Challenges and opportunities in strengthening primary mental healthcare for older people in India: a qualitative stakeholder analysis.

BACKGROUND: Primary mental healthcare (PMHC) allows for complex mental health issues in old age to be addressed. India has sought to improve PMHC through legislation, strategies and programmes. This study analyses the challenges and opportunities involved in strengthening PMHC for older persons in India from the perspectives of key stakeholders. METHODS: Semistructured interviews were conducted with 14 stakeholders selected from the PMHC system in India and analysed using thematic analysis. First, the analysis was organizationally structured in accordance with the six WHO mental health system domains: (1) policy and legislative framework, (2) mental health services, (3) mental health in primary care, (4) human resources, (5) public information and links to other sectors, and (6) monitoring and research. Second, for each building block, challenges and opportunities were derived using inductive coding. RESULTS: This study highlights the numerous challenges that may be encountered when attempting to strengthen age-inclusive PMHC. Among these challenges are poor public governance, a lack of awareness and knowledge among policy-makers and other stakeholders, and existing policies that make unrealistic promises to weak primary healthcare (PHC) structures with an excessive focus on medicalizing mental health problems. Thus, the mental health system often fails to reach vulnerable older people through PHC. Established approaches to comprehensive, family- and community-oriented PHC support attempts to strengthen intersectoral approaches to PMHC that emphasize mental health promotion in old age. Targeting the PHC workforce through age-inclusive mental health education is considered particularly necessary. Experts further argue that adequate monitoring structures and public spending for mental health must be improved. CONCLUSIONS: In this study, we aim to elaborate on the mental healthcare developments that may serve to achieve equity in access to mental healthcare in India. Coordinated and collaborative efforts by public and private stakeholders involved in the care of older persons, both with and without lived mental health experiences, as well as their families and communities, are necessary to bring the vision of those policies for PMHC to fruition. The findings presented in this study can also inform future research, policies and practice in other low- and middle-income countries.

[Interprofessional collaboration of general practitioners and nurses in primary care: A qualitative study]. / Interprofessionelle Zusammenarbeit von Hausärzt_innen und Pflegefachpersonen in der Primärversorgung.

Interprofessional collaboration of general practitioners and nurses in primary care: A qualitative study Abstract. Background: There is a need to strengthen interprofessional collaboration of general practitioners and home care nurses in the primary care of people with chronic diseases and long-term care needs. Aim: This study investigated a) how general practitioners and nurses in Germany perceive their collaboration in primary care and b) which development perspectives of collaboration exist from their point of view. Methods: Expert interviews were conducted with seven general practitioners and eight home care nurses. The data were analysed using thematic-structured qualitative content analysis. Results: The interviewees from both professional groups report that their collaboration is hindered by poor mutual accessibility. At the same time, they emphasise their appreciation of the professional exchange with the other professional group. Nevertheless, the perceptions of the professional competence of home care nurses differ. To improve their cooperation, the interviewees recommend the establishment of interprofessional meetings and cooperation in spatial proximity for regular professional exchange. They expect this to lead to a joint development of trust and competence and to an expansion of the area of responsibility of home care nurses in primary care. Conclusions: Binding communication structures, cooperation in spatial proximity and an expansion of the area of responsibility of home care nurses offer high potential for strengthening primary care in Germany.

Primary mental healthcare for older people in India: between stigmatization and community orientation.

BACKGROUND: Questions of equitable access to primary mental healthcare (PMHC) for older persons in India have been examined mostly in terms of the coverage of services, although perceptions of mental health and old age and social norms at the community level should be considered in the shaping of PMHC approaches. The present qualitative study, therefore, examined how social perceptions and norms of mental health in old age are and should be considered in the design and implementation of primary healthcare approaches in India. METHODS: A secondary thematic analysis of semi-structured interviews with key stakeholders (n = 14) of PMHC in India was conducted. RESULTS: Four key themes emerged from the analysis, in which social perceptions and norms were discussed: (1) family participation and low threshold access to mental healthcare, (2) the position of community health workers as an important pillar of old age and mental health-sensitive community-based care, (3) the role of social cohesion and traditional values in fostering a positive and supportive community environment for old age mental health, and (4) the empowerment of communities, families and older persons through mental health education. CONCLUSIONS: PMHC, with its focus on mental health promotion, could be an important anchor for combatting negative attitudes about mental health and old age. The findings presented in this study can inform age-sensitive policies and programmes for mental health in India and could inform future research on the subject.

Barriers to and enablers of the promotion of patient and family participation in primary healthcare nursing in Brazil, Germany and Spain: A qualitative study.

BACKGROUND: Most health systems are insufficiently prepared to promote the participation of chronically ill patients in their care. Strong primary health care (PHC) strengthens patients' resources and thus promotes their participation. The tasks of providing continuous care to people with chronic diseases and promoting self-management are the responsibility of PHC nurses. Recent research assessing enablers of or barriers to nurses' efforts to support patients' participation has mostly not considered the special situation of patients with chronic diseases or focused on the PHC setting. OBJECTIVE: To investigate enablers of and barriers to PHC nurses' efforts to promote the participation of chronically ill patients in their care. METHODS: We interviewed 34 practicing PHC nurses and 23 key informants with advanced knowledge of PHC nursing practice in Brazil, Germany and Spain. The data was analyzed using thematic coding. RESULTS: We identified four categories of barriers and enablers. (1) Establishing bonds with patients: Interviewees emphasized that understanding patients' views and behaviours is important for PHC nurses. (2) Cooperation with relatives and families: Good relationships with families are fundamental, however conflicts within families could challenge PHC nurses efforts to strengthen participation. (3) Communication and cooperation within PHC teams: PHC nurses see Cooperative team structures as a potential enabler, while the dominance of a 'biomedical' approach to patient care is seen as a barrier. (4) Work environment: Interviewees agreed that increased workload is a barrier to patient participation. DISCUSSION AND CONCLUSIONS: Supporting patient participation should be acknowledged as an important responsibility for nurses by general practitioners and PHC planners. PHC nurses should be trained in communicative competence when discussing participation with chronically ill patients. Interprofessional education could strengthen other professionals' understanding of patient participation as a nursing task. PATIENT OR PUBLIC CONTRIBUTION: This study is part of a research project associated with the research network 'forges: User-oriented care: Promotion of health in the context of chronic diseases and care dependency'. The study's focus and provisional results were discussed continuously with partners in health and social care practice and presented to and discussed with the public at two conferences in which patient representatives, professionals and researchers participated.

Interprofessional qualification of prenatal care in the context of primary health care. / Qualificação interprofissional da atenção pré-natal no contexto da atenção primária à saúde.

This study aims to describe and analyze an interprofessional educational intervention for the qualification of prenatal care in the context of primary health care. METHOD: action-research comprising a prenatal care qualification course with 65 primary health care professionals. Collaborative learning activities were conducted in synchronous and asynchronous meetings. RESULTS: the reflexive thematic analysis of participants' experiences, views and perceptions on the meanings of the intervention revealed three categories: quality of prenatal care: conceptions and meanings; collaborative learning: strategy to overcome linear and isolated care; the need to evolve from acting locally to thinking globally. CONCLUSION: the analysis of the interprofessional educational intervention for the qualification of prenatal care in the context of primary health care showed that constructivist, participatory and interprofessional approaches are relevant and pertinent to broaden theoretical perceptions and give new meanings to the work process at different settings of the health network.

O objetivo deste artigo é descrever e analisar intervenção educativa interprofissional para a qualificação da atenção pré-natal no contexto da atenção primária à saúde. Trata-se de uma pesquisa-ação cujo processo de intervenção teve como cenário a qualificação pré-natal, a partir de um curso sistematizado em atividades síncronas e assíncronas, com a participação de 65 profissionais que atuam em Unidades Básicas de Saúde. Da análise temática do tipo reflexive, que possibilitou o registro de ideias, insights e a significação da intervenção, resultaram três categorias: qualidade da atenção pré-natal - concepções e significados; aprendizagem colaborativa - estratégia para transcender a atenção linear e pontual; necessidade de evoluir do agir local ao pensar global. A análise da intervenção educativa interprofissional para a qualificação da atenção pré-natal no contexto da atenção primária à saúde demonstrou que percursos construtivistas, participativos e interprofissionais são relevantes e pertinentes para ampliar percepções teóricas e ressignificar o processo de trabalho nos diversos pontos da rede de saúde.

Longing for normalcy in couple relationships: How chronic illness and care dependency change the relationship of long-married couples.

Introduction: Coping with chronic illness and care dependency in a marital dyad challenges many older couples. In our qualitative research study, we are interested in how long-married spouses in Germany experience their couple relationship while dealing with long-term care and adapting everyday life to the care situation. Methods: We conducted problem-centered interviews with 17 spouses according to the interpretive-reconstructive documentary method. Results: We derived four thematic areas: (1) partner(ship) disappears behind the disease; (2) partners struggle with changing tasks and roles; (3) caring partners mourn the loss of intimacy; and (4) partners strive to rebalance the partnership. Discussion: When chronic illness and care dependency enter couples' lives, the self-image as husband or wife is affected. Primary health care professionals should be sensitive to the specific constellation of care in couple relationships and recognize the significance of this dyadic relationship as living in a satisfying couple relationship is essential for the health and wellbeing of both partners.

Qualificação interprofissional da atenção pré-natal no contexto da atenção primária à saúde / Interprofessional qualification of prenatal care in the context of primary health care

Resumo O objetivo deste artigo é descrever e analisar intervenção educativa interprofissional para a qualificação da atenção pré-natal no contexto da atenção primária à saúde. Trata-se de uma pesquisa-ação cujo processo de intervenção teve como cenário a qualificação pré-natal, a partir de um curso sistematizado em atividades síncronas e assíncronas, com a participação de 65 profissionais que atuam em Unidades Básicas de Saúde. Da análise temática do tipo reflexive, que possibilitou o registro de ideias, insights e a significação da intervenção, resultaram três categorias: qualidade da atenção pré-natal - concepções e significados; aprendizagem colaborativa - estratégia para transcender a atenção linear e pontual; necessidade de evoluir do agir local ao pensar global. A análise da intervenção educativa interprofissional para a qualificação da atenção pré-natal no contexto da atenção primária à saúde demonstrou que percursos construtivistas, participativos e interprofissionais são relevantes e pertinentes para ampliar percepções teóricas e ressignificar o processo de trabalho nos diversos pontos da rede de saúde.

Abstract This study aims to describe and analyze an interprofessional educational intervention for the qualification of prenatal care in the context of primary health care. Method: action-research comprising a prenatal care qualification course with 65 primary health care professionals. Collaborative learning activities were conducted in synchronous and asynchronous meetings. Results: the reflexive thematic analysis of participants' experiences, views and perceptions on the meanings of the intervention revealed three categories: quality of prenatal care: conceptions and meanings; collaborative learning: strategy to overcome linear and isolated care; the need to evolve from acting locally to thinking globally. Conclusion: the analysis of the interprofessional educational intervention for the qualification of prenatal care in the context of primary health care showed that constructivist, participatory and interprofessional approaches are relevant and pertinent to broaden theoretical perceptions and give new meanings to the work process at different settings of the health network.

[Oral health in nursing homes as an interprofessional task : Results of qualitative interviews with nurses and dentists on their current and future collaboration]. / Mundgesundheit im Pflegeheim als interprofessionelle Aufgabe : Ergebnisse einer qualitativen Befragung von Pflegefachpersonen und Zahnärzt*innen zu ihrer aktuellen und zukünftigen Zusammenarbeit.

BACKGROUND: People with long-term care needs have significantly poorer oral health than their peers without care needs. Internationally, this is increasingly being addressed through interprofessional collaboration and expanded roles of nurses. This article investigates the perspectives of dentists and nurses in Germany on the current status and future of their collaboration in nursing homes. METHODS: A total of eight expert interviews were conducted with four practising dentists and nurses from the Westphalia-Lippe region via Zoom or by telephone. The fully transcribed interview material was analyzed by thematic coding on a case-specific and cross-case basis. RESULTS: From the perspective of the interviewees, collaboration of dentists and nurses is indispensable for promoting the oral health of nursing home residents. They describe a lack of time and competence in the oral and dental care of home residents, which should be countered with new roles of responsibility for specially qualified nurses in cooperation with dentists. At the same time, they advocate a stronger anchoring and embedding of (dental) medical care in the routines of nursing homes. CONCLUSION: New forms of cooperation between dentists and nurses in nursing homes should be piloted and further developed in Germany.

"Talking on the Phone Is Very Cold"-Primary Health Care Nurses' Approach to Enabling Patient Participation in the Context of Chronic Diseases during the COVID-19 Pandemic.

Strengthening patient participation is considered a crucial element of primary health care (PHC) nurses' practice when working with chronically ill patients. The COVID-19 pandemic had extraordinary effects on PHC nursing routines and how chronically ill patients' could be involved in their own care. This study investigates the adaptation of Spanish PHC nurses' approaches to supporting the participation of patients living with chronic illness during the COVID-19 pandemic. To reach this goal, we interviewed 13 PHC nurses who practiced in PHC centers in Spain. The interviews were analyzed using thematic coding. Three themes emerged from the descriptions of the nurses: (1) High COVID-19-related workload, decreasing health promotion, and chronic care, (2) Emphasis on patients' and families' self-responsibility, (3) Expanded digital and telephone communication with fewer in-person consultations. Nurses felt especially challenged to uphold the support for vulnerable groups, such as older people or patients without family support. Future research should focus on how the participation of the most vulnerable chronic patients can be supported in the context of the growing relevance of remote care.

How do nurses support chronically ill clients' participation and self-management in primary care? A cross-country qualitative study.

BACKGROUND: In the context of the advancement of person-centered care models, the promotion of the participation of patients with chronic illness and complex care needs in the management of their care (self-management) is increasingly seen as a responsibility of primary care nurses. It is emphasized that nurses should consider the psychosocial dimensions of chronic illness and the client's lifeworld. Little is known about how nurses shape this task in practice. METHODS: The aim of this analysis is to examine how primary care nurses understand and shape the participation of patients with chronic illness and complex care needs regarding the promotion of self-management. Guided interviews were conducted with nurses practicing in primary care and key informants in Germany, Spain, and Brazil with a subsequent cross-case evaluation. Interpretive and practice patterns were identified based on Grounded Theory. RESULTS: Two interpretive and practice patterns were identified: (1) Giving clients orientation in dealing with chronic diseases and (2) supporting the integration of illness in clients' everyday lives. Nurses in the first pattern consider it their most important task to provide guidance toward health-promoting behavior and disease-related decision-making by giving patients comprehensive information. Interview partners emphasize client autonomy, but rarely consider the limitations chronic disease imposes on patients' everyday lives. Alternatively, nurses in the second pattern regard clients as cooperation partners. They seek to familiarize themselves with their clients' social environments and habits to give recommendations for dealing with the disease that are as close to the client's lifeworld as possible. Nurses' recommendations seek to enable patients and their families to lead a largely 'normal life' despite chronic illness. While interview partners in Brazil or Spain point predominantly to clients' socio-economic disadvantages as a challenge to promoting client participation in primary health care, interview partners in Germany maintain that clients' high disease burden represents the chief barrier to self-management. CONCLUSIONS: Nurses in practice should be sensitive to client's lifeworlds, as well as to challenges that arise as they attempt to strengthen clients' participation in care and self-management. Regular communication between clients, nurses, and further professionals should constitute a fundamental feature of person-centered primary care models.

Primary healthcare nurses' involvement in patient and community participation in the context of chronic diseases: An integrative review.

BACKGROUND: Primary healthcare nurses' potential to enable patient and community participation has been increasingly acknowledged. A conceptual understanding of their contributions within a broad range of participation processes is still lacking. AIMS: The aims of this study were to develop a conceptual framework that provides information on the role of primary healthcare nurses in shaping participation processes with patients and communities in the context of chronic diseases and to identify conditions that enable or hinder the promotion of patient and community participation by nurses. DESIGN: An integrative review was conducted. DATA SOURCES: Twenty-three articles published from 2000 to 2019 were included in the analysis: 19 retrieved from PubMed and CHINAL and 4 added through other sources. REVIEW METHODS: An inductive data analysis and quality appraisal of studies were conducted. RESULTS: The analysis reveals four areas where nurses are involved in facilitating patient and community participation: (1) sharing understanding of health problems and needs, (2) developing resources and facilitating patient education for self-management, (3) raising patients' voices as an advocate in service development and (4) supporting individual and community networks. The conditions affecting nurses' engagement in fostering participation processes are as follows: (1) care priorities and overall workload, (2) nurses' attitudes towards participation and (3) users' acceptance of nurses as partners. CONCLUSIONS: Future research can use the framework as a basis for empirical studies investigating nurses' involvement in pursuing patient and community participation. Interventions should focus less on indirect forms of participation, like patient education or advocacy, but should also focus on active forms of participation. Research is needed on nurses' involvement in community participation processes. IMPACT: This framework can be used and adapted in future research on patient and community participation in primary healthcare. It describes areas of participation and the facilitators and barriers within the broad range of activities of primary healthcare nurses.

The architecture of the primary mental healthcare system for older people in India: what public policies tell us.

BACKGROUND: Old age mental healthcare is an issue that cuts across old age, general health, and mental healthcare policies. While strengthening the primary mental healthcare system in India is a common strategy across policy fields to improve the mental health of older persons, very little is known about the system's planned architecture. This study explores public policy strategies for and approaches to the mental health of older persons, focusing on the primary healthcare (PHC) level and the role of the family. METHODS: A document analysis of 39 key public national policy documents (2007 - 2019) from three thematically grouped policy fields (mental health, old age, and general health) was conducted. RESULTS: Comprehensive community-based primary mental healthcare - focusing on vulnerable population groups including older persons - has been strengthened significantly since 2007. The promulgated approaches and strategies build on traditional community-based approaches to mental healthcare in India. They focus on (a) integrating community health workers into primary mental healthcare, (b) empowering the community to participate in healthcare planning, implementation, and monitoring, (c) supporting the family through a family-led approach to mental healthcare, and (d) integrating traditional Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-Rigpa and Homeopathy (AYUSH) services into primary mental healthcare. CONCLUSIONS: While all policy fields address mental PHC, they do so in different ways, and approaches and strategies that promote an integrated perspective across policy fields are lacking. To realize the policies vision, strengthening PHC will be essential. Further research should evaluate strategies and approaches in light of social developments, such as eroding family norms and the poor state of the public health system in India, in order to assess their opportunities, challenges, and overall feasibility, with the benefits older people would experience taking centre stage in these inquiries.

Primary mental health care for older persons in India: how age-inclusive are public policies?

The need to improve the primary mental healthcare system in India has gained increasing public health attention. Concomitantly, efforts to frame and develop appropriate public mental health care through legislation and related strategies and programmes have been undertaken. Because older people in India are particularly prone to mental health problems, this study explores the inclusiveness of Indian public policies in addressing the primary mental health care needs of older people from a cross-policy perspective. The basis of this thematic document analysis is 41 key national strategic documents (1999-2018) from different thematically grouped policy fields. In the context of population ageing, socio-economic challenges for older people and changing family norms, the policies delineate a pronounced interest in old-age-inclusive primary mental health care, whereas international policies are regarded as important reference points. While some of the policies address older persons as a vulnerable group in general, others delineate a more differentiated picture of the older population. Moreover, as new rights with implications for old-age mental health care, including community-based access to mental health care, have emerged, an integrated old-age mental healthcare policy spanning across sectors remains absent. Although old-age-inclusive primary mental health care is an emerging trend in India, its development as a cross-cutting policy issue remains in its infancy. Accordingly, unambiguous integrated policy approaches are needed to address the complex mental healthcare needs of older persons, and further research should be undertaken to focus on mental healthcare strategies and approaches at the primary care level.

Implementación de la Estrategia Madre-Hijo São-Borjense: investigación-acción / Implementação da Estratégia Mãe-Bebê São-Borjense: pesquisa-ação / Implementation of the São-Borjense Mother-Baby Strategy: Action research

Objective: To describe the process of conception and implementation of the São-Borjense Mother- Baby Strategy. Materials and method: This is an action research study developed between March 2018 and October 2019, from a simple random sampling resulting in the participation of 5 managers, 27 health professionals, and 23 pregnant women from the maternal and child health care network in the municipality of São Borja, Rio Grande do Sul, Brazil. The participants of the focus groups guided the identification and survey of data; thematic content analysis was used to categorize data. Results: Based on a systematic and collaborative plan of intervention the following path was defined: i) conception of the Strategy and agreements with local managers; ii) sensitization of the actors and identification of demands, through focus groups with managers, professionals and health care users; and iii) implementation of actions of the São-Borjense Mother-Baby Strategy. Conclusions: Based on the course taken from the conception to the implementation of the Strategy, we conclude that leading innovative processes and transposing traditional models of intervention is possible through interaction, sharing and translation of knowledge and practices among academy, agents, managers, professionals and health care users.

Objetivo: describir el proceso de concepción e implementación de la Estrategia Madre-Hijo São-Borjense. Materiales y método: estudio de investigación-acción, desarrollado entre marzo de 2018 y octubre de 2019, a partir de un muestreo aleatorio simple que contó con la participación de 5 gestores, 27 profesionales de la salud y 23 mujeres embarazadas de la red de atención de salud materno infantil en el municipio de São Borja, Rio Grande do Sul, Brasil. La técnica de grupo focal fue empleada para la identificación y recolección de datos, mientras que el análisis de contenido temático permitió la categorización de estos. Resultados: a partir de un plan sistematizado y colaborativo de intervenciones, fue posible definir la siguiente ruta de trabajo: i) concepción de la Estrategia y acuerdos con gestores locales; ii) sensibilización de los actores e identificación de demandas a través de grupos focales con gestores, profesionales y usuarios de la salud; iii) implementación de acciones de la Estrategia Madre-Hijo São-Borjense. Conclusiones: con base en la ruta tomada desde la concepción hasta la implementación de la Estrategia, concluimos que liderar procesos innovadores y transponer modelos tradicionales de intervención es posible a través de la interacción, el intercambio y la traducción de conocimientos y prácticas entre agentes, academia, gestores, profesionales y usuarios de la salud.

Objetivo: descrever o processo de concepção e implementação da Estratégia Mãe-Bebê São-Borjense. Materiais e método: trata-se de uma pesquisa-ação, desenvolvida entre março de 2018 e outubro de 2019, a partir de uma amostragem aleatória simples que contou com a participação de 5 gestores, 27 profissionais da saúde e 23 gestantes da rede de atenção à saúde materno-infantil do município de São Borja, Rio Grande do Sul, Brasil. O grupo focal guiou a identificação e o levantamento dos dados, e a análise de conteúdo temática permitiu a categorização dos dados. Resultados: a partir de um plano sistematizado e colaborativo de intervenções, foi possível o seguinte percurso: i) concepção da Estratégia e acordos com gestores locais; ii) sensibilização dos atores e identificação de demandas, por meio de grupos focais com gestores, profissionais e usuários da saúde; iii) implementação de ações da Estratégia Mãe-Bebê São-Borjense. Conclusões: com base no percurso transcorrido da concepção à implementação da Estratégia, conclui-se que protagonizar processos inovadores e transpor modelos tradicionais de intervenção é possível pela interação, pelo compartilhamento e pela tradução de conhecimentos e práticas entre agentes, academia, gestores, profissionais e usuários da saúde.

[From nursing home to community-oriented center for health and long-term care : Continuity of care as reflected in an expanded range of services]. / Vom Heim zum Zentrum für Pflege und Gesundheit im Quartier : Versorgungskontinuität im Spiegel eines erweiterten Angebotsspektrums.

BACKGROUND: Opening nursing homes for and in the community not only promotes the inclusion of the residents. Likewise, older people living close to the homes could benefit if the nursing homes offer support for them as well. This article focuses on the extent to which "nursing homes" succeed in contributing to the continuity of care for older people in the community by developing into "centers". METHODS: Episodic interviews with users/relatives and expert interviews were conducted as part of the evaluation of the project "Long-term care institutions - further thinking!". A secondary analysis of interviews was conducted by means of structuring content analysis; the views of users and experts were triangulated on a metalevel. RESULTS: Users and relatives refer to three types of continuity of care in the facilities-management, relational and informational. In this respect, sustainable relationships with professionals in the facilities are just as important to them as "custom fitted" care offers even in the case of intensified need for support. Some family caregivers desire a more reliable flow of information between them and the professionals. It is also important for the experts interviewed that the facilities cover the entire spectrum of continuity of care; however, they underestimate the need of relatives in particular to be involved in care as informal carers. CONCLUSION: Nursing homes can contribute to strengthening continuity of care in the community by expanding their range of services. They should take the diversity of different user groups into account.

Co-production in coping with care dependency in Germany: How can integrated local care centres contribute?

In Germany, most care dependent people are looked after by family members at home. Professional support can help ease the burden of caring relatives and stabilise home care. Ideally, care then is provided through the co-production of formal and informal caregivers. This article analyses how care dependent people and their family caregivers integrate professional support into their care arrangements. An analysis was conducted using data collected for a qualitative study evaluating integrated local care centres in North-Rhine-Westphalia, Germany. The study is based on episodic interviews with users of these care centres and their family caregivers (N = 26). During the analysis, three interpretive and practice patterns relating to co-production of care were identified. These patterns reveal how the interviewees deal with (increasing) needs for assistance and care while incorporating professional care into their lives. The patterns help differentiate whether the interviewees (a) use developed care skills to contribute actively to the co-production with their layman knowledge, or (b) seek relief of their care responsibilities and withdraw temporarily from the direct sphere of care applying freed capacities to organise family daily life, or (c) use the services of the care centres to meet with other older people and to develop spaces for mutual help and co-production. The interpretive and practice patterns thus differ in the extent to which care users and family caregivers continue to play an 'active role' in the care process and contribute their own knowledge, ideas, expectations and particular care activities. In order to achieve a functioning co-production, professionals face the challenge of understanding these patterns that have been established over many years and of taking them into account appropriately.

Between Social Inclusion and Exclusion: Integration of Daycare Guests in the Nursing Home Setting.

BACKGROUND AND OBJECTIVES: In integrated daycare, community-dwelling older people in need of care join existing groups in residential care facilities during the day. This study focuses on how nursing home residents experience the integrative care approach, exploring opportunities for social inclusion and mechanisms of exclusion. RESEARCH DESIGN AND METHODS: A purposive sample of residents differing in cognitive capacity and level of (non)conflictual interaction with daycare guests was selected. Episodic interviews with residents (N = 10) and close relatives (N = 2) were conducted in 3 pilot facilities in Germany and analyzed using thematic coding. RESULTS: The analysis revealed different orientation patterns towards the presence of daycare guests: respondents (a) demonstrated indifference to the daycare guests, (b) saw bonding with guests as a means to connect to the outside world, and (c) perceived incompatibility between in-group and out-group. Criticisms included disruption of daily routines and loss of privacy. Most interviewees came to terms with the care situation using rational and moral arguments. DISCUSSION AND IMPLICATIONS: The study reveals the importance of residents' participation when integrating daycare guests. Institutional procedures are required to prevent exclusion of daycare guests and avoid overtaxing residents.

Community participation and empowerment in primary health care in Emilia-Romagna: A document analysis study.

Community participation and empowerment are seen as fundamental for achieving equitable, people-centred primary health care. Emilia-Romagna region introduced the Casa della Salute aiming to foster comprehensive primary health care and support community participation. Since the 1990s, community involvement has been promoted to improve the regional health system. The pivotal role of third sector organisations as service providers and advocates for users' rights has been underlined. This contribution explores the evolution of the meaning and conceptualisation of community participation and empowerment in policies addressing the Casa della Salute. A qualitative document analysis study was undertaken. Three national and twelve regional documents dated between 2006 and 2019 were evaluated. The policies continuously address community participation. The Casa della Salute is seen as a designated place to promote participation and empowerment. The documents point to the need for democratic practice and shared decision-making power; third sector organisations are seen as salient community representatives and mediators. However, the policies show only a vague conceptualisation of how to empower communities; moreover, strategies to promote participation of vulnerable groups are lacking. Policies that consider the ambiguous role of the third sector, specify community empowerment, identify strategies to facilitate it and collaborate with vulnerable groups could be beneficial for further progress.

Advanced Practice Nursing in Primary Health Care in the Spanish National Health System / Enfermagem Prática Avançada em atenção primária no Sistema Nacional de Saúde espanhol

Abstract The primary health care in the Spanish National Health System is organised in health centres with multi-professional teams, composed of doctors and nurses specialised in family and community health, in addition to other professionals. This article analyses the role of primary health care nurses in the Spanish National Health System. In the last decade, new concepts of task sharing between doctors and nurses as well as advanced nursing roles have been evolved in the health centres that focus on improving care for chronically ill patients and access to primary care. With shared responsibility, nurses are responsible for chronic patients in stable conditions, health prevention and promotion. The scaling up of advanced nursing tasks is limited by uncertainties of roles, disparities between states, and legislations that do not cover the full extent of advanced nursing tasks. The case study of Spain indicates that a strong multi-professional model of primary health care teams is a crucial basis for the evolvement of advanced nursing practice and its acceptance in daily routines. However, advantageous education structures and legislations are needed to allow nurses to develop their contribution in the full potential.

Resumo A atenção primária no Sistema Nacional de Saúde espanhol é prestada em centros de saúde públicos, com equipe composta de médicos e enfermeiros especialistas em família e comunidade, além de outros profissionais. Neste artigo, se analisa a atuação do enfermeiro na atenção primária no Serviço Nacional de Saúde espanhol. Na última década, buscando efetividade no manejo de condições crônicas e melhor acesso à atenção, novos modelos de ações compartilhadas entre médicos e enfermeiros, bem como práticas avançadas de enfermagem foram desenvolvidas. Atualmente, com responsabilidades compartilhadas, enfermeiros são responsáveis por pacientes com condições crônicas estáveis, além de ações de prevenção e promoção. Não obstante, a prática avançada em enfermagem é limitada por indefinição de funções, disparidade de atuação entre Estados e legislação insuficiente, que não abarca o potencial desta prática. O caso da Espanha indica que um modelo de atenção multiprofissional forte na atenção primária é crucial para o desenvolvimento da enfermagem de prática avançada. Entretanto, promover formação e legislação adequada à essa prática é necessário, para que os enfermeiros contribuam com todo o seu potencial na atenção primária à saúde.