Evaluación quinquenal de los ejes sanitarios de un programa nacional de Atención Primaria de la Salud / Five-year evaluation of the sanitary axes of a national program of Primary Health Care

Se realizó una evaluación quinquenal de los ejes sanitarios (que dan lugar a objetivos estratégicos con sus correspondientes metas e indicadores, áreas de intervención y líneas de acción) dentro del marco de la gestión sanitaria de uno de los 10 principales agentes de la seguridad social argentinos quien implementaba desde hacía 20 años un Programa Nacional de Atención Primaria de la Salud (PNAPS). El mismo promedió alrededor de 800 mil beneficiarios anuales dentro de una red asistencial nacional propia en el primer nivel de atención compuesta por 45 Centros de Atención Primaria (CAPs). Se implementó una investigación evaluativa que incluyó un trazado de línea de base con la valoración de cinco Ejes Sanitarios (ES). Se trata de un diseño de corte transversal de un periodo de 5 años. Se definieron metas, indicadores y recomendaciones para cada uno de los ES, recopilando información de fuentes diferentes y complementarias para su análisis. Los resultados mostraron una evolución favorable en el período evaluado, aunque el cumplimiento de las metas estuvo bastante alejado de lo propuesto de manera teórica. Conclusiones: este trabajo aporta información valiosa y original para subsidiar la toma de decisiones e incentivar la investigación en el ámbito de la APS, buscando reformular los actuales modelos de gestión y de atención de la salud (AU)

A five-year evaluation of the health axes (which give rise to strategic objectives with their corresponding goals and indicators, areas of intervention and lines of action) was carried out within the framework of health management of one of the 10 main argentine social security agents who had been implementing a National Primary Health Care Program (PNAPS) for 20 years. It averaged around 800,000 annual beneficiaries within its own national care network at the first level of care made up of 45 Primary Care Centers (CAPs). An evaluative investigation was implemented that included a baseline drawing with the assessment of five Sanitary Axis (ES). It is a cross-sectional design of a period of 5 years. Goals, indicators and recommendations were defined for each of the ES, collecting information from different and complementary sources for analysis. Results: they showed a favorable evolution in the period evaluated, although the fulfillment of the goals was quite far from what was theoretically proposed. The results of this work provides valuable and original information to support decision-making and encourage research in the field of PHC, seeking to reformulate current management and health care models (AU)

The QualiRede intervention: improving the performance of care continuum in HIV, congenital syphilis, and hepatitis C in health regions.

INTRODUCTION: Care continuum models have supported recent strategies against sexually transmitted diseases, such as HIV and Hepatitis C (HCV). METHODS: HIV, HCV, and congenital syphilis care continuum models were developed, including all stages of care, from promotion/prevention to clinical control/cure. The models supported the intervention QualiRede, developed by a University-Brazilian National Health System (SUS) partnership focused on managers and other professionals from six priority health regions in São Paulo and Santa Catarina. Indicators were selected for each stage of the care continuum from the SUS information systems and from the Qualiaids and QualiAB facility's process evaluation questionnaires. The indicators acted as the technical basis of two workshops with professionals and managers in each region: the first one to identify problems and to create a Regional Technical Group; and the second one to design action plans for improving regional performance. RESULTS: The indicators are available at www.qualirede.org. The workshops took place in the regions of Alto Tietê, Baixada Santista, Grande ABC, and Registro (São Paulo) and of Foz do Rio Itajaí (Santa Catarina), which resulted in regional action plans in São Paulo, but not in Santa Catarina. A lack of awareness was observed regarding the new HIV and HCV protocols, as well as an incipient use of indicators in routine practices. CONCLUSION: Improving the performance of the care continuum requires appropriation of performance indicators and coordination of care flows at local, regional, and state levels of management.

The QualiRede intervention: improving the performance of care continuum in HIV, congenital syphilis, and hepatitis C in health regions / A intervenção QualiRede: melhoria do desempenho do contínuo do cuidado em HIV, sífilis congênita e hepatite C em regiões de saúde

ABSTRACT Introduction: Care continuum models have supported recent strategies against sexually transmitted diseases, such as HIV and Hepatitis C (HCV). Methods: HIV, HCV, and congenital syphilis care continuum models were developed, including all stages of care, from promotion/prevention to clinical control/cure. The models supported the intervention QualiRede, developed by a University-Brazilian National Health System (SUS) partnership focused on managers and other professionals from six priority health regions in São Paulo and Santa Catarina. Indicators were selected for each stage of the care continuum from the SUS information systems and from the Qualiaids and QualiAB facility's process evaluation questionnaires. The indicators acted as the technical basis of two workshops with professionals and managers in each region: the first one to identify problems and to create a Regional Technical Group; and the second one to design action plans for improving regional performance. Results: The indicators are available at www.qualirede.org. The workshops took place in the regions of Alto Tietê, Baixada Santista, Grande ABC, and Registro (São Paulo) and of Foz do Rio Itajaí (Santa Catarina), which resulted in regional action plans in São Paulo, but not in Santa Catarina. A lack of awareness was observed regarding the new HIV and HCV protocols, as well as an incipient use of indicators in routine practices. Conclusion: Improving the performance of the care continuum requires appropriation of performance indicators and coordination of care flows at local, regional, and state levels of management.

RESUMO Introdução: Modelos de cuidado contínuo baseiam recentes estratégias em HIV, infecções sexualmente transmissíveis e hepatite C (HCV). Métodos: Desenvolveram-se modelos de contínuo do cuidado em HIV, HCV e sífilis congênita incluindo todas as etapas da atenção, desde a promoção e a prevenção até o controle clínico/cura. O modelo baseou a intervenção QualiRede, desenvolvida em parceria entre universidade e Sistema Único de Saúde (SUS), direcionada a gestores e demais profissionais de 6 regiões de saúde prioritárias em São Paulo e Santa Catarina. Selecionaram-se indicadores para cada etapa do contínuo do cuidado, provenientes dos sistemas de informação do SUS e dos questionários de avaliação de processo Qualiaids e QualiAB. Os indicadores formaram a base técnica de duas oficinas com profissionais e gestores de cada região: a primeira para identificar problemas e formar um Grupo Técnico Regional; e a segunda para construir planos de ação e metas a fim de melhorar o desempenho regional. Resultados: Os indicadores estão disponíveis no website www.qualirede.org. As oficinas ocorreram em quatro regiões de São Paulo (Alto Tietê, Baixada Santista, Grande ABC e Registro) e uma região de Santa Catarina (Foz do Rio Itajaí), resultando em planos regionais em São Paulo, mas não em Santa Catarina. Observou-se domínio limitado dos novos protocolos para HIV e HCV e uso incipiente de indicadores na rotina dos serviços. Conclusão: Melhorar o desempenho do contínuo do cuidado exige apropriação dos indicadores de desempenho e coordenação integrada dos fluxos de atenção em todos os níveis de gestão.

A mapping of nursing and midwifery research in the Eastern Mediterranean Region, 2006-2016.

BACKGROUND: Nurses and midwives constitute the largest group of health care professionals globally. Challenges to these professions make it difficult to set regional priorities for policies and research development. AIMS: The purpose of this study was to map current nursing and midwifery research in the Eastern Mediterranean Region. METHODS: Nursing and midwifery schools were identified by each country's nursing and midwifery board and ministries of education/public health. Information was collected for the years 2006-2016 via surveys, websites, Google scholar and expert informants. RESULTS: A total of 299 schools were identified and 241 of these were contacted; 85 completed surveys from 15 countries were analysed. A total of 1116 research topics covered by 3287 publications were identified, many of which were clustered into the five World Health Organization priority areas. The least developed areas were disaster management and emergency preparedness. CONCLUSIONS: This study provides a database of nursing and midwifery research in the Region. Some gaps were identified based on the research priorities of the Region, but these gaps could be addressed by close collaboration among local researchers.

Evaluation of the performance of actions and outcomes in primary health care.

OBJECTIVE: The objective of this study has been to evaluate the performance of the primary care of Brazilian municipalities in relation to health actions and outcomes. METHODS: This is an evaluative, cross-sectional research, with a quantitative approach, aimed at the identification of the efficiency frontier of the primary care in health actions and outcomes in Brazilian municipalities. Secondary data have been collected from the Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (National Program for Improving Access and Quality of Primary Care) and the Department of Informatics of the Brazilian Unified Health System, in 2012. The data envelopment analysis tool has been used for variable returns to scale with product orientation. RESULTS: Municipalities have been analyzed by population size, and small municipalities have presented a high percentage of inefficiency for both models. CONCLUSIONS: The analysis of efficiency has indicated the existence of a higher percentage of effective municipalities in the model of health actions than in the model of health outcomes.

OBJETIVO: Avaliar o desempenho da atenção básica dos municípios brasileiros quanto a ações e resultados em saúde. MÉTODOS: Pesquisa avaliativa, transversal, com abordagem quantitativa, para identificar a fronteira de eficiência da atenção básica em ações e resultados em saúde nos municípios brasileiros. Foi realizada coleta de dados secundários a partir do Programa Nacional de Melhoria do Acesso e da qualidade da Atenção Básica e do Departamento de Informática do Sistema Único de Saúde, no ano de 2012. Utilizou-se a ferramenta análise envoltória de dados para retornos variáveis de escala com orientação para produto. RESULTADOS: Os municípios foram analisados por porte populacional e verificou-se que para ambos os modelos, os municípios de pequeno porte apresentaram alto percentual de ineficiência. CONCLUSÕES: A análise da eficiência indicou a existência de um percentual maior de municípios eficientes no modelo de ações em saúde do que no modelo de resultados em saúde.

Análise da assistência à saúde com a Naturologia na perspectiva do usuário / Analysis of health care with Naturology in perspective of the users

A pesquisa realizada objetivou analisar a assistência à saúde na perspectiva do usuário, atendido na Seção de Naturologia Aplicada da Assembleia Legislativa do Estado de Santa Catarina (ALESC). Trata-se de um estudo descritivo, exploratório de natureza quantitativa. Foi realizado entre o período de Setembro a Outubro de 2012. A amostra foi constituída por 80 usuários. Os dados foram obtidos por meio de questionário. A coleta de dados enfocou questões referentes ao conhecimento e aceitação das práticas naturais, à satisfação do usuário e à resolutividade da assistência à saúde com a Naturologia. A análise dos dados ocorreu através da estatística descritiva e para comparação entre as porcentagens utilizou-se o Teste Exato de Fisher. Os resultados demonstraram que a maioria (67,1%) conhecia as práticas naturais, mas grande parte (52,5%) não fazia uso. A prática natural mais popular foram os florais, tanto no conhecimento quanto no uso. A análise da satisfação dos usuários pela assistência com a Naturologia mostrou-se positiva, onde a maioria (83,8%) se considera satisfeito pelo atendimento no local, (85,3%) relataram que o atendimento com a Naturologia melhorou sua saúde e (49,4%) que o seu problema de saúde foi resolvido com o atendimento. A maioria (97,4%) acredita que a Seção de Naturologia tem resolutividade no atendimento de seu usuário, (95,0%) acredita no efeito das práticas naturais, (97,4%) indicariam o tratamento com a Naturologia para outras pessoas, demonstrando que as práticas naturais são aceitas. Este estudo apontou que é possível analisar a assistência à saúde sob as diferentes perspectivas do usuário, identificando fatores que possam melhorar a qualidade das ações prestadas pela Naturologia.(AU)

The research aimed to analyze the health care in the user´s perspective, attended the Section of Naturology of the Assembleia Legislativa do Estado de Santa Catarina (ALESC). The study was descriptive, exploratory and quantitative analysis was descriptive, performed between September and Octuber 2012. The sample consisted of 80 users and data collection was made by means of questionnaire. The analysis focused on issues related to knowledge and acceptance of natural practices, user satisfaction and resoluteness of health care with Naturology. The results showed that the majority (67,1%) knew the natural practices, but most, but (52,5%) was not used. The analysis of user satisfaction for assistance with Naturology was positive, where the majority (83,8%) is considered satisfied with the service, (85,3%) reported that the treatment with naturology improved their health and (49,4%) that this health problem was solved with the service. Most (97,4%) believes that Naturology has resoluteness in the service of their user, (95.0%) believe the effect of natural practices, (97,4%) indicate treatment with Naturology to others demonstrating that natural practices are accepted. This study showed that is possible to analyze the health care unde different user perspectives, indentifying faactors that can improve the quality of the actions provided by Naturology.(AU)

A contribuição da Naturologia para a implementação da política nacional de práticas integrativas e complementares na concepção dos naturólogos que atuam no Sistema Único de Saúde / Contribution of naturology in regard to the implementation of the National Policy of Integrative and Complementary practices into the conception of naturology who work for brazilian Unique Health System

Introdução: Organização Mundial de Saúde (OMS) demonstrou a valorização das Medicinas Tradicionais e Medicinas Alternativas/Complementares como forma de melhorar resultados no campo da saúde. O Brasil atendeu as recomendações da OMS e instituiu a Política Nacional de Práticas Integrativas e Complementares (PNPIC). A PNPIC legitimou a institucionalização destas práticas inaugurando novas perspectivas com foco na saúde e em sua complexidade, visando garantir a integralidade na atenção à saúde. Objetivo: compreender a contribuição da Naturologia para a implementação da PNPIC na concepção de naturólogos que atuam no Sistema Único de Saúde (SUS). Percurso metodológico: realizou-se, no primeiro semestre de 2015, um estudo de campo com abordagem qualitativa, exploratória e descritiva, aprovado pelo Comitê de Ética em Pesquisa da Universidade do Sul de Santa Catarina. Os dados foram coletados através de entrevista semi estruturada com oito naturólogos atuantes em quatro estados brasileiros e tratados por meio da análise do conteúdo de Bardin. Resultados: foram descritos cinco categorias temáticas: (1) O naturólogo em equipe multidisciplinar de saúde, (2) Abordagem do naturólogo no SUS, (3) A implementação da PNPIC nos municípios de atuação, (4) Princípios da Naturologia que contribuem com a implementação da PNPIC e (5) Estratégias para a inserção dos naturólogos no SUS. Considerações finais: Considera-se que a atuação dos naturólogos em equipe multiprofissional contribui com a implementação da PNPIC no SUS, cooperando para que as práticas abarcadas pela PNPIC sejam incorporadas em sua potencialidade desmedicalizante. Esta pesquisa contribui também para refletir a inserção da Naturologia no contexto da saúde pública.(AU)

Introduction: World Health Organization (WHO) has demonstrated the appreciation of Traditional Medicines and Alternative / Complementary Medicines as a way to improve health outcomes. Brazil complied with WHO recommendations and instituted the National Policy on Integrative and Complementary Pratices (PNPIC). The PNPLIClegitimized the institutionalization of these pratices, opening new perspectives with a focus on health and its complexity, aiming to guarantee integrality on health care. Objective: to understand the contribution of Naturology to the implementation of PNPIC in the conception of naturologists who work in the Unified Health System (SUS). Results: five thematic categories were described: (1) The naturologist in a multidisciplinary health team, (2) The naturologist´s approach to the SUS, (3) The implementation of the PNPIC in the minicipalities of operation, (4) Naturology principles that contribute to Implementation of PNPIC and (5) Strategies for the insertion of naturologists in SUS. Final considerations: It is considered that the performance of the naturologists in a multiprofessional team contributes to the implementation of the PNPIC in the SUS, cooperating so that the pratices covered by the PNPIC are incorporated in its demedicalizing potential. This research also contributes to reflect the insertion of Naturology in the context of public health.(AU)

Evaluation of the performance of actions and outcomes in primary health care / Avaliação do desempenho das ações e resultados em saúde da atenção básica

ABSTRACT OBJECTIVE The objective of this study has been to evaluate the performance of the primary care of Brazilian municipalities in relation to health actions and outcomes. METHODS This is an evaluative, cross-sectional research, with a quantitative approach, aimed at the identification of the efficiency frontier of the primary care in health actions and outcomes in Brazilian municipalities. Secondary data have been collected from the Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (National Program for Improving Access and Quality of Primary Care) and the Department of Informatics of the Brazilian Unified Health System, in 2012. The data envelopment analysis tool has been used for variable returns to scale with product orientation. RESULTS Municipalities have been analyzed by population size, and small municipalities have presented a high percentage of inefficiency for both models. CONCLUSIONS The analysis of efficiency has indicated the existence of a higher percentage of effective municipalities in the model of health actions than in the model of health outcomes.

RESUMO OBJETIVO Avaliar o desempenho da atenção básica dos municípios brasileiros quanto a ações e resultados em saúde. MÉTODOS Pesquisa avaliativa, transversal, com abordagem quantitativa, para identificar a fronteira de eficiência da atenção básica em ações e resultados em saúde nos municípios brasileiros. Foi realizada coleta de dados secundários a partir do Programa Nacional de Melhoria do Acesso e da qualidade da Atenção Básica e do Departamento de Informática do Sistema Único de Saúde, no ano de 2012. Utilizou-se a ferramenta análise envoltória de dados para retornos variáveis de escala com orientação para produto. RESULTADOS Os municípios foram analisados por porte populacional e verificou-se que para ambos os modelos, os municípios de pequeno porte apresentaram alto percentual de ineficiência. CONCLUSÕES A análise da eficiência indicou a existência de um percentual maior de municípios eficientes no modelo de ações em saúde do que no modelo de resultados em saúde.

Impact of health research on advances in knowledge, research capacity-building and evidence-informed policies: a case study on maternal mortality and morbidity in Brazil.

CONTEXT AND OBJECTIVE: National health research systems aim to generate high-quality knowledge so as to maintain and promote the population's health. This study aimed to analyze the impact of maternal mortality/morbidity research funded by the Brazilian Ministry of Health and institutional partners, on the dimensions: advancing in knowledge, research capacity-building and informing decision-making, within the framework of the Canadian Academy of Health Sciences. DESIGN AND SETTING: Descriptive study based on secondary data, conducted at a public university. METHODS: The advancing in knowledge dimension was estimated from the principal investigators' publication counts and h-index. Data on research capacity-building were obtained from the Ministry of Health's information system. The informing decision-making dimension was analyzed from citations in Stork Network (Rede Cegonha) documents. RESULTS: Between 2002 and 2010, R$ 21.6 million were invested in 128 maternal mortality/morbidity projects. Over this period, the principal investigators published 174 articles, resulting in an h-index of 35, thus showing progress in the advancing in knowledge dimension. Within the research capacity-building dimension, training of 71 students (undergraduate/postgraduate) was observed. Progress in the informing decision-making dimension was modest: 73.5% of the 117 citations in the Stork Network documents were institutional documents and norms. One of the projects funded, the 2006/7 National Demography and Health Survey, was cited in program documents. CONCLUSION: Impacts were shown in the advancing in knowledge and research capacity-building dimensions. The health research system needs to incorporate research for evidence-informed policies.

Impact of health research on advances in knowledge, research capacity-building and evidence-informed policies: a case study on maternal mortality and morbidity in Brazil / Impacto da pesquisa em saúde nos avanços de conhecimento, construção de capacidades de pesquisa e políticas informadas por evidências: um estudo de caso sobre a morbimortalidade materna no Brasil

ABSTRACT: CONTEXT AND OBJECTIVE: National health research systems aim to generate high-quality knowledge so as to maintain and promote the population's health. This study aimed to analyze the impact of maternal mortality/morbidity research funded by the Brazilian Ministry of Health and institutional partners, on the dimensions: advancing in knowledge, research capacity-building and informing decision-making, within the framework of the Canadian Academy of Health Sciences. DESIGN AND SETTING: Descriptive study based on secondary data, conducted at a public university. METHODS: The advancing in knowledge dimension was estimated from the principal investigators' publication counts and h-index. Data on research capacity-building were obtained from the Ministry of Health's information system. The informing decision-making dimension was analyzed from citations in Stork Network (Rede Cegonha) documents. RESULTS: Between 2002 and 2010, R$ 21.6 million were invested in 128 maternal mortality/morbidity projects. Over this period, the principal investigators published 174 articles, resulting in an h-index of 35, thus showing progress in the advancing in knowledge dimension. Within the research capacity-building dimension, training of 71 students (undergraduate/postgraduate) was observed. Progress in the informing decision-making dimension was modest: 73.5% of the 117 citations in the Stork Network documents were institutional documents and norms. One of the projects funded, the 2006/7 National Demography and Health Survey, was cited in program documents. CONCLUSION: Impacts were shown in the advancing in knowledge and research capacity-building dimensions. The health research system needs to incorporate research for evidence-informed policies.

RESUMO: CONTEXTO E OBJETIVO: Sistemas nacionais de pesquisa em saúde buscam gerar conhecimentos de qualidade para manter e promover a saúde da população. Este estudo visou analisar o impacto das pesquisas sobre morbimortalidade materna financiadas pelo Ministério de Saúde do Brasil e instituições parceiras, nas dimensões: avanços no conhecimento, construção de capacidade de pesquisa e tomada de decisão informada, da matriz da Canadian Academy of Health Sciences. DESENHO DO ESTUDO E LOCAL: Estudo descritivo baseado em dados secundários, realizado em universidade pública. MÉTODOS: A dimensão avanços no conhecimento foi estimada pelas publicações dos coordenadores de pesquisa e índice h. Dados sobre a capacidade de pesquisa foram obtidos no sistema de informação do Ministério da Saúde. A dimensão tomada de decisão informada foi analisada pelas citações nos documentos da Rede Cegonha. RESULTADOS: Foram investidos R$ 21,6 milhões de reais em 128 pesquisas sobre morbimortalidade materna entre 2002 e 2010. Nesse período, os coordenadores das pesquisas publicaram 174 artigos, resultando no índice h de 35, mostrando progressos na dimensão avanços no conhecimento. Na dimensão capacidade de pesquisa, foi constatado o treinamento de 71 estudantes (graduação e pós-graduação). Na dimensão tomada de decisão informada, o progresso foi modesto: 73,5% das 117 citações nos documentos da Rede Cegonha eram documentos institucionais e normas. Um dos projetos financiados, Pesquisa Nacional de Demografia e Saúde 2006/7, foi citado em documentos programáticos. CONCLUSÃO: Impactos foram demonstrados nas dimensões avanços no conhecimento e capacidade de pesquisa. O sistema de pesquisa em saúde necessita da incorporação de pesquisas para políticas informadas por evidências.

[Indication for total knee arthroplasty: evidence mapping]. / Indikation zur endoprothetischen Versorgung des Kniegelenks - ein Evidence Mapping.

BACKGROUND: Joint replacement surgery is one of the most often performed routine procedures for the treatment of knee osteoarthritis in Germany. Currently, there is no consensus on indication criteria for total knee arthroplasty (TKA). OBJECTIVES: The topic indication for TKA was processed using six guiding questions concerning: 1) Common practice in determining the indication for TKA; 2) Inclusion criteria in clinical trials; 3) Treatment goals/goal criteria; 4) Predictors for goal attainment; 5) Economic aspects of determining a TKA indication; 6) Guidelines of the "Working Group of Scientific Medical Societies" (AWMF) in other areas. METHODS: The evidence mapping was conducted by systematically searching Medline via Ovid, the Cochrane Library, through hand searching national guidelines and selected journals as well as the AWMF guideline portal. RESULTS OF THE GUIDING QUESTIONS: 1) In Germany there is currently no consented guideline regarding indications for TKA surgery. 2) Indication criteria for clinical trials are: diagnosed osteoarthritis of the knee, limitations of age and BMI. The most common criteria for exclusion include rheumatoid/inflammatory arthritis, secondary diagnoses and allergies. 3) As yet, no international initiatives have been identified which, by involving all relevant stakeholders, have reached consensus regarding the indication criteria for TKA. 4) A variety of predictors were identified with effects on individual treatment goals acting in different directions. 5) Very few studies were identified concerning economic aspects of determining TKA indication. 6) Comparable AWMF guidelines are currently not available. CONCLUSION: The findings of this study suggest that specific systematic reviews are needed to explore the following questions: What are the treatment goals of a TKA intervention? For whom are these relevant? And how are they measured? Continuous analyses are recommended in the field of predictors for a positive TKA outcome.

Dynamic reflexivity in action: an armchair walkthrough of a qualitatively driven mixed-method and multiple methods study of mindfulness training in schoolchildren.

Dynamic reflexivity is central to enabling flexible and emergent qualitatively driven inductive mixed-method and multiple methods research designs. Yet too often, such reflexivity, and how it is used at various points of a study, is absent when we write our research reports. Instead, reports of mixed-method and multiple methods research focus on what was done rather than how it came to be done. This article seeks to redress this absence of emphasis on the reflexive thinking underpinning the way that mixed- and multiple methods, qualitatively driven research approaches are thought about and subsequently used throughout a project. Using Morse's notion of an armchair walkthrough, we excavate and explore the layers of decisions we made about how, and why, to use qualitatively driven mixed-method and multiple methods research in a study of mindfulness training (MT) in schoolchildren.

Stepped-wedge cluster randomised controlled trials: a generic framework including parallel and multiple-level designs.

Stepped-wedge cluster randomised trials (SW-CRTs) are being used with increasing frequency in health service evaluation. Conventionally, these studies are cross-sectional in design with equally spaced steps, with an equal number of clusters randomised at each step and data collected at each and every step. Here we introduce several variations on this design and consider implications for power. One modification we consider is the incomplete cross-sectional SW-CRT, where the number of clusters varies at each step or where at some steps, for example, implementation or transition periods, data are not collected. We show that the parallel CRT with staggered but balanced randomisation can be considered a special case of the incomplete SW-CRT. As too can the parallel CRT with baseline measures. And we extend these designs to allow for multiple layers of clustering, for example, wards within a hospital. Building on results for complete designs, power and detectable difference are derived using a Wald test and obtaining the variance-covariance matrix of the treatment effect assuming a generalised linear mixed model. These variations are illustrated by several real examples. We recommend that whilst the impact of transition periods on power is likely to be small, where they are a feature of the design they should be incorporated. We also show examples in which the power of a SW-CRT increases as the intra-cluster correlation (ICC) increases and demonstrate that the impact of the ICC is likely to be smaller in a SW-CRT compared with a parallel CRT, especially where there are multiple levels of clustering. Finally, through this unified framework, the efficiency of the SW-CRT and the parallel CRT can be compared.

Avaliação do atributo integralidade em serviços de puericultura na atenção primária à saúde / Evaluation attribute integrality in childcare services in primary health care

Introdução: A integralidade, atributo essencial dos serviços de Atenção Primária à Saúde, baseia-se em ações de promoção, prevenção de agravos e recuperação da saúde, permitindo uma percepção holística do indivíduo, estando associado aos serviços assistenciais prestados, a fim de responder as necessidades dos sujeitos envolvidos. Objetivo: Avaliar o atributo essencial da Atenção Primária à Saúde, integralidade, no serviço de Puericultura com crianças menores de dois anos. Métodos: Estudo avaliativo, quantitativo, de caráter descritivo, com amostra composta por 186 pais/responsáveis de crianças de 0 à 2 anos de idade que utilizam os serviços da APS da cidade de Santa Cruz, estado do Rio Grande do Norte, Brasil, utilizando um questionário validado no Brasil denominado PCA Tools, versão para crianças. Resultados: Os resultados mostraram que 77.4% das crianças de 0 a 2 anos de idade encontram-se com o cartão de vacinas em dia, e que seus responsáveis possuem conhecimentos sobre planejamento familiar e métodos anticoncepcionais (82.3%). Quanto ao programa de suplementação nutricional para crianças 45.7% já tiveram tais informações. A maioria da amostra (91.4%) recebeu orientações sobre manter a criança saudável, como manter a segurança no lar (55.9%) (exemplo: como guardar medicamentos com segurança), sobre mudanças do crescimento e desenvolvimento da criança (57.0%), maneiras de lidar com o comportamento da criança (52.2%), e maneiras para mantê-la segura (46.8%). Conclusão: Este estudo permitiu identificar potencialidades e grandes avanços pertinentes ao atributo integralidade, bem como necessidades de estratégias a partir das fragilidades apontadas (AU).

Introduction: Integrality, essential attribute of primary health care services, is based on promotion, disease prevention and recovery, allowing a holistic perception of the individual and is associated with welfare services in order to answer the needs of those involved. Objective: To evaluate the essential attribute of Primary Health Care, integrality, in the service of Child Care with children under two years. Methods: Assessment study, quantitative, descriptive, with a sample of 186 parents / guardians of children aged 0 to 2 years old who use the services of the APS of the city of Santa Cruz, Rio Grande do Norte, Brazil, using a questionnaire validated in Brazil called PCA Tools, version for children. Results: The results showed that 77.4% of children 0-2 years of age are of the day vaccination card, and that those responsible have knowledge about family planning and contraceptive methods (82.3%). As for the supplemental nutrition program for children 45.7% had such information. Most of the sample (91.4%) received guidance on maintaining healthy child, how to maintain safety in the home (55.9%) (example: how to store medicines safely) on changes in the growth and development of children (57.0%), ways to deal with the child's behavior (52.2%), and ways to keep it safe (46.8%). Conclusion: This study revealed potential and major advances relevant to the integrality attribute as well as strategies needs from the identified weaknesses (AU).

Research priorities in spiritual care: an international survey of palliative care researchers and clinicians.

CONTEXT: Spiritual distress, including meaninglessness and hopelessness, is common in advanced disease. Spiritual care is a core component of palliative care, yet often neglected by health care professionals owing to the dearth of robust evidence to guide practice. OBJECTIVES: To determine research priorities of clinicians/researchers and thus inform future research in spiritual care in palliative care. METHODS: An online, cross-sectional, mixed-methods survey was conducted. Respondents were asked whether there is a need for more research in spiritual care, and if so, to select the five most important research priorities from a list of 15 topics. Free-text questions were asked about additional research priorities and respondents' single most important research question, with data analyzed thematically. RESULTS: In total, 971 responses, including 293 from palliative care physicians, 112 from nurses, and 111 from chaplains, were received from 87 countries. Mean age was 48.5 years (standard deviation, 10.7), 64% were women, and 65% were Christian. Fifty-three percent reported their work as "mainly clinical," and less than 2.5% stated that no further research was needed. Integrating quantitative and qualitative data demonstrated three priority areas for research: 1) development and evaluation of conversation models and overcoming barriers to spiritual care in staff attitudes, 2) screening and assessment, and 3) development and evaluation of spiritual care interventions and determining the effectiveness of spiritual care. CONCLUSION: In this first international survey exploring researchers' and clinicians' research priorities in spiritual care, we found international support for research in this domain. Findings provide an evidence base to direct future research and highlight the particular need for methodologically rigorous evaluation studies.

Health care utilisation in subjects with osteoarthritis, chronic back pain and osteoporosis aged 65 years and more: mediating effects of limitations in activities of daily living, pain intensity and mental diseases.

Musculoskeletal diseases (MDs) have major consequences for the individual, and also for society and may thus lead to increased use of health care. It was the aim of this study to explore health care utilisation in patients with self-reported osteoarthritis, chronic back pain or osteoporosis compared with people of the same age without those diseases, based on data of the Austrian health interview survey including 3,097 subjects aged ≥ 65 years. Patients with MDs in our study visited a general practitioner (GP) and were hospitalised significantly more often compared with persons without the respective diseases. Problems in the activities of daily living (ADLs), pain intensity and anxiety/depression influenced GP consultations. Complex factors explain the higher health care utilisation in subjects with MDs in our study. Our results indicate that integrated strategies are needed to manage those patients, which should focus on management of ADL problems, pain and mental health.

[Psychosomatic and psychotherapeutic outpatient care in Germany - Capacity profile based on data from the National Association of Statutory Health Insurance Physicians]. / Ambulante psychosomatische und psychotherapeutische Versorgung in Deutschland - Versorgungsprofile abgebildet durch Daten der Kassenärztlichen Bundesvereingung (KBV).

OBJECTIVES: At the centre of the study lay a representation of outpatient psychosomatic and psychotherapeutic care with a focus on different groups of medical and psychological therapists. METHODS: The routine data of the National Association of Statutory Health Insurance Physicians (KBV) from the year 2008 were analyzed based on a systematic literature review (Medline, ISI, to November 2010). RESULTS: Neurologists and psychiatrists see the most patients (n = 3,172 vs n = 1,347 cases per practice), but they rarely provide services according to the directives for psychotherapy (4,4 %). However, specialists for psychosomatic medicine and psychotherapy (65 %), physicians providing only psychotherapy (66 %) and psychological psychotherapists (73 %) provide care mainly according to the directives for psychotherapy and therefore see fewer patients (170-190 cases per practice).Medical psychotherapists work more often on a psychodynamic basis, while psychological psychotherapists perform more often behavioral therapy. CONCLUSIONS: The treatment of patients with mental and psychosomatic disorders is based on three columns of care, which differ in their supply profile and each make a specific contribution to the treatment.

Probabilistic choice models in health-state valuation research: background, theories, assumptions and applications.

Interest is rising in measuring subjective health outcomes, such as treatment outcomes that are not directly quantifiable (functional disability, symptoms, complaints, side effects and health-related quality of life). Health economists in particular have applied probabilistic choice models in the area of health evaluation. They increasingly use discrete choice models based on random utility theory to derive values for healthcare goods or services. Recent attempts have been made to use discrete choice models as an alternative method to derive values for health states. In this article, various probabilistic choice models are described according to their underlying theory. A historical overview traces their development and applications in diverse fields. The discussion highlights some theoretical and technical aspects of the choice models and their similarity and dissimilarity. The objective of the article is to elucidate the position of each model and their applications for health-state valuation.

Alternative and complementary treatment needs and experiences of women with breast cancer.

OBJECTIVES: The study objectives were to explore the potential need for and use of complementary and alternative (CAM) services among women diagnosed with breast cancer and to investigate reasons for nonreceipt of CAM. DESIGN: The Alaska Breast Cancer Needs Assessment Survey was completed by female breast cancer survivors in Alaska. The survey assessed physical and psychologic symptoms, services received, satisfaction with treatment, communication with providers, and informational needs. Survey responses were obtained from 309 women with breast cancer, with a mean age of 56 years and high level of education. RESULTS: Results revealed that most breast cancer survivors have significant needs for CAM services, and yet only a small proportion actually receives them. For example, virtually all women reported symptoms potentially amenable to treatment via individual counseling or nutritional interventions; however, only 29% and 45%, respectively, received such services. Women who did and those who did not receive CAM services (e.g., counseling, massage, meditation, and supplementation) generally did not differ in terms of their need for such services as measured via symptoms that could be supported by these interventions. However, the majority failed to be referred for such treatments or were unable to access them if referred. CONCLUSIONS: Results suggest that while access to services played a small role in nonreceipt of CAM services, the largest reason for CAM nonreceipt was failure to recognize their potential benefit on the part of providers and at least some patients. Raising awareness about the potential value of CAM among care providers for women with breast cancer is crucial, as it will likely lead to more CAM acceptance and utilization. Once providers accept and refer for CAM, patients' quality of life may be considerably enhanced, as the extant literature has demonstrated the potential value of CAM for breast cancer survivors.