Abordaje integral de un caso crónico complejo a través de un equipo interdisciplinar en atención primaria / Integrated approach to a complex chronic case through an interdisciplinary team in primary care

Con este artículo se pretende ilustrar cuáles han sido los mecanismos de coordinación sociosanitaria con el caso práctico de un paciente de 65 años con obesidad, riesgo cardiovascular alto, hipertensión, enolismo, tabaquismo e ictus isquémicos silentes. Divorciado en dos ocasiones y con cinco hijos. Tras su última separación hace 8 años trasladó su residencia a casa de su padre. Mientras vivió su padre, su situación de salud se mantuvo estable y con seguimiento por parte de los profesionales del equipo de atención primaria. Recientemente fue derivado a la trabajadora social del centro de salud por situación de abandono en la higiene personal y de la vivienda. Fruto del trabajo interdisciplinar de la trabajadora social y la enfermera gestora de casos comunitaria se implementó un plan de actuación conjunto. El padre falleció hacía un año y desde entonces no se había vuelto a tener noticias del paciente en el centro de salud y tampoco constaba la retirada de medicación de la farmacia. La vivienda era propiedad por herencia del más pequeño de los cuatro hermanos, que había amenazado con expulsarlo. En la entrevista, el hermano aseguró que no se dejaba ayudar y que solo recibía visitas de uno de sus hijos de manera ocasional para obtener dinero. Se realizaron varias visitas en el domicilio por parte de los profesionales de atención primaria. El paciente se mostró colaborador y participativo a la hora de elaborar un plan conjunto con los profesionales implicados, lo que permitió activar la coordinación sociosanitaria para lograr un buen manejo de sus procesos crónicos

This article tends to illustrate the coordination mechanisms used through an example centred on a case study of a 65 year-old patient who presents obesity, hypertension, high cardiovascular risk, alcoholism, smoking and silent ischaemic strokes; divorced twice and with five children. After his last separation 8 years ago he moved to his father's house. While his father was still alive his health situation was stable and monitored by professionals of the primary care team. He was recently referred to the Social Worker at the Health Centre due to his lack of personal hygiene and housing. The interdisciplinary work of the Social Worker and Community Nurse Case Manager resulted in a shared action plan. His father died a year ago and since then there was no news of the patient in the health centre and also he did not collect his medication from the pharmacy. The house was owned by inheritance by the smallest of the four brothers, who had threatened to expel him. In the interview, the brother claimed that he didn't want to be helped and only received visits from one of his sons occasionally to receive money. Primary care professionals visited him several times at home. The patient was cooperative and engaged when preparing a joint plan with the professionals involved. This joint plan allowed to activate the care coordination for a successful management of his chronic conditions

[Integrated approach to a complex chronic case through an interdisciplinary team in primary care]. / Abordaje integral de un caso crónico complejo a través de un equipo interdisciplinar en atención primaria.

This article tends to illustrate the coordination mechanisms used through an example centred on a case study of a 65 year-old patient who presents obesity, hypertension, high cardiovascular risk, alcoholism, smoking and silent ischaemic strokes; divorced twice and with five children. After his last separation 8 years ago he moved to his father's house. While his father was still alive his health situation was stable and monitored by professionals of the primary care team. He was recently referred to the Social Worker at the Health Centre due to his lack of personal hygiene and housing. The interdisciplinary work of the Social Worker and Community Nurse Case Manager resulted in a shared action plan. His father died a year ago and since then there was no news of the patient in the health centre and also he did not collect his medication from the pharmacy. The house was owned by inheritance by the smallest of the four brothers, who had threatened to expel him. In the interview, the brother claimed that he didn't want to be helped and only received visits from one of his sons occasionally to receive money. Primary care professionals visited him several times at home. The patient was cooperative and engaged when preparing a joint plan with the professionals involved. This joint plan allowed to activate the care coordination for a successful management of his chronic conditions.

La violencia de género en la atención primaria / Gender violence in primary care

En este artículo presentamos la línea de investigación sobre violencia de género en mujeres atendidas en centros de atención primaria por parte de un equipo de profesionales que incluye médicos de familia, trabajadores sociales y personal de enfermería, y se orienta a la investigación-acción. Inicialmente, tras el contacto con mujeres residentes en casas de acogida y con sus hijos, se realizan estudios descriptivos sobre sus características y necesidades de salud, así como se evalúa la efectividad de las intervenciones orientadas a la mejora de la calidad y la adecuación de la atención que se les presta desde los centros de salud. La complejidad del problema y la tendencia a la intervención directiva y unidireccional de los profesionales sanitarios llevan a la necesidad de conocer la perspectiva de las mujeres, utilizando una metodología cualitativa (análisis de relatos biográficos grabados en audio, mediante teoría fundamentada) para responder preguntas de investigación, como los motivos para salir de la situación o permanecer en ella, la visión que de los agresores tienen las mujeres y la adecuación a modelos explicativos como el modelo de estadios de cambio. Como investigación en proyecto está el estudio con igual metodología,de la perspectiva de los hombres que han infligido violencia

In this assay, we present a line of research into gender violence against women as seen in primary care centers by a team of doctors, social workers and nurses who focus on a research-action approach. First, we contacted women and their children who were living in sheltered accommodation, and descriptive studies were made into their characteristics and health needs. In addition, the effectiveness of the actions designed to improve the quality and the adaptation of the attention in primary care centers for this population were evaluated. The complexity of the matter and the health professionals’ tendency to direct the interventions make it necessary to know the women’s views. Qualitative methodology was used (audio recordings were made of biographical narrations and analyzed by Grounded Theory) to answer the main research questions: reasons for leaving or remaining in the situation; the women’s view of their aggressors, and the adaptation to explanatory models, such as the Stages of Change Model. Another research project with the same methodology which focuses on the male aggressor’s view is currently being undertaken.

Modelo de estadios de cambio: compatibilidad con relatos biográficos de mujeres que sufren violencia doméstica / Stages of change model: adjustment to biographical narrations of women whose are victims of intimate partner violence

El objetivo es analizar el ajuste de las vivencias de mujeres que sufren violencia inflingida por sus parejas o exparejas al Modelo de Cambio o Transteorético de Prochaska y Di Clemente. Se realiza una investigación cualitativa interpretativa con participación de 35 mujeres que sufren violencia de género, detectadas en atención primaria, que reconocen su situación (maltrato percibido). Se trata de un estudio multicéntrico realizado en seis centros de salud urbanos de Málaga. Se utiliza la técnica de Relato Biográfico mediante entrevista, que es audio grabado y transcrito, sobre el que se realiza el análisis de contenido según fases del Modelo Transteorético. Para la codificación se usa el programa ATLAS-TI 5.0.Las fases más relevante son la precontemplativa y las de mantenimiento y finalización, con poca presencia de las fases de acción. Las principales características de cada fase son la ceguera e inexplicabilidad en la precontemplativa; el análisis de pros y contras en la contemplativa; la dificultad en la toma de decisiones en las fases de acción; el sufrimiento y la lucha por salir adelante en la fase de mantenimiento y la determinación y capacidad de análisis en la de finalización. Se ofrecen claves para la intervención según la fase del proceso (AU)

This study aims to analyze the adjustment of women, victims of intimate partner violence, by applying the Prochaska and Di Clemente Stages of Change Model. An interpretative qualitative study was made in 35 domestic violence victims women detected in primary care, women who recognized their relationship as abusive (perceived maltreatment). This is a multicentric study, with participation of six health centers of Malaga city. Biographical Narration technique by audio-recorded and transcribed interview was used; about this, thematic analysis adjustment to Transtheoretic Model phases was applied. ATLAS-TI 5.0 program was used for codification. Precontemplative, maintenance and ending stages were more represented while action phases were poorly mentioned. Main phases characteristics were: "blindness" and inexplicability in precontemplative stage; pros / cons analysis in contemplative phase; making decisions difficulty in action phases; suffering and going ahead purpose in maintenance stage, and determination and analysis capacity in the ending stage. Keys for intervention according to the phase of the process were offered (AU)

El torbellino de la violencia. Relatos biográficos de mujeres que sufren maltrato / Coming out of the whirlwind of abuse. Qualitative research on gender violence

Objetivo. Analizar la experiencia de mujeres que sufren violencia de género desde su propio punto de vista. Identificar los factores relacionados con el mantenimiento o la ruptura de la situación. Diseño. Investigación cualitativa interpretativa. Perspectiva fenomenológica.EmplazamientoEstudio multicéntrico en 6 centros de salud urbanos de Málaga.ParticipantesMujeres que sufren violencia de género. Estos casos se detectaron en atención primaria y las mujeres reconocieron su situación (maltrato percibido).MétodosTécnica de relato biográfico mediante entrevista entre la mujer informante y la trabajadora social, de forma audiograbada y transcrita. Asimismo, se utilizó la teoría fundamentada de Glasser y Strauss, la codificación abierta y axial, y el programa ATLAS-TI 5.2.ResultadosSe analizaron 35 relatos. La vivencia del maltrato fue descrita mediante la metáfora del «torbellino» (ceguera, aislamiento, indefensión, sufrimiento, destino, dependencia, fantasías y círculos viciosos). Ésta se relacionó con el término «aguantar»: valores inculcados, ideal de familia, incertidumbre, anulación, fracaso personal, amor, falta de apoyos, imagen de sí misma y pública, protección a los hijos, miedos múltiples y aspectos materiales. Las mujeres identifican 2 tipos de «salidas» con distintas repercusiones según la participación en la toma de decisiones: una activa y otra pasiva. El término «salir» se relacionó con: situaciones límite, hartazgo, intervención de los hijos, ruptura del ideal de familia y pérdida del miedo. Salir es un proceso de cambio o un «camino». No siempre se da el apoyo institucional y se valora más el apoyo emocional que el legal. Conclusiones. Las mujeres definen «aguantar» y «salir» como estados cualitativamente distintos, con intervención de múltiples factores personales y culturales, y definen un «camino» o proceso entre ambos, que puede ser distinto según el grado de protagonismo de la mujer en la toma de decisiones (AU)

Objectives. To analyse the experience from the point of view of women who have suffered domestic violence. To identify factors related to continuing or resolving the problem.DesignQualitative interpretative research from a phenomenological perspective.Population sampleWomen, detected in primary care, who have suffered domestic violence and have recognised the problem, and who accepted to participate in this research.Multicentre StudySix health centres in the city of Malaga.Methods and techniquesThe technique used is the biographical narration using individual open interviews between social workers and women. This narration was tape-recorded and verbatim transcribed to written text. Grounded theory. Qualitative analysis was made with ATLAS-TI 5.2.OutcomesA total of 35 narrations were analysed. The abuse situation was described as “whirl-wind” metaphor (blindness-isolation-helplessness-suffering-destiny-dependence-fantasies -about love, protection, happiness, change- and vicious circles). Enduring experience is reported to be related to several factors: inculcated gender values, family-ideal, uncertainty, annulment, personal failure sensation, love, support defects, self-image, children protection, multiple fears and material aspects. They identified two types of “exit”: passive and active with different mechanisms and repercussions. Exit experience is related to: limit situations, children intervention, family ideal attempts, and fear-loss. Leaving is a transitional process or “pathway”. Institutional support is not always guaranteed and emotional support is better evaluated than a legal one.ConclusionsEnduring and coming out are reported as two qualitatively different states, which involve many cultural and personal factors. There is a gap between these two states with a process that varies depending on the involvement of the women in decision-making(AU)

[Coming out of the whirlwind of abuse. Qualitative research on gender violence]. / El torbellino de la violencia. Relatos biográficos de mujeres que sufren maltrato.

OBJECTIVES: To analyse the experience from the point of view of women who have suffered domestic violence. To identify factors related to continuing or resolving the problem. DESIGN: Qualitative interpretative research from a phenomenological perspective. POPULATION SAMPLE: Women, detected in primary care, who have suffered domestic violence and have recognised the problem, and who accepted to participate in this research. MULTICENTRE STUDY: Six health centres in the city of Malaga. METHODS AND TECHNIQUES: The technique used is the biographical narration using individual open interviews between social workers and women. This narration was tape-recorded and verbatim transcribed to written text. Grounded theory. Qualitative analysis was made with ATLAS-TI 5.2. OUTCOMES: A total of 35 narrations were analysed. The abuse situation was described as "whirl-wind" metaphor (blindness-isolation-helplessness-suffering-destiny-dependence-fantasies -about love, protection, happiness, change- and vicious circles). Enduring experience is reported to be related to several factors: inculcated gender values, family-ideal, uncertainty, annulment, personal failure sensation, love, support defects, self-image, children protection, multiple fears and material aspects. They identified two types of "exit": passive and active with different mechanisms and repercussions. Exit experience is related to: limit situations, children intervention, family ideal attempts, and fear-loss. Leaving is a transitional process or "pathway". Institutional support is not always guaranteed and emotional support is better evaluated than a legal one. CONCLUSIONS: Enduring and coming out are reported as two qualitatively different states, which involve many cultural and personal factors. There is a gap between these two states with a process that varies depending on the involvement of the women in decision-making.