Resilience among primary care professionals in a time of pandemic: a qualitative study in the Spanish context.

OBJECTIVES: This study explores the impact of the COVID-19 pandemic on the Spanish primary care structure and services and the mechanisms implemented by the primary care workforce to restore and reinforce their reference care model. DESIGN: An exploratory, qualitative study with semistructured interviews and a focus group discussion conducted during the fall semester of 2020. SETTING: Primary health centres in Madrid (Spain), chosen based on factors such as infection rates during the earliest stages of the pandemic and demographic and socioeconomic aspects. PARTICIPANTS: A total of 19 primary health and social care professionals were purposively selected. Criteria for inclusion were gender (male/female), at least 5 years of experience in their current position, category (health/social/administrative worker), and whether they worked in a rural or urban healthcare setting. RESULTS: Two main themes were identified: (1) reflecting on a model in crisis-particularly the reopening of centres to users and the proactive, participative strategies implemented by primary care professionals to reach their community; and (2) regaining a sense of purpose-how healthcare professionals implemented strategies to sustain their vision of their reference model. The COVID-19 pandemic exposed leadership deficiencies that, together with the initial unavailability of resources and difficulties maintaining face-to-face contact with users, triggered a sense of loss of professional identity. On the other hand, the analysis revealed potential strategies to restore and reinforce the traditional model, such as the adoption of digital technologies and reliance on community networks. CONCLUSION: This study highlights the importance of a solid reference framework and enhances the strengths and skills of the workforce to reinforce the community-based service provision model.

Front-of-Package Nutrition Labeling and Its Impact on Food Industry Practices: A Systematic Review of the Evidence.

The obesity epidemic has become a major public health concern globally, and the food supply is a significant driver of this trend. Front-of-package (FOP) labels have been implemented in many countries to encourage healthier food choices. This systematic review aimed to examine the effect of FOP label implementation on food manufacturers' practices. A comprehensive search of multiple databases was conducted following PRISMA guidelines, identifying 39 relevant articles from 1990 to 2021. The studies indicated that FOP labels conveying intuitive information influenced product reformulation, whereas those with numerical information without specific guidance had no impact on reducing unhealthy nutrients. The most common outcomes were sodium, sugar, and calorie reduction. Mandatory policies reported higher and more consistent effects on product reformulation compared to voluntary approaches. Voluntary FOP labeling resulted in low uptake and tended to be applied to healthier products. Food manufacturers responded to FOP labeling heterogeneously, depending on the label design and type of enforcement. FOP label implementation can reduce nutrients of concern but food manufacturers behave strategically by labeling healthier choices. This review provides recommendations for maximizing the benefits of using FOP labels to prevent obesity, and findings can inform future public health research and policymaking.

Federal Food Assistance Program Participation during the COVID-19 Pandemic: Participant Perspectives and Reasons for Discontinuing.

This study aims to describe reasons for discontinuing participation and experiences participating in the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC) during the COVID-19 pandemic. We analyzed data from a cross-sectional online survey distributed to a national sample, restricted to (1) households that discontinued participating in SNAP (n = 146) or WIC (n = 149) during the pandemic and (2) households that participated in SNAP (n = 501) or WIC (n = 141) during spring 2021-approximately one year into the pandemic. We conducted thematic analyses of open-ended survey questions and descriptive statistics for Likert-scale items. Themes raised by respondents who discontinued participating in SNAP or WIC included difficulty recertifying and virus exposure concerns. Former WIC participants reported the program was not worth the effort and former SNAP participants reported failing to requalify. Respondents participating in WIC or SNAP during the pandemic mentioned transportation barriers and insufficient benefit value. WIC participants had trouble redeeming benefits in stores and SNAP participants desired improved online grocery purchasing experiences. These results suggest that enhancements to WIC and SNAP, such as expanded online purchasing options, program flexibilities, and benefit increases, can improve program participation to ensure access to critical nutrition supports, especially during emergencies.

School Garden Prevalence Before and After the Implementation of the Healthy Hunger-Free Kids Act.

BACKGROUND: The Healthy Hunger-Free Kids Act (HHFKA) of 2010 supported implementation of school gardens for promoting fruit and vegetable consumption. We examined school garden prevalence over time by school-level factors during the period before and after the implementation of HHFKA. METHODS: Using data from the New Jersey Child Health Study, conducted in 4 low-income New Jersey cities, prevalence of school gardens among K-12 schools (n = 148) was assessed between school year 2010-2011 and 2017-2018. Multivariable analysis estimated changes in garden prevalence over time adjusting for school-level factors. RESULTS: Overall, the sample included 97 elementary and 51 middle/high schools. Multivariable logistic regression showed that compared to 2010-2011 (19%) a higher proportion of schools reported having a garden in 2013-2014 (32%, p = 0.025). Over the entire study period, schools with majority Hispanic student enrollment had approximately half the odds of having a garden compared to schools with majority Black students (p = 0.036). CONCLUSION: School garden prevalence increased in the year immediately following the implementation of the HHFKA but this increase was not sustained over time. Future research should investigate the reasons for this decline and potential disparities by race/ethnicity.

Towards a liquid healthcare: primary care organisational and management strategies during the COVID-19 pandemic - a qualitative study.

BACKGROUND: The COVID-19 pandemic has changed the organisational and management strategies of healthcare institutions such as primary care centres. Organisational culture as well as leadership style are key issues for the success of these institutions. Due to the multidimensional nature of identity processes, it is necessary to explore the changes experienced by health professionals from these perspectives. This study explores health professionals' organisational and management strategies in primary care settings during the COVID-19 pandemic. DESIGN: Qualitative, exploratory study based on the analysis of participants' accounts within a hermeneutic phenomenologicaly approach. METHODS: Research was conducted in primary care settings in two neighbouring Spanish healthcare regions. The sample included participants with different demographics (gender, age), professional roles (practice managers, general practitioners, paediatricians), employment status (permanent, temporary, zero-hours), and years of experience (under or over ten years' experience). Data were collected between July and December 2020 through focus groups and in-depth, semi-structured individual interviews. RESULTS: A total of 53 primary care workers participated in the study, of which 38 were individually interviewed and 15 participated in three focus groups. Of these, 78.4% were healthcare professionals, 49% were female nurses, and 70.5% had more than 10 years of work experience in primary care. Two main themes emerged: "liquid" healthcare and "the best healthcare system in the world". During the first wave of the COVID-19 pandemic, new, more fluid organisational and management models were implemented in primary care settings, which have remained in place since. Primary care workers' perceived a lack of appreciation and inclusion in decision-making that risked their alienation and disengagement. CONCLUSION: Primary care workers' professional identity became gradually blurred due to shifting perceptions of their professional roles in a context of increasing improvisation and flexible working practices. This affected their professional performance. TRIAL REGISTRATION: The study was approved by the Clinical Research Ethical Committee of the Talavera de la Reina Integrated Management Area (CEIm del AGI de Talavera de la Reina in Spain, Hospital Nuestra Señora del Prado, ref: 23/2020).

Internal dynamics within primary care teams in two Spanish regions during the COVID-19 pandemic: a qualitative study.

BACKGROUND: Pandemics and epidemics have represented public health emergencies with severe consequences at a global level. Primary care teams have played a crucial role in disease surveillance and monitoring during the COVID-19 pandemic through early detection, contact tracing, and isolation of positive cases. The objective of this study was to explore the impact of the COVID-19 pandemic on primary care teams regarding their internal dynamics and their professional performance. METHODS: Qualitative study carried out between July and December 2020 in two large central and southern Spanish regions (Castilla la Mancha and Madrid). Semi-structured interviews and focus groups were conducted with primary care workers. Data was analysed using thematic content analysis. Participants were accessed using purposive sampling. RESULTS: A total of 53 primary care workers participated in the study, of which 38 were individually interviewed, and 15 participated in three focus groups.The analysis of their experiences revealed two main themes regarding the impact of the COVID-19 pandemic on primary care teams: 1) The need to reorganise traditional roles: Primary care settings closed their doors to the public and their workers restructured their roles to ensure the delivery of essential services; 2) The need to implement a new primary care delivery model: Each primary care team had to self-organise, making sure their reference population was cared for and developing resource optimisation strategies. CONCLUSIONS: Primary care teams have quickly adapted their roles and internal dynamics to respond to the demands generated by COVID-19. In the new delivery model, some positive aspects could be highlighted - such as increased communication between professionals and the use of telemedicine for some cases. However, it is important to address the negative impact that the COVID-19 crisis has had on of the main functions of primary care. These measures are necessary to promote well-being in primary care teams, and to provide quality care that addresses the complex and individual needs of each person and reduces inequalities in healthcare delivery.

Emotions in the Time of COVID-19: Affections and Impacts among the Spanish Primary Care Workforce.

BACKGROUND: The literature review shows that most studies on the psychological impact of COVID-19 on healthcare professionals have focused on hospital staff, with few specifically addressing the primary care workforce. This study aims to explore primary care workers' verbal accounts of the emotions they experienced. METHODS: This is a qualitative study carried out between July and December 2020 in Spain. Semi-structured interviews and focus groups were conducted with primary care workers. Data were analysed through thematic content analysis. Participants were selected using purposive sampling. RESULTS: A total of 53 primary care workers participated in the study, of whom 38 were individually interviewed, and 15 participated in three focus groups. Our analysis revealed themes in two categories: (1) from infection to affection; and (2) affected, but not patients-a discourse based on the acceptance of their experience as part of their work in primary care, creating an ideological construct or "shield" based on emotional self-management. CONCLUSIONS: Self-reflection on the emotional impact of COVID-19 is scarce. Examples of emotional affections include an obsessive focus on hygiene, the inability to establish clear boundaries between the personal and the professional spheres, and experiencing-and having to self-manage-emotional strain.

Management of burnout among the staff of primary care centres in Spain during the pandemic caused by the SARS-CoV-2.

BACKGROUND: The provision of healthcare during the pandemic caused by the SARS-CoV-2 virus represented a challenge for the management of the resources in the primary care centres. We proposed assessing burnout among the staff of those centres and identifying factors that contributed to its appearance and those that limited it. METHODS: An observational study which, by means of anonymous questionnaires, collected information about: (i) demographic variables; (ii) the characteristics of each position; (iii) the measures implemented by the medical decision-makers in order to provide care during the pandemic; and (iv) the Burnout Clinical Subtype Questionnaire (BCSQ-36). We performed a descriptive analysis of the burnout mentioned by the staff, and, by means of a multivariate analysis, we identified the factors which influenced it. Using logit models, we analysed whether receiving specific training in COVID-19, feeling involved in decision-making processes, and/or working within different healthcare systems had effects on the development of burnout. RESULTS: We analysed the replies of 252 employees of primary care centres in Spain with an average age of 45 (SD = 15.7) and 22 (SD = 11.4) years of experience. 68% of the participants (n = 173) indicated burnout of the frenetic subtype. 79% (n = 200) of the employees had high scores in at least one burnout subtype, and 62% (n = 156) in at least two. Women older than 45 had a lower probability of suffering burnout. Receiving specific training (OR = 0.28; CI95%: 0.11-0.73) and feeling involved in decision-making (OR = 0.32; CI95%:0.15-0.70) each reduced the probability of developing burnout. Working in a different department increased the likelihood of developing burnout of at least one clinical subtype (OR = 2.85; CI95%: 1.38-5.86). CONCLUSIONS: The staff in primary care centres have developed high levels of burnout. Participation in decision-making and receiving specific training are revealed as factors that protect against the development of burnout. The measures taken to contain the adverse effects of a heavy workload appear to be insufficient. Certain factors that were not observed, but which are related to decisions taken by the healthcare management, appear to have had an effect on the development of some burnout subtypes.

A Spatio-temporal Model for Detecting the Effect of Cocaine Use Disorder on Functional Connectivity.

Drug addiction can lead to many health-related problems and social concerns. Researchers are interested in the association between long-term drug usage and abnormal functional connectivity. Functional connectivity obtained from functional magnetic resonance imaging data promotes a variety of fundamental understandings in such association. Due to the complex correlation structure and large dimensionality, the modeling and analysis of the functional connectivity from neuroimage are challenging. By proposing a spatio-temporal model for multi-subject neuroimage data, we incorporate voxel-level spatio-temporal dependencies of whole-brain measurements to improve the accuracy of statistical inference. To tackle large-scale spatio-temporal neuroimage data, we develop a computational efficient algorithm to estimate the parameters. Our method is used to first identify functional connectivity, and then detect the effect of cocaine use disorder (CUD) on functional connectivity between different brain regions. The functional connectivity identified by our spatio-temporal model matches existing studies on brain networks, and further indicates that CUD may alter the functional connectivity in the medial orbitofrontal cortex subregions and the supplementary motor areas.

The Influence of Front-of-Package Nutrition Labeling on Consumer Behavior and Product Reformulation.

Countries worldwide have implemented mandatory or voluntary front-of-package nutrition labeling systems. We provide a narrative review of (a) real-world evaluations of front-of-package nutrition labels that analyze objective sales data and (b) studies that objectively assess product reformulation in response to a front-of-package nutrition label implementation. We argue that there is sufficient scientific evidence to recommend that governments implement mandatory front-of-package nutrition labeling systems to improvepopulation health. We also present a conceptual framework to describe front-of-package label influence and provide recommendations for the optimal label design, emphasizing that labeling systems should be highly visible and salient, be simple and easy to understand, leverage automatic associations, and integrate informational and emotional messaging. The existing research suggests that Guideline Daily Amount labels should be avoided and that the Health Star Rating and Nutri-Score systems are promising but that systems with warning labels like the one in Chile are likely to produce the largest public health benefits.

SMOOTH DENSITY SPATIAL QUANTILE REGRESSION.

We derive the properties and demonstrate the desirability of a model-based method for estimating the spatially-varying effects of covariates on the quantile function. By modeling the quantile function as a combination of I-spline basis functions and Pareto tail distributions, we allow for flexible parametric modeling of the extremes while preserving non-parametric flexibility in the center of the distribution. We further establish that the model guarantees the desired degree of differentiability in the density function and enables the estimation of non-stationary covariance functions dependent on the predictors. We demonstrate through a simulation study that the proposed method produces more efficient estimates of the effects of predictors than other methods, particularly in distributions with heavy tails. To illustrate the utility of the model we apply it to measurements of benzene collected around an oil refinery to determine the effect of an emission source within the refinery on the distribution of the fence line measurements.

Spatiotemporal signal detection using continuous shrinkage priors.

Periodontal disease (PD) is a chronic inflammatory disease that affects the gum tissue and bone supporting the teeth. Although tooth-site level PD progression is believed to be spatio-temporally referenced, the whole-mouth average periodontal pocket depth (PPD) has been commonly used as an indicator of the current/active status of PD. This leads to imminent loss of information, and imprecise parameter estimates. Despite availability of statistical methods that accommodates spatiotemporal information for responses collected at the tooth-site level, the enormity of longitudinal databases derived from oral health practice-based settings render them unscalable for application. To mitigate this, we introduce a Bayesian spatiotemporal model to detect problematic/diseased tooth-sites dynamically inside the mouth for any subject obtained from large databases. This is achieved via a spatial continuous sparsity-inducing shrinkage prior on spatially varying linear-trend regression coefficients. A low-rank representation captures the nonstationary covariance structure of the PPD outcomes, and facilitates the relevant Markov chain Monte Carlo computing steps applicable to thousands of study subjects. Application of our method to both simulated data and to a rich database of electronic dental records from the HealthPartners ® Institute reveal improved prediction performances, compared with alternative models with usual Gaussian priors for regression parameters and conditionally autoregressive specification of the covariance structure.

The impact of population mobility on estimates of environmental exposure effects in a case-control study.

In many studies of environmental risk factors for disease, researchers use the location at diagnosis as a geographic reference for environmental exposures. However, many environmental pollutants change continuously over space and time. The dynamic characteristics of these pollutants coupled with population mobility in the United States suggest that for diseases with long latencies like cancer, historic exposures may be more relevant than exposure at the time of diagnosis. In this article, we evaluated to what extent the commonly used assumption of no population mobility results in increased bias in the estimates of the relationship between environmental exposures and long-latency health outcomes disease in a case-control study. We conducted a simulation study using the residential histories of a random sample from the National Institutes of Health-AARP (formerly American Association of Retired Persons) Diet and Health Study. We simulated case-control status based on subject exposure and true exposure effects that varied temporally. We compared estimates from models using only subject location at diagnosis to estimates where subjects were assumed to be mobile. Ignoring population mobility resulted in underestimates of subject exposure, with largest deviations observed at time points further away from study enrollment. In general, the effect of population mobility on the bias of the estimates of the relationship between the exposure and the outcome was more prominent with exposures that showed substantial spatial and temporal variability. Based on our results, we recommend using residential histories when environmental exposures and disease latencies span a long enough time period that mobility is important.

Multi-element effects on arsenate accumulation in a geochemical matrix determined using µ-XRF, µ-XANES and spatial statistics.

Soils regulate the environmental impacts of trace elements, but direct measurements of reaction mechanisms in these complex, multi-component systems can be challenging. The objective of this work was to develop approaches for assessing effects of co-localized geochemical matrix elements on the accumulation and chemical speciation of arsenate applied to a soil matrix. Synchrotron X-ray fluorescence microprobe (µ-XRF) images collected across 100 µm × 100 µm and 10 µm × 10 µm regions of a naturally weathered soil sand-grain coating before and after treatment with As(V) solution showed strong positive partial correlations (r' = 0.77 and 0.64, respectively) between accumulated As and soil Fe, with weaker partial correlations (r' > 0.1) between As and Ca, and As and Zn in the larger image. Spatial and non-spatial regression models revealed a dominant contribution of Fe and minor contributions of Ca and Ti in predicting accumulated As, depending on the size of the sample area analyzed. Time-of-flight secondary ion mass spectrometry analysis of an area of the sand grain showed a significant correlation (r = 0.51) between Fe and Al, so effects of Fe versus Al (hydr)oxides on accumulated As could not be separated. Fitting results from 25 As K-edge microscale X-ray absorption near-edge structure (µ-XANES) spectra collected across a separate 10 µm × 10 µm region showed ∼60% variation in proportions of Fe(III) and Al(III)-bound As(V) standards, and fits to µ-XANES spectra collected across the 100 µm × 100 µm region were more variable. Consistent with insights from studies on model systems, the results obtained here indicate a dominance of Fe and possibly Al (hydr)oxides in controlling As(V) accumulation within microsites of the soil matrix analyzed, but the analyses inferred minor augmentation from co-localized Ti, Ca and possibly Zn.

Spatial Signal Detection Using Continuous Shrinkage Priors.

Motivated by the problem of detecting changes in two-dimensional X-ray diffraction data, we propose a Bayesian spatial model for sparse signal detection in image data. Our model places considerable mass near zero and has heavy tails to reflect the prior belief that the image signal is zero for most pixels and large for an important subset. We show that the spatial prior places mass on nearby locations simultaneously being zero, and also allows for nearby locations to simultaneously be large signals. The form of the prior also facilitates efficient computing for large images. We conduct a simulation study to evaluate the properties of the proposed prior and show that it outperforms other spatial models. We apply our method in the analysis of X-ray diffraction data from a two-dimensional area detector to detect changes in the pattern when the material is exposed to an electric field.

Qualitative evaluation of a complex intervention to implement health promotion activities according to healthcare attendees and health professionals: EIRA study (phase II).

OBJECTIVE: To evaluate the implementation and development of a complex intervention on health promotion and changes in health-promoting behaviours in primary healthcare according to healthcare attendees and health professionals. DESIGN: Descriptive qualitative evaluation research conducted with 94 informants. Data collection techniques consisted of 14 semistructured individual interviews, 9 discussion groups, 1 triangular group and 6 documents. Three analysts carried out a thematic content analysis with the support of Atlas.ti software. This evaluation was modelled on Proctor and colleagues' concept of outcomes for implementation research. SETTING: 7 primary care centres from seven Spanish regions: Andalusia, Aragon, Balearic Islands, Basque Country, Castilla-La Mancha, Castilla-Leon and Catalonia. PARTICIPANTS: The study population were healthcare attendees (theoretical sampling) and health professionals (opportunistic sampling) who had participated in the exploratory trial of the EIRA intervention (2015). RESULTS: Healthcare attendees and professionals had a positive perception of the study. Healthcare attendees even reported that they would recommend participation to family and friends. Health professionals became aware of the significance of the motivational interview, especially for health promotion, and emphasised social prescribing of physical activity. They also put forward recommendations to improve recruitment, screening and retention of participants. Healthcare attendees modified behaviours and health professionals modified working practices. To achieve sustainability, health professionals believe that it is crucial to adapt agendas and involve all the staff. CONCLUSIONS: The discourses of all stakeholders on the intervention must be taken into consideration for the successful, setting-specific implementation of adequate, acceptable, equitable and sustainable strategies aimed at health promotion and well-being.

[Impact of the financial crisis on activity and efficiency at a high-technology university hospital]. / Impacto de la crisis económica en la actividad y eficiencia de un hospital terciario universitario.

OBJECTIVE: The financial crisis that begun in 2008 significantly decreased the budget of the public health system on Spain. The aim of this study was to evaluate the impact of the financial crisis on the activity, quality and efficiency of a high-technology university hospital. METHODS: We retrospectively analyzed the outcomes of four sets of hospital management indicators between 2007 and 2016 (A: activity; B: quality and complexity of inpatientcare; C: staff, global production and budget expenses; D: patients satisfaction survey). The data were obtained from the center's information systems and treated as longitudinal series of descriptive type. The impact of the crisis was assessed by analyzing the percentage deviations of the different indicators in relation to the values of the year 2009, the year before initial budget adjustments. RESULTS: The overall activity of the hospital, adjusted for complexity, decreased 9% during the first two years of the crisis and recovered later. Inpatient complexity increased 14%. Quality set indicators did not deteriorate. Expenses decreased 16% between the years 2009 and 2014, and efficiency and global productivity improved by 13%. Patient satisfaction survey results did not change. CONCLUSIONS: The financial crisis and the subsequent decrease of budget provoked an initial reduction of hospital activity, associated with a complexity increase. It was progressively made up for with increased efficiency and global productivity. The financial crisis did not have negative effects on quality of care or patient satisfaction.

OBJETIVO: La crisis económica iniciada el año 2008 provocó una caída importante del gasto sanitario público en España. El objetivo del estudio fue evaluar el impacto de la crisis en la actividad, calidad y eficiencia de un hospital terciario universitario de alta complejidad. METODOS: Se analizó retrospectivamente la evolución entre los años 2007 y 2016 de cuatro grupos de indicadores de gestión (A: actividad asistencial; B: calidad y complejidad de las altas; C: plantilla, producción global y gasto; D: satisfacción de los pacientes hospitalizados). Los datos se obtuvieron de los sistemas de información del centro y se trataron como series longitudinales de tipo descriptivo. El impacto de la crisis se valoró analizando las desviaciones porcentuales de los diferentes indicadores en relación a los valores del año 2009, el año previo al inicio de los ajustes presupuestarios. RESULTADOS: La actividad global ajustada por complejidad disminuyó un 9% los dos primeros años de la crisis, y se recuperó en los años posteriores. La complejidad de los pacientes hospitalizados se incrementó en un 14%. Los indicadores de calidad no se deterioraron. El gasto ejecutado anual disminuyó un 16% entre el 2009 y el 2014, y la eficiencia y la productividad global aumentaron un 13%. Los indicadores de satisfacción no se modificaron. CONCLUSIONES: La crisis económica y la consecuente reducción del presupuesto y del gasto provocaron una disminución inicial de la actividad del centro, asociada a un incremento de la complejidad, que fue compensada progresivamente gracias a una mejora en la eficiencia y en la productividad global. La crisis no impactó negativamente ni en la calidad ni en la satisfacción de los pacientes atendidos en régimen de hospitalización.

Percepción de familia entre mujeres embarazadas del norte de Portugal / Perception of family among pregnant women in the north of Portugal / Perceção da familia nas mulheres grávidas no norte de Portugal / Perception de famille chez les femmes enceintes dans le nord du Portugal

Resumen Objetivo: Analizarlas diferentes formas de construir la referencia de "ser una familia" en distintos ámbitos rurales y urbanos, a partir de las razones que hay detrás de la decisión de tener hijos. Materiales y métodos: Estudio cualitativo diseñado y analizado a partir del estudio de casos de diferentes áreas de salud del norte de Portugal. La metodología implicó la realización de entrevistas semi-estructuradas a 50 mujeres embarazadas en busca de sus significados recurriendo para ello al análisis de contenido. Resultados: Se identificó la categoría que denominamos "Modelo de referencia familiar", en la cual se señalan dos subcategorías: el sueño sobre la construcción de una nueva familia y el sueño hecho realidad. Estos resultados hacen coincidir la idea de las aspiraciones (ideal inicial, antes de quedar embarazada) y la de las representaciones (ideal abstracto). Los resultados apuntan a unos ideales orientados a la familia y pero muestran una disminución en el número de hijos por mujer consecuencia también de un cálculo en el cual son ponderados los costos asociados con esta decisión. Conclusiónes: Del universo de las aspiraciones, se impone la evocación del deseo de tener hijos, pues fueron realmente pocas las encuestadas que diseñaron un proyecto de vida sin hijos. Sin embargo, vemos una disonancia entre las aspiraciones iniciales y la nueva realidad. Se concluye que existe un proceso de elección entre tener o no hijos, así como la transición a la parentalidad como proyecto conyugal.

Abstract Objective: To analyze the different ways of 'being a family' and that predomínate in different social contexts ranging from rural to urban spaces based on the reasons that support the decision to have children. Materials and methods: A qualitative study was designed and analyzed using case studies of different health areas of northern Portugal. The methodology used was based on semi-structured interviews with 50 pregnant women. It was done a content analysis of interviews. Results: Based on the stories obtained through interviews, we identified the category "reference model of family ", in which two subcategories listed was identified: "the dream of building a new family" and "the dream come true". These results match the idea of aspirations (initial ideal) and representations (abstract ideal). The results suggest a family oriented by ideals and show a decrease in the number of children per woman. This is the result of a perception of the associated costs of this decision. Conclusions: From the universe of aspirations centered in the desire for children, only a few women prefer a life without children. However, we identified a dissonance between the initial aspirations and the practices. It is concluded that there is a process of choice between having children, as well as the transition to parenthood as a conjugal project.

Resumo Objectivo: Analisar os diferentes modos de «ser familia¼ e que predominam em contextos sociais que vão desde a ruralidade até a urbanidade tendo por base as razões que sustentam a decisão de ter descendência. Materiais e métodos: Estudo qualitativo com base em estudo de casos em diferentes centros de saúde no norte de Portugal. A metodologia envolveu a realização de entrevistas semiestruturadas a 50 mulheres grávidas. Para analisar os dados recorreu-se a análise de conteúdo. Resultados: Com base nos relatos obtidos identificou-se a categoria "Modelo de referencia familiar", que identifica duas subcategorias: A construção da nova familia: o sonho e o sonho tornado realidade. Estes resultados correspondem as aspirações de ideia (ideal inicial, antes de engravidar) e as representações (ideal abstracto). Conclusões: Os resultados apontam para um ideal de familia orientado para os dois filhos e demonstram uma diminução do número de filhos por mulher. A diminução do número de filhos é também o resultado de um cálculo onde são ponderados os custos associados a esta decisão. Do universo das aspirações impõe-se a evocação da vontade de ter filhos. Foram realmente poucas as inquiridas que traçaram um projeto de vida sem filhos. Todavia verificamos uma dissonancia entre as aspirações iniciais e por conseguinte com as práticas.

Résumé Objectif: Analyser les différentes formes de «etre famille¼ qui prédominent dans des contextes sociaux allant du rural a la vie urbaine ayant pour motifs la décision d'avoir des enfants. Matériaux et méthodes: Étude qualitative basée sur des études de cas dans des centres de santé primaires dans le nord du Portugal. La méthodologie se base sur des entrevues semi-structurées a 50 femmes enceintes. Pour analyser les données, on a utilisé l'analyse des contenus.. Résultats: Basé sur les données, on a identifié la catégorie «Modele de famille¼, qui identifie deux sous-catégories: la construction de la nouvelle famille : le reve et le reve devenu réalité. Ces résultats correspondent aux aspirations de l'idée (idéal, avant la grossesse) et représentations (idéal abstrait). Les résultats pointent vers un idéal de famille orienté vers les enfants et montrent une diminution du nombre d'enfants par femme qui est également la conséquence de facteurs socioéconomiques qui influencent cette décision. L'univers des aspirations permet l'évocation du désir d'avoir des enfants. Conclusions: On a eu tres peu de femmes qui désirent une vie sans enfant. Cependant, nous voyons une dissonance entre les aspirations initiales (idéal) et les représentations (idéal abstrait). On conclut qu'il existe un choix entre avoir enfants, bien comme la transition vers la parentalité en tant que projet conjugal.

Impacto de la crisis económica en la actividad y eficiencia de un hospital terciario universitario / Impact of the financial crisis on activity and efficiency at a high-technology university hospital

Fundamentos: La crisis económica iniciada el año 2008 provocó una caída importante del gasto sanitario público en España. El objetivo del estudio fue evaluar el impacto de la crisis en la actividad, calidad y eficiencia de un hospital terciario universitario de alta complejidad. Métodos: Se analizó retrospectivamente la evolución entre los años 2007 y 2016 de cuatro grupos de indicadores de gestión (A: actividad asistencial; B: calidad y complejidad de las altas; C: plantilla, producción global y gasto; D: satisfacción de los pacientes hospitalizados). Los datos se obtuvieron de los sistemas de información del centro y se trataron como series longitudinales de tipo descriptivo. El impacto de la crisis se valoró analizando las desviaciones porcentuales de los diferentes indicadores en relación a los valores del año 2009, el año previo al inicio de los ajustes presupuestarios. Resultados: La actividad global ajustada por complejidad disminuyó un 9% los dos primeros años de la crisis, y se recuperó en los años posteriores. La complejidad de los pacientes hospitalizados se incrementó en un 14%. Los indicadores de calidad no se deterioraron. El gasto ejecutado anual disminuyó un 16% entre el 2009 y el 2014, y la eficiencia y la productividad global aumentaron un 13%. Los indicadores de satisfacción no se modificaron. Conclusiones: La crisis económica y la consecuente reducción del presupuesto y del gasto provocaron una disminución inicial de la actividad del centro, asociada a un incremento de la complejidad, que fue compensada progresivamente gracias a una mejora en la eficiencia y en la productividad global. La crisis no impactó negativamente ni en la calidad ni en la satisfacción de los pacientes atendidos en régimen de hospitalización

Background: The financial crisis that begun in 2008 significantly decreased the budget of the public health system on Spain. The aim of this study was to evaluate the impact of the financial crisis on the activity, quality and efficiency of a high-technology university hospital. Methods: We retrospectively analyzed the outcomes of four sets of hospital management indicators between 2007 and 2016 (A: activity; B: quality and complexity of inpatientcare; C: staff, global production and budget expenses; D: patients satisfaction survey). The data were obtained from the center's information systems and treated as longitudinal series of descriptive type. The impact of the crisis was assessed by analyzing the percentage deviations of the different indicators in relation to the values of the year 2009, the year before initial budget adjustments. Results: The overall activity of the hospital, adjusted for complexity, decreased 9% during the first two years of the crisis and recovered later. Inpatient complexity increased 14%. Quality set indicators did not deteriorate. Expenses decreased 16% between the years 2009 and 2014, and efficiency and global productivity improved by 13%. Patient satisfaction survey results did not change. Conclusions: The financial crisis and the subsequent decrease of budget provoked an initial reduction of hospital activity, associated with a complexity increase. It was progressively made up for with increased efficiency and global productivity. The financial crisis did not have negative effects on quality of care or patient satisfaction

Los dilemas propios de una investigación cualitativa en el ámbito de la cooperación al desarrollo: una cuestión delicada / Dilemmas appropriate for qualitative research in the field of development cooperation: a delicate question / Os dilemas próprios de uma pesquisa qualitativa na área da cooperação para o desenvolvimento: uma questão delicada

Este artículo analiza los dilemas éticos a los que tuvo que enfrentarse la autora durante la realización de la investigación antropológica para lo que sería su tesis doctoral, en el marco de un proyecto de cooperación al desarrollo en el ámbito de la salud. Se apunta un proceso de integración, de comprensión y de entendimiento en la propia investigadora, asumiendo, a veces resolviendo, e incluso entendiéndolos como parte del mismo proceso de investigación, por tanto, se apropia de ellos y los interioriza. Las disyuntivas que se presentan en el trabajo de campo se valoran como parte de este tipo de trabajos iniciáticos, contrastando con investigaciones e investigadores consolidados y observando que estas dificultades se presentan en diferentes ámbitos y de múltiples formas. Se considera necesario el abordaje de este tipo de cuestiones con rigurosidad metodológica, así como el consiguiente análisis, estimándolas como algo intrínseco a las investigaciones realizadas con otros y que sustentan intervenciones en salud. Se pretende poner el énfasis en este aspecto, a pesar de ser la ética un tema central cuando hablamos de investigaciones con sujetos y grupos sociales, pues se le dedica poco tiempo en la formación y práctica investigadora.

This article analyzes the ethical dilemmas which the authoress had to face during the accomplishment of the anthropologic investigation for what it would be his doctoral thesis, in the frame of a project of cooperation the development in the area of the health. There signs a process of integration, of comprehension and of understanding in the own investigator, taking up office, sometimes resolving, and even understanding them as part of the same process of investigation, therefore it appropriates of them, internalizes them. The dilemmas that they present in the fieldwork are valued as part of this type of initiation works, contrasting with investigations and consolidated investigators and, observing that these difficulties appear in different areas and of multiple forms, is considered to be necessary the boarding of this type of questions by methodological rigor, as well as the consequent analysis, estimating them as something intrinsically to the investigations realized with others and that sustain interventions in health. The emphasis is tried to put in this aspect, in spite of being a central topic the ethics, when we speak about investigations with subjects and social groups, since one dedicates him a little time in the formation and investigative practice.

Este artigo analisa os dilemas éticos enfrentados pela autora durante a realização da pesquisa antropológica para o que seria sua tese de doutorado, no âmbito de um projeto de cooperação para o desenvolvimento na área da saúde. Observa-se um processo de integração, compreensão e entendimento na própria pesquisadora, assumindo, às vezes resolvendo e até mesmo os entendendo como parte do processo de investigação, portanto se apropria deles e os interioriza. Os dilemas que surgem no trabalho de campo se valoram como parte deste tipo de trabalho inicial, contrastando com pesquisas e pesquisadores consolidados e constatando que estas dificuldades surgem em diferentes áreas e em diferentes aspectos, considera-se necessário abordar esses tipos de questões com rigor metodológico, bem como a análise subsequente, apreciando-as como algo intrínseco às investigações realizadas com outros e que sustentam as intervenções em saúde. Pretende enfatizar este aspecto, apesar da ética ser um tema central, quando falamos de pesquisa com sujeitos e grupos sociais, uma vez que pouco tempo é dedicado à formação e prática de investigação.