Evaluation of a Community Intervention to Reduce Harmful Alcohol Consumption among Adult Population: A Study Protocol.

Harmful alcohol consumption is shaped by a complex range of structural, social, and individual determinants that interact with inequality axes, which can be addressed at the community level. Under the framework of Barcelona Health in the Neighborhoods, which is a community strategy to reduce health inequalities in Barcelona's most deprived neighborhoods, a community steering group will co-design a multicomponent community intervention. Aims: to assess its effects on: (1) alcohol accessibility, availability, and consumption at the environmental level, and (2) psychosocial and cognitive determinants of harmful alcohol consumption at the individual level. Methods: Quasi-experimental design with a comparison group, and pre- and post-intervention measures. Three Barcelona neighborhoods will be assigned to the intervention or comparison group based on three criteria: healthcare data on alcohol use, socioeconomic characteristics, and population size. The intervention includes activities promoting community mobilization, law enforcement, and communication campaigns in the intervened neighborhoods. Non-participant observations in standardized census sections will be performed in public spaces to collect information on three outcomes: alcohol accessibility, availability, and signs of alcohol consumption. Data collection includes a survey to a sample of 622 subjects to detect differences on these outcomes: risk awareness, knowledge, and self-efficacy about harmful alcohol consumption and drinking patterns. Discussion: This protocol to assess the effects of a multicomponent community intervention on harmful alcohol consumption at the environmental and population level will provide evidence on effective community health interventions and enable informed decisions for policy makers. This protocol could also be used as an implementation guide for studies aimed at reducing harmful drinking in cities with similar characteristics.

Improving mental health and wellbeing in elderly people isolated at home due to architectural barriers: A community health intervention / Mejorando la salud mental y el bienestar de las personas mayores aisladas en casa debido a las barreras arquitectónicas: una intervención de salud comunitaria

Objetivos: Explorar los efectos sobre la salud de una intervención de salud comunitaria en personas mayores aisladas en casa debido a problemas de movilidad o a barreras arquitectónicas, identificar las características asociadas y evaluar la satisfacción de las personas participantes. Diseño: Estudio cuasi-experimental antes-después. Emplazamiento: Cinco barrios de baja renta de Barcelona durante 2010-15. Participantes: Se entrevistó a 147 participantes, ≥59 años, antes y 6 meses después de la intervención. Intervención: Equipos de atención primaria, trabajadores sociales, de salud pública y otros agentes comunitarios desarrollaron una intervención que consistía en salidas semanales, facilitadas por voluntarios. Mediciones: Se evalúo la salud autopercibida, la salud mental utilizando la escala GHQ-12 y la calidad de vida mediante la escala EuroQol. La satisfacción se evaluó mediante un conjunto de preguntas. Analizamos los datos previos y posteriores con pruebas de McNemar y modelos de regresión lineal y de Poisson ajustados. Resultados: A los 6 meses, los participantes mostraron mejoras en la salud percibida, en la salud mental y en la reducción de la ansiedad. Las mejoras fueron mayores entre las mujeres, las personas que no habían salido de casa durante ≥4 meses, las de bajo nivel educativo y las que habían realizado ≥9 salidas. La salud percibida (aRR: 1,29 [1,04-1,62]) y las mejoras en salud mental [(β: 2,92 [1,64-4,2]) permanecieron significativas en los modelos multivariados. La satisfacción media fue de 9,3 sobre 10. Conclusión: Esta intervención de salud comunitaria parece mejorar varios resultados de salud en las personas mayores aisladas, especialmente en los grupos más vulnerables. Replicar este tipo de intervención podría funcionar en contextos similares.(AU)

Objectives: To explore the health effects of a community health intervention on older people who are isolated at home due to mobility problems or architectural barriers, to identify associated characteristics and to assess participants’ satisfaction.Design: Quasi-experimental before–after study. Setting: Five low-income neighbourhoods of Barcelona during 2010–15. Participants: 147 participants, aged ≥59, living in isolation due to mobility problems or architectural barriers were interviewed before the intervention and after 6 months. Intervention: Primary Health Care teams, public health and social workers, and other community agents carried out a community health intervention, consisting of weekly outings, facilitated by volunteers. Measurements: We assessed self-rated health, mental health using the General Health Questionnaire (GHQ-12), and quality of life through the EuroQol scale. Satisfaction with the programme was evaluated using a set of questions. We analysed pre and post data with McNemar tests and fitted lineal and Poisson regression models. Results: At 6 months, participants showed improvements in self-rated health and mental health and a reduction of anxiety. Improvements were greater among women, those who had not left home for ≥4 months, those with lower educational level, and those who had made ≥9 outings. Self-rated health [aRR: 1.29(1.04–1.62)] and mental health improvements [β: 2.92(1.64–4.2)] remained significant in the multivariate models. Mean satisfaction was 9.3 out of 10. Conclusion: This community health intervention appears to improve several health outcomes in isolated elderly people, especially among the most vulnerable groups. Replications of this type of intervention could work in similar contexts.(AU)

Improving mental health and wellbeing in elderly people isolated at home due to architectural barriers: A community health intervention.

OBJECTIVES: To explore the health effects of a community health intervention on older people who are isolated at home due to mobility problems or architectural barriers, to identify associated characteristics and to assess participants' satisfaction. DESIGN: Quasi-experimental before-after study. SETTING: Five low-income neighbourhoods of Barcelona during 2010-15. PARTICIPANTS: 147 participants, aged ≥59, living in isolation due to mobility problems or architectural barriers were interviewed before the intervention and after 6 months. INTERVENTION: Primary Health Care teams, public health and social workers, and other community agents carried out a community health intervention, consisting of weekly outings, facilitated by volunteers. MEASUREMENTS: We assessed self-rated health, mental health using the General Health Questionnaire (GHQ-12), and quality of life through the EuroQol scale. Satisfaction with the programme was evaluated using a set of questions. We analysed pre and post data with McNemar tests and fitted lineal and Poisson regression models. RESULTS: At 6 months, participants showed improvements in self-rated health and mental health and a reduction of anxiety. Improvements were greater among women, those who had not left home for ≥4 months, those with lower educational level, and those who had made ≥9 outings. Self-rated health [aRR: 1.29(1.04-1.62)] and mental health improvements [ß: 2.92(1.64-4.2)] remained significant in the multivariate models. Mean satisfaction was 9.3 out of 10. CONCLUSION: This community health intervention appears to improve several health outcomes in isolated elderly people, especially among the most vulnerable groups. Replications of this type of intervention could work in similar contexts.

Community-Based Interventions to Reduce Alcohol Consumption and Alcohol-Related Harm in Adults.

Alcohol consumption was associated with 3 million deaths worldwide in 2016. Although community action has proven to be effective and has become a priority area of the global strategy to reduce alcohol consumption, there is a gap in the knowledge of community interventions to reduce alcohol use among adults. This study aims to analyze the evidence on effective community-based interventions to reduce alcohol consumption and harm among adults and to identify their components and underlying theories. Search strategy involved five databases (January 2000-March 2020). We included multicomponent, evaluated, and community interventions addressing to adults in urban settings of high-income countries. Furthermore, two conceptual frameworks were adapted to identify the social determinants of alcohol related harms and modifiable factors through community interventions. The initial search yielded 164 articles. The final sample included eight primary studies. Six of them were effective and shared three components (community mobilization; law enforcement and media campaigns), they combined approaches at individual and environmental levels addressing structural determinants of health and some cultural aspects related to consumption. Health outcomes focused mainly on reducing consumption, modifying patterns and acute effects on health. Few studies addressed social problems arising from harmful consumption. This review has identified several effective community-based interventions to reduce harmful use of alcohol among adults as well as some mechanisms and theories supporting them. It also provides a framework to guide new designs, with potential evidence of factors, as well as possible combinations of methods to improve health at community level across different settings and contexts.

Efectos de un programa de formación profesional para jóvenes de barrios desfavorecidos en la salud autopercibida, la autoestima y los consumos / Effects of an occupational training programme for young people from disadvantaged neighbourhoods on self-perceived health, self-esteem and substance use

OBJETIVOS: Evaluar la efectividad de una intervención comunitaria de formación profesional para jóvenes en riesgo de exclusión social, en la salud autopercibida, la autoestima y el consumo de sustancias (alcohol, tabaco y cannabis). Evaluar la satisfacción de los participantes. MÉTODOS: Diseño: estudio de intervención pre-post. Emplazamiento: tres barrios de renta baja de Barcelona durante 2013-2017. Participantes: 185 participantes, de 21 años de media y predominio masculino (65,5%). Intervención: programa de 4 meses de formación profesional de diferentes disciplinas e itinerarios orientados a la inserción laboral. Mediciones principales: análisis bivariado (McNemar) para datos apareados, comparando la salud autopercibida, autoestima y consumos pre-post intervención. Modelos de regresión de Poisson para las variables resultado, ajustando por variables explicativas. Además, se evaluó la satisfacción con el programa a través de un cuestionario y una discusión grupal. RESULTADOS: la salud autopercibida era elevada antes de la intervención (87,7% hombres y 82,1% mujeres) y se mantuvo tras ella (90,6% y 83,9% respectivamente). Los niveles elevados de autoestima previos a la intervención (92,8% en hombres y 92,9% mujeres) aumentaron tras ella (95,5% y 100% respectivamente), de forma significativa en las mujeres (p < 0,05). El consumo de sustancias no varió tras la intervención. La satisfacción con el programa fue elevada. CONCLUSIÓN: la intervención parece haber mejorado la autoestima en las mujeres, un colectivo con elevado desempleo y normalmente infrarrepresentado en los programas formativos. Esta intervención no incidió en el consumo de sustancias. Los programas de inserción laboral para jóvenes pueden promover factores beneficiosos para la salud mental

OBJECTIVES: To evaluate the effectiveness of a community occupational training intervention for young people at risk of social exclusion on self-perceived health, self-esteem and substance use (alcohol, tobacco and cannabis). To assess participant's satisfaction. METHODS: Design: Quasi-experimental before-after study. Setting: Three low-income neighbourhoods in Barcelona during 2013-2017. Participants: 185 participants with an average age of 21 years and mainly males (65.5%). Intervention: Four-month programme on specific occupational skills and itineraries oriented towards occupational integration. Most important measurements: Bivariate analysis (McNemar test) for paired data to compare self-rated health and self-esteem pre-intervention and post-intervention. Poisson regression models for result variables, adjusting for explanatory variables. In addition, satisfaction with the programme was evaluated by means of a questionnaire and group discussion. RESULTS: Pre-intervention self-rating was good (87.7% men and 82.1% women) and remained good post-intervention (90.6% and 83.9% respectively). Pre-intervention self-esteem was good (92.8% in men and 92.9% in women) and increased after the intervention (95.5% and 100% respectively). This was statistically significant in women (P<0.05). Substance use was unaltered after the intervention. Satisfaction with the programme was high. CONCLUSION: The intervention appears to have improved self-esteem among young women, who are an important group among the unemployed, as they are usually underrepresented in training and professional programmes. Programmes that foster young people moving into working life may also promote factors beneficial to mental health

Impact of a community contraceptive counselling intervention on adolescent fertility rates: a quasi-experimental study.

BACKGROUND: From 2000 to 2008, in urban areas in Spain, adolescent fertility and abortion rates underwent unprecedented increases, consecutive to intensive immigration from developing countries. To address unmet needs for contraception information and services, a community-based, gender-sensitive and culturally adapted brief counselling intervention (SIRIAN program) was launched in some deprived neighbourhoods with a high proportion of immigrants in Barcelona. Once a randomized controlled trial demonstrated its effectiveness in increasing the use of contraceptives, we aim to examine its population impact on adolescent fertility rates. METHODS: Quasi-experimental study with comparison group, using population data from 2005 to 2016. Five neighbourhoods in the lowest tercile of Disposable Household Income were intervened in 2011-13. The comparison group included the three neighbourhoods which were in the same municipal district and in the lowest Disposable Household Income tercile, and displayed the highest adolescent fertility rates. Generalized linear models were fitted to assess absolute adolescent fertility rates and adjusted by immigrant population between pre-intervention (2005-10) and post-intervention periods (2011-16); Difference in Differences and relative pre-post changes analysis were performed. RESULTS: In 2005-10 the intervention group adolescent fertility rate was 27.90 (per 1000 women 15-19) and 21.84 in the comparison group. In 2011-16 intervention areas experienced great declines (adolescent fertility rate change: - 12.30 (- 12.45 to - 12.21); p < 0.001), while comparison neighbourhoods remained unchanged (adolescent fertility rate change: 1.91 (- 2.25 to 6.07); p = 0.368). A reduction of - 10.97 points (- 13.91 to - 8.03); p < 0.001) is associated to the intervention. CONCLUSION: Adolescent fertility rate significantly declined in the intervention group but remained stable in the comparison group. This quasi-experimental study provide evidence that, in a country with universal health coverage, a community counselling intervention that increases access to contraception, knowledge and sexual health care in hard-to-reach segments of the population can contribute to substantially reduce adolescent fertility rates. Reducing adolescent fertility rates could become a feasible goal in cities with similar conditions.

Salud comunitaria confinada: reflexiones y experiencias desde la salud pública local / Confined community health: reflections and experiences from the local public health

Este artículo pretende compartir las reflexiones sobre la acción comunitaria en que la Agència de Salut Pública de Barcelona ha estado involucrada en la emergencia de COVID-19. El trabajo realizado puede ordenarse en tres etapas, frecuentemente solapadas: detectar necesidades o problemas, e informar; contactar con las personas participantes y agentes territoriales para valorar qué hacer y cómo hacerlo; y adaptar las intervenciones a la "nueva normalidad" y generar respuestas con los activos comunitarios a las necesidades detectadas. Los problemas emergentes incluyeron: no poder realizar el confinamiento (por falta de casa, condiciones materiales, vivir en situación de violencia); brecha digital (falta de conocimientos, dispositivos, acceso a Wifi); mayor exposición al COVID-19 en los trabajos esenciales pero precarizados, feminizados y racializados (cuidados, limpieza, alimentación), frecuentes en los barrios en que trabajamos; barreras idiomáticas y culturales para seguir las recomendaciones; pérdida de empleo; ingresos insuficientes para cubrir necesidades básicas; dificultades de conciliación; aislamiento social; y deterioro de la salud emocional provocado por la situación. Durante el proceso, algunas intervenciones se adaptaron para continuar de forma telemática, y se intentaron cubrir las necesidades primarias sobre conocimientos y dispositivos de algunas personas participantes a través de las redes solidarias y recursos existentes. La acción comunitaria en salud, desde una mirada crítica, interseccional y local, mediante trabajo intersectorial y la participación de la comunidad, puede contribuir a: facilitar una respuesta adaptada al contexto en caso de crisis sanitaria y mitigar los efectos derivados de esta crisis económica y social

This paper aims to share the reflections related to the community actions in which the Agència de Salut Pública de Barcelona has been involved during the emergency of COVID-19. The tasks carried out can be arranged in three stages, frequently overlapping: detection of needs and problems; contact with key stakeholders to assess what to do and how to do it; adaptation of the interventions to the "new normal" and generation of new responses. The emerging problems included: not being able to do the confinement (due to homelessness, material conditions, living in a situation of violence); digital gap (lack of knowledge, devices, access to Wifi); greater exposure to COVID-19 in the essential but precarious, feminized and racialized jobs (care, cleaning, food shops) that are the most frequent in the neighborhoods in where we work; language and cultural barriers that preclude to follow recommendations; to lose employment; insufficient income to cover basic needs; social isolation; and the deterioration of emotional health caused by the situation. During the process, some interventions were adapted to be delivered on-line. Solidarity networks and local resources were key to meet basic needs, but also other needs related to lack of digital knowledge or device. Community action in health, from a critical, intersectional and local perspective, and with intersectoral work and community participation, can contribute to: facilitate a contextualized response in the event of a health crisis; mitigate the effects derived from its economic and social crisis

La priorización comunitaria en el programa Barcelona Salut als Barri / Community prioritization in Barcelona Salut als Barris program

Priorizar es el proceso de selección y ordenación de las necesidades en salud identificadas tras el diagnóstico de necesidades y activos en salud de una comunidad. La valoración de las necesidades en salud se ha reforzado con la perspectiva comunitaria, lo que aporta múltiples beneficios: sensibiliza y empodera a la comunidad sobre su salud, fomenta el apoyo mutuo entre sus integrantes y promueve su protagonismo haciéndola corresponsable del proceso de mejora de su propia realidad. El objetivo de esta nota es describir el modelo de priorización de Barcelona Salut als Barris, estrategia de salud comunitaria liderada por la Agencia de Salud Pública de Barcelona para promover la equidad en salud en los barrios más desfavorecidos de la ciudad (AU)

Prioritizing corresponds to the process of selecting and managing health needs identified after diagnosing the community's health needs and assets. Recently, the health needs assessment has been reinforced with the community perspective, providing multiple benefits: it sensitizes and empowers the community about their health, encourages mutual support among its members and promotes their importance by making them responsible for the process of improving their own reality. The objective of this paper is to describe the prioritization of Barcelona Salut als Barris, a community health strategy led by the Barcelona Public Health Agency to promote equity in health in the most disadvantaged neighborhoods of the city (AU)

Understanding communication breakdown in the outpatient referral process in Latin America: a cross-sectional study on the use of clinical correspondence in public healthcare networks of six countries.

An adequate use of referral and reply letters-the main form of communication between primary care (PC) and out-patient secondary care (SC)-helps to avoid medical errors, test duplications and delays in diagnosis. However, it has been little studied to date in Latin America. The aim is to determine the level and characteristics of PC and SC doctors' use of referral and reply letters and to explore influencing factors in public healthcare networks of Argentina, Brazil, Chile, Colombia, Mexico and Uruguay. A cross-sectional study was conducted through a survey of PC and SC doctors working in public healthcare networks (348 doctors per country). The COORDENA questionnaire was applied to measure the frequency of use and receipt of referral and reply letters, quality of contents, timeliness and difficulties in using them. Descriptive analyses were conducted and a multivariate logistic regression model was generated to assess the relationship between frequent use and associated factors. The great majority of doctors claim that they send referral letters to the other level. However, only half of SC doctors (a higher proportion in Chile and Mexico) report that they receive referral letters and <20% of PC doctors receive a reply from specialists. Insufficient recording of data is reported in terms of medical history, tests and medication and the reason for referral. The factor associated with frequent use of the referral letter is doctors' age, while the use of reply letters is associated with identifying PC doctors as care coordinators, knowing them and trusting in their clinical skills, and receiving referral letters. Significant problems are revealed in the use of referral and reply letters which may affect quality of care. Multifaceted strategies are required that foster a direct contact between doctors and a better understanding of the PC-based model.

[Community prioritization in Barcelona Salut als Barris program]. / La priorización comunitaria en el programa Barcelona Salut als Barris.

Prioritizing corresponds to the process of selecting and managing health needs identified after diagnosing the community's health needs and assets. Recently, the health needs assessment has been reinforced with the community perspective, providing multiple benefits: it sensitizes and empowers the community about their health, encourages mutual support among its members and promotes their importance by making them responsible for the process of improving their own reality. The objective of this paper is to describe the prioritization of Barcelona Salut als Barris, a community health strategy led by the Barcelona Public Health Agency to promote equity in health in the most disadvantaged neighborhoods of the city.

Doctors' experience of coordination across care levels and associated factors. A cross-sectional study in public healthcare networks of six Latin American countries.

Improving coordination between primary care (PC) and secondary care (SC) has become a policy priority in recent years for many Latin American public health systems looking to reinforce a healthcare model based on PC. However, despite being a longstanding concern, it has scarcely been analyzed in this region. This paper analyses the level of clinical coordination between PC and SC experienced by doctors and explores influencing factors in public healthcare networks of Argentina, Brazil, Chile, Colombia, Mexico and Uruguay. A cross-sectional study was carried out based on a survey of doctors working in the study networks (348 doctors per country). The COORDENA questionnaire was applied to measure their experiences of clinical management and information coordination, and their related factors. Descriptive analyses were conducted and a multivariate logistic regression model was generated to assess the relationship between general perception of care coordination and associated factors. With some differences between countries, doctors generally reported limited care coordination, mainly in the transfer of information and communication for the follow-up of patients and access to SC for referred patients, especially in the case of PC doctors and, to a lesser degree, inappropriate clinical referrals and disagreement over treatments, in the case of SC doctors. Factors associated with a better general perception of coordination were: being a SC doctor, considering that there is enough time for coordination within consultation hours, job and salary satisfaction, identifying the PC doctor as the coordinator of patient care across levels, knowing the doctors of the other care level and trusting in their clinical skills. These results provide evidence of problems in the implementation of a primary care-based model that require changes in aspects of employment, organization and interaction between doctors, all key factors for coordination.

Patient perceptions of continuity of health care and associated factors. Cross-sectional study in municipalities of central Colombia and north-eastern Brazil.

Despite the fragmentation of healthcare provision being considered one of the main obstacles to attaining effective health care in Latin America, very little is known about patients' perceptions. This paper analyses the level of continuity of health care perceived by users and explores influencing factors in two municipalities of Colombia and Brazil, by means of a cross-sectional study based on a survey of a multistage probability sample of people who had suffered at least one health problem within the previous three months (2163 in Colombia; 2167 in Brazil). An adapted and validated version of the CCAENA© (Questionnaire of care continuity across levels of health care) was applied. Logistic regression models were generated to assess the relationship between perceptions of the different types of health care continuity and sociodemographic characteristics, health needs, and organizational factors. The results show lower levels of continuity across care levels in information transfer and care coherence and higher levels for the ongoing patient-doctor relationship, albeit with differences between the two countries. They also show greater consistency of doctors in the Brazilian study areas, especially in primary care. Consistency of doctors was not only positively associated with the patient-doctor ongoing relationship in the study areas of both countries, but also with information transfer and care coherence across care levels. The study area and health needs (the latter negatively for patients with poor self-rated health and positively for those with at least one chronic condition) were associated with all types of continuity of care. The influence of the sex or income varied depending on the country. The influence of the insurance scheme in the Colombian sample was not statistically significant. Both countries should implement policies to improve coordination between care levels, especially regarding information transfer and job stability for primary care doctors, both key factors to guarantee quality of care.

Health inequality between immigrants and natives in Spain: the loss of the healthy immigrant effect in times of economic crisis.

BACKGROUND: The immigrant population living in Spain grew exponentially in the early 2000s but has been particularly affected by the economic crisis. This study aims to analyse health inequalities between immigrants born in middle- or low-income countries and natives in Spain, in 2006 and 2012, taking into account gender, year of arrival and socioeconomic exposures. METHODS: Study of trends using two cross-sections, the 2006 and 2012 editions of the Spanish National Health Survey, including residents in Spain aged 15-64 years (20 810 natives and 2950 immigrants in 2006, 14 291 natives and 2448 immigrants in 2012). Fair/poor self-rated health, poor mental health (GHQ-12 > 2), chronic activity limitation and use of psychotropic drugs were compared between natives and immigrants who arrived in Spain before 2006, adjusting robust Poisson regression models for age and socioeconomic variables to obtain prevalence ratios (PR) and 95% confidence interval (CI). RESULTS: Inequalities in poor self-rated health between immigrants and natives tend to increase among women (age-adjusted PR2006 = 1.39; 95% CI: 1.24-1.56, PR2012 = 1.56; 95% CI: 1.33-1.82). Among men, there is a new onset of inequalities in poor mental health (PR2006 = 1.10; 95% CI: 0.86-1.40, PR2012 = 1.34; 95% CI: 1.06-1.69) and an equalization of the previously lower use of psychotropic drugs (PR2006 = 0.22; 95% CI: 0.11-0.43, PR2012 = 1.20; 95% CI: 0.73-2.01). CONCLUSIONS: Between 2006 and 2012, immigrants who arrived in Spain before 2006 appeared to worsen their health status when compared with natives. The loss of the healthy immigrant effect in the context of a worse impact of the economic crisis on immigrants appears as potential explanation. Employment, social protection and re-universalization of healthcare would prevent further deterioration of immigrants' health status.

Adaptación y validación de la escala CCAENA(R) para evaluar la continuidad asistencial entre niveles de atención en Colombia y Brasil / Adaptation and validation of the CCAENA(R) scale for the measurement of continuity of care between healthcare levels in Colombia and Brazil

Objetivo: Adaptar y validar la escala del Cuestionario de Continuidad Asistencial Entre Niveles de Atención (CCAENA©) en el contexto de los sistemas de salud colombiano y brasileño. Métodos: El estudio consistió en dos fases: 1) adaptación de la escala CCAENA© al contexto de cada país mediante dos pretests y una prueba piloto; y 2) validación mediante la aplicación de la escala en una encuesta poblacional en Colombia y Brasil. Se analizaron las siguientes propiedades psicométricas: validez de constructo (análisis factorial), consistencia interna (alfa de Cronbach; correlaciones ítem-resto), multidimensionalidad de las escalas (coeficientes de correlación de Spearman) y análisis de grupos conocidos (test de ji al cuadrado). Resultados: Se seleccionaron 14 de los 21 ítems de la escala original y se reformularon pasando de una afirmación con opciones de respuesta de acuerdo a una pregunta con opciones de respuesta de frecuencia. El análisis factorial mostró que los ítems se agrupan en tres factores: continuidad entre niveles asistenciales, continuidad de relación con el proveedor de atención primaria y continuidad de relación con el proveedor de atención especializada. El alfa de Cronbach indicó una buena concordancia interna (>0,80 en todas las escalas). Los coeficientes de correlación indican que los tres factores pueden interpretarse como escalas separadas (<0,70) y presentan una adecuada capacidad de diferenciar entre grupos. Conclusiones: La versión adaptada del CCAENA© muestra adecuadas validez y fiabilidad en ambos países, manteniendo una alta equivalencia con la versión original. Es una herramienta útil y viable para evaluar la continuidad asistencial entre niveles asistenciales desde la perspectiva del usuario en ambos contextos (AU)

Objective: To adapt and to validate the scale of the questionnaire Continuity of Care between Care Levels (CCAENA©) in the context of the Colombian and Brazilian health systems. Methods: The study consisted of two phases: 1) adaptation of the CCAENA© scale to the context of each country, which was tested by two pretests and a pilot test, and 2) validation by means of application of the scale in a population survey in Colombia and Brazil. The following psychometric properties were analyzed: construct validity (exploratory factor analysis), internal consistency (Cronbach's alpha and item-rest correlations), the multidimensionality of the scales (Spearman correlation coefficients), and known group validity (chi-square test). Results: Of the 21 items of the original scale, 14 were selected and reformulated based on a statement with response options of agreement to a question with frequency response options. Factor analysis showed that items could be grouped into three factors: continuity across healthcare levels, the patient-primary care provider relationship, and the patient-secondary care provider relationship. Cronbach's alpha indicated good internal consistency (>0.80 in all the scales). The correlation coefficients suggest that the three factors could be interpreted as separated scales (<0.70) and had adequate ability to differentiate between groups. Conclusion: The adapted version of the CCAENA© shows adequate validity and reliability in both countries, maintaining a high equivalence with the original version. It is a useful and feasible tool to assess the continuity of care between healthcare levels from the users’ perspective in both contexts (AU)

[Adaptation and validation of the CCAENA(©) scale for the measurement of continuity of care between healthcare levels in Colombia and Brazil]. / Adaptación y validación de la escala CCAENA(©) para evaluar la continuidad asistencial entre niveles de atención en Colombia y Brasil.

OBJECTIVE: To adapt and to validate the scale of the questionnaire Continuity of Care between Care Levels (CCAENA(©)) in the context of the Colombian and Brazilian health systems. METHODS: The study consisted of two phases: 1) adaptation of the CCAENA(©) scale to the context of each country, which was tested by two pretests and a pilot test, and 2) validation by means of application of the scale in a population survey in Colombia and Brazil. The following psychometric properties were analyzed: construct validity (exploratory factor analysis), internal consistency (Cronbach's alpha and item-rest correlations), the multidimensionality of the scales (Spearman correlation coefficients), and known group validity (chi-square test). RESULTS: Of the 21 items of the original scale, 14 were selected and reformulated based on a statement with response options of agreement to a question with frequency response options. Factor analysis showed that items could be grouped into three factors: continuity across healthcare levels, the patient-primary care provider relationship, and the patient-secondary care provider relationship. Cronbach's alpha indicated good internal consistency (>0.80 in all the scales). The correlation coefficients suggest that the three factors could be interpreted as separated scales (<0.70) and had adequate ability to differentiate between groups. CONCLUSION: The adapted version of the CCAENA(©) shows adequate validity and reliability in both countries, maintaining a high equivalence with the original version. It is a useful and feasible tool to assess the continuity of care between healthcare levels from the users' perspective in both contexts.

Determinantes del uso de distintos niveles asistenciales en el Sistema General de Seguridad Social en Salud y Sistema Único de Salud en Colombia y Brasil / Determinants of the use of different healthcare levels in the General System of Social Security in Health in Colombia and the Unified Health System in Brazil

Objetivo. Analizar comparativamente la utilización de servicios de los distintos niveles asistenciales y sus determinantes, de dos sistemas de salud diferentes, Sistema General de Seguridad Social en Salud (SGSSS) y Sistema Único de Salud (SUS), en municipios de Colombia y Brasil. Métodos. Estudio transversal basado en encuesta poblacional en dos municipios de Colombia (n = 2163) y dos de Brasil (n = 2155). Variables resultado: utilización de los servicios de atención primaria, especializada y urgencias en los últimos 3 meses. Variables explicativas: necesidad, factores capacitantes y predisponentes. Análisis bivariado y regresiones logísticas multivariadas por nivel asistencial y país. Resultados. Los determinantes de la utilización varían según el nivel asistencial y el país. Padecer una enfermedad crónica se asocia a un mayor uso de atención primaria y especializada en Colombia, y además a las urgencias en Brasil. En Colombia, los afiliados al régimen contributivo utilizan más los servicios del SGSSS que los del subsidiado en atención primaria y especializada, o que los no asegurados en cualquier nivel; en Brasil, la población de baja renta y sin seguro privado hace un mayor uso del SUS en cualquier nivel de atención. En ambos países, conocer el centro de salud asignado y tener una fuente regular de atención incrementa el uso de la atención primaria y el conocimiento del hospital de referencia, el de especializada y urgencias. Conclusiones. La influencia de los determinantes del uso difiere según el nivel de atención utilizado en ambos países, por lo que se subraya la necesidad de analizarlo desagregando por nivel asistencial (AU)

Objective. To compare the use of different healthcare levels, and its determinants, in two different health systems, the General System of Social Security in Health (GSSSH) and the Unified Health System (UHS) in municipalities in Colombia and Brazil. Methods. A cross-sectional study was carried out, based on a population survey in two municipalities in Colombia (n = 2163) and two in Brazil (n = 2155). Outcome variables consisted of the use of primary care services, outpatient secondary care services, and emergency care in the previous 3 months. Explanatory variables were need and predisposing and enabling factors. Bivariate and multivariate logistic regression analyses were performed by healthcare level and country. Results. The determinants of use differed by healthcare level and country: having a chronic disease was associated with a greater use of primary and outpatient secondary care in Colombia, and was also associated with the use of emergency care in Brazil. In Colombia, persons enrolled in the contributory scheme more frequently used the services of the GSSSH than persons enrolled with subsidized contributions in primary and outpatient secondary care and more than persons without insurance in any healthcare level. In Brazil, the low-income population and those without private insurance more frequently used the UHS at any level. In both countries, the use of primary care was increased when persons knew the healthcare center to which they were assigned and if they had a regular source of care. Knowledge of the referral hospital increased the use of outpatient secondary care and emergency care. Conclusions. In both countries, the influence of the determinants of use differed according to the level of care used, emphasizing the need to analyze healthcare use by disaggregating it by level of care (AU)

Acceso a los servicios de salud de la población inmigrante en España / Immmigrant´s access to health care in Spain: a review

Fundamentos: Una importante proporción de población en España es inmigrante y la evidencia internacional señala su acceso inadecuado a los servicios de salud. El objetivo es conocer el acceso a la atención de la población inmigrante en España. Métodos: Revisión bibliográfica de los artículos originales (1998- 2012) sobre acceso y utilización de los servicios de la población inmigrante en España registrados en Medline y MEDES. Se identificaron 319 artículos de los que se seleccionaron 20. Se utilizó el modelo de Aday y Andersen para el análisis. Resultados: Entre los artículos seleccionados, 13 estudios cuantitativos analizaron diferencias en la utilización de los servicios entre inmigrantes y autóctonos y 7 determinantes del acceso en inmigrantes. En líneas generales estos muestran menor utilización de la atención especializada, mayor de las urgencias y no se observaron diferencias entre grupos en atención primaria. Los 5 estudios cuantitativos sobre determinantes se centraron en las características de la población (sexo, edad, nivel de estudios y posesión de seguro privado) sin observarse un patrón claro. Los 2 estudios cualitativos analizaron factores relacionados con los servicios de salud y encontraron barreras en el acceso, como la provisión de información o los requisitos para obtener la tarjeta sanitaria. Conclusiones: El acceso a la atención en inmigrantes ha sido limitadamente abordado, con aproximaciones diferentes y los factores relacionados con la oferta, escasamente analizados. No se observa un patrón de utilización, las diferencias dependen de la clasificación de los inmigrante según origen y nivel asistencial. No obstante, en inmigrantes se observa menor utilización de la atención especializada y mayor de las urgencias, así como determinantes del acceso distintos a la necesidad (AU)

Background: An important proportion of the population in Spain is immigrant and the international literature indicates their inadequate access to health services. The objective is to contribute to improving the knowledge on access to health care of the immigrant population in Spain. Methods: Review of original papers published (1998-2012) on access to health services of the immigrant population in Spain published in Medline and MEDES. Out of 319 studies, 20 were selected, applying predefined criteria. The results were analyzed using the Aday and Andersen framework. Results:Among the publications, 13 quantitative studies analysed differences in health care use between the immigrant and the native population, and 7 studied determinants of access of immigrants. Studies showed less use of specialized care by immigrants, higher use of emergency care and no differences in the use of primary care between groups. Five quantitative articles on determinants of access focused on factors related to the immigrant population (sex, age, educational level and holding private health insurance), but without observing clear patterns. The two qualitative studies analyzed factors related to health services, describing access to healthcare barriers such as the limited provision of information or the requirements for personal health card. Conclusion: Access to health care in immigrants has been scarcely studied, using different approaches and the barely analysed factors related to the services. No clear patterns were observed, as differences depend on the classification of migrants according to country of origin and the level of care. However, studies showed less use of specialized care by immigrants, higher use of emergency care and the existence of determinants of access different to their needs (AU)

[Immigrants' access to health care in Spain: a review]. / Acceso a los servicios de salud de la población inmigrante en España.

BACKGROUND: An important proportion of the population in Spain is immigrant and the international literature indicates their inadequate access to health services. The objective is to contribute to improving the knowledge on access to health care of the immigrant population in Spain. METHODS: Review of original papers published (1998-2012) on access to health services of the immigrant population in Spain published in Medline and MEDES. Out of 319 studies, 20 were selected, applying predefined criteria. The results were analyzed using the Aday and Andersen framework. RESULTS: Among the publications, 13 quantitative studies analysed differences in health care use between the immigrant and the native population, and 7 studied determinants of access of immigrants. Studies showed less use of specialized care by immigrants, higher use of emergency care and no differences in the use of primary care between groups. Five quantitative articles on determinants of access focused on factors related to the immigrant population (sex, age, educational level and holding private health insurance), but without observing clear patterns. The two qualitative studies analyzed factors related to health services, describing access to healthcare barriers such as the limited provision of information or the requirements for personal health card. CONCLUSION: Access to health care in immigrants has been scarcely studied, using different approaches and the barely analysed factors related to the services. No clear patterns were observed, as differences depend on the classification of migrants according to country of origin and the level of care. However, studies showed less use of specialized care by immigrants, higher use of emergency care and the existence of determinants of access different to their needs.

Changes in access to health services of the immigrant and native-born population in Spain in the context of economic crisis.

AIM: To analyze changes in access to health care and its determinants in the immigrant and native-born populations in Spain, before and during the economic crisis. METHODS: Comparative analysis of two iterations of the Spanish National Health Survey (2006 and 2012). Outcome variables were: unmet need and use of different healthcare levels; explanatory variables: need, predisposing and enabling factors. Multivariate models were performed (1) to compare outcome variables in each group between years, (2) to compare outcome variables between both groups within each year, and (3) to determine the factors associated with health service use for each group and year. RESULTS: unmet healthcare needs decreased in 2012 compared to 2006; the use of health services remained constant, with some changes worth highlighting, such as the decline in general practitioner visits among autochthons and a narrowed gap in specialist visits between the two populations. The factors associated with health service use in 2006 remained constant in 2012. CONCLUSION: Access to healthcare did not worsen, possibly due to the fact that, until 2012, the national health system may have cushioned the deterioration of social determinants as a consequence of the financial crisis. Further studies are necessary to evaluate the effects of health policy responses to the crisis after 2012.

[Determinants of the use of different healthcare levels in the General System of Social Security in Health in Colombia and the Unified Health System in Brazil]. / Determinantes del uso de distintos niveles asistenciales en el Sistema General de Seguridad Social en Salud y Sistema Único de Salud en Colombia y Brasil.

OBJECTIVE: To compare the use of different healthcare levels, and its determinants, in two different health systems, the General System of Social Security in Health (GSSSH) and the Unified Health System (UHS) in municipalities in Colombia and Brazil. METHODS: A cross-sectional study was carried out, based on a population survey in two municipalities in Colombia (n=2163) and two in Brazil (n=2155). Outcome variables consisted of the use of primary care services, outpatient secondary care services, and emergency care in the previous 3 months. Explanatory variables were need and predisposing and enabling factors. Bivariate and multivariate logistic regression analyses were performed by healthcare level and country. RESULTS: The determinants of use differed by healthcare level and country: having a chronic disease was associated with a greater use of primary and outpatient secondary care in Colombia, and was also associated with the use of emergency care in Brazil. In Colombia, persons enrolled in the contributory scheme more frequently used the services of the GSSSH than persons enrolled with subsidized contributions in primary and outpatient secondary care and more than persons without insurance in any healthcare level. In Brazil, the low-income population and those without private insurance more frequently used the UHS at any level. In both countries, the use of primary care was increased when persons knew the healthcare center to which they were assigned and if they had a regular source of care. Knowledge of the referral hospital increased the use of outpatient secondary care and emergency care. CONCLUSIONS: In both countries, the influence of the determinants of use differed according to the level of care used, emphasizing the need to analyze healthcare use by disaggregating it by level of care.