstico principal de SIDA, tripanossomíase, paracoccidioidomicose, hanseníase e outras DIP, foram identificados os medicamentos mais utilizados e os custos inerentes, assim como desvios dos parâmetros de preenchimento da prescrição quanto a dose e frequencia de administração dos medicamentos e limites máximo e mínimo das doses, em relação aos padroes propostos na bibliografia, bem como do registro de administração dos mesmos pelo pessoal de enfermagem. Ainda que não se possa afirmar que os desvios encontrados tenham necessariamente resultado em falhas da assistência propriamente dita, representaram, falhas de registro. Ressalta a importância da construção de critérios para controle prospectivo e continuado, a partir da discussão conjunta dos vários profissionais envolvidos

Acesso, utilizaçäo e aceitaçäo dos serviços de dermatologia de um centro de saúde-escola sob o modo de ver dos hansenianos / Access, utilization and acceptance of a school-health center dermatological service under the leper patients perception

Os objetivos consideram como eixos principais de análise, o acesso em seus múltiplos aspectos, a utilizaçäo e aceitaçäo dos serviços de dermatologia por pacientes de hanseníase do Centro de Saúde da Escola Paulista de Medicina (CSE). As entrevistas apontaram que o acesso ao CSE, nos seus aspectos geográfico e financeiro, apresentou algumas barreiras como o tempo e o valor gastos com os meios de transporte utilizados, face ao baixo nível sócio-econômico da grande maioria dos hansenianos e a distância dos locais de residência. Quanto ao início e continuidade do controle näo ocorreu nenhum obstáculo a esse acesso, com exceçäo, de serviços assistenciais de retaguarda. A utilizaçäo, pelos pacientes, da consulta médica nas áreas de dermatologia e gineco/obstetrícia foi maior que o padräo estabelecido. Esses doentes valorizaram muito o atendimento prestado, sem agendamento, em funçäo de necessidades emergentes, com destaque para os atributos técnico e de relacionamento interpessoal. Ao julgarem a boa qualidade do atendimento prestado no CSE, as experiências pretéritas constituíram o padräo de referência. A satisfaçäo geral e a preocupaçäo de alguns pacientes com a possibilidade de serem transferidos para outras Unidades Básicas de Saúde, indicaram a boa qualidade da assistência prestada