Risk factors for COVID-19 mortality in hospitalized patients in Bolivia.

Objectives: This study aimed to ascertain which factors are associated with higher risk of mortality among hospitalized COVID-19 Bolivian patients. Methods: This retrospective observational study assessed risk factors associated with mortality in patients (n = 549) hospitalized for SARS-CoV-2 infection in a Bolivian hospital between April 6, 2020, and August 18, 2022. Results: The results provide evidence of association between male sex (odds ratio [OR] = 1.6, 95% confidence interval [CI] 1.06-2.6), older age, 51-61 years-old (OR = 5.2, 95% CI 2.2-12.6), 62-70 years-old (OR = 8.7, 95% CI 3.7-20.5), >70 years-old (OR = 16.9, 95% CI 7.1-39.9), and blood group A (OR = 1.9, 95% CI: 1.1-3.4) with higher mortality risk. The strong association between mortality and relatively young age, may be due to high frequency of undiagnosed comorbidities. Vaccination was associated with a reduction in mortality only when time period of hospitalization was not adjusted for. Conclusion: Among hospitalized patients in Bolivia male sex, older age, and blood group A are associated with higher mortality risk. Mortality risk increased markedly from a relatively young age and decreased in parallel to the uptake of the vaccination program. However, the gradual reduction in mortality can also be due to improved patient management and changes in natural immunity and virulence of circulating strains as the pandemic progressed.

From disease- to people-centred pandemic management: organized communities, community-oriented primary care and health information systems.

BACKGROUND: The COVID-19 pandemic exposed the health equity gap between and within countries. Western countries were the first to receive vaccines and mortality was higher among socially deprived, minority and indigenous populations. Surprisingly, many sub-Saharan countries reported low excess mortalities. These countries share experiences with community organization and participation in health. The aim of this article was to analyse if and how this central role of people can promote a successful pandemic response. METHODS: This analysis was partly based on local and national experiences shared during an international and Latin American conference on person-and people-centred care in 2021. Additionally, excess mortality data and pandemic control-relevant data, as well as literature on the pandemic response of countries with an unexpected low excess mortality were consulted. RESULTS: Togo, Mongolia, Thailand and Kenya had a seven times lower mean excess mortality for 2020 and 2021 than the United States of America. More successful pandemic responses were observed in settings with experience in managing epidemics like Ebola and HIV, well-established community networks, a national philosophy of mutual aid, financial government assistance, more human resources for primary care and paid community health workers. DISCUSSION: Since trust in authorities and health needs vary greatly, local strategies are needed to complement national and international pandemic responses. Three key levers were identified to promote locally-tailored pandemic management: well-organized communities, community-oriented primary care, and health information systems. An organized community structure stems from a shared ethical understanding of humanity as being interconnected with each other and the environment. This structure facilitates mutual aid and participation in decision making. Community-oriented primary care includes attention for collective community health and ways to improve health from its roots. A health information system supports collective health and health equity analysis by presenting health needs stratified for social deprivation, ethnicity, and community circumstances. CONCLUSIONS: The difference in excess mortality between countries during the COVID-19 pandemic and various country experiences demonstrate the potential of the levers in promoting a more just and effective health emergency response. These same levers and strategies can promote more inclusive and socially just health systems.

RESUMEN: ANTECEDENTES: La pandemia de COVID-19 expuso la brecha de equidad en salud dentro y entre países. Los países occidentales fueron los primeros en recibir vacunas y la mortalidad fue mayor entre las poblaciones indígenas, minoritarias y socialmente desfavorecidas dentro de los países. Sorprendentemente, muchos países subsaharianos reportaron un exceso de mortalidad bajo. Estos países comparten experiencias de organización y participación comunitaria en salud. El objetivo es analizar si y cómo este papel central de las personas puede promover una respuesta exitosa a la pandemia. MéTODOS: Este análisis se basa en parte en las experiencias locales y nacionales compartidas durante una conferencia internacional y latinoamericana sobre la atención centrada en las personas y comunidades en 2021. Además, se consultó los datos de exceso de mortalidad y los datos relevantes para el control de la pandemia, así como la literatura sobre la respuesta a la pandemia de países con un exceso de mortalidad inesperadamente bajo. RESULTADOS: Togo, Mongolia, Tailandia y Kenia tuvieron un exceso de mortalidad promedio por 2020 y 2021 siete veces menor que los Estados Unidos de América. Se observaron respuestas pandémicas más exitosas en entornos con experiencia en el manejo de epidemias como el ébola y el VIH, redes comunitarias bien establecidas, una filosofía nacional de ayuda mutua, asistencia financiera del gobierno, más recursos humanos para atención primaria y trabajadores de salud comunitarios remunerados. DISCUSIóN: Dado que la confianza en autoridades y las necesidades en salud varían mucho, se necesitan estrategias locales para complementar las respuestas nacionales e internacionales a la pandemia. Se identificaron tres palancas clave para promover la gestión de pandemias adaptada localmente: comunidades bien organizadas, atención primaria orientada a la comunidad y sistemas de información de salud. Una estructura comunitaria organizada surge de una comprensión ética compartida que concibe a la humanidad interconectada entre sí y con el medio ambiente. Esta estructura facilita la ayuda mutua y la participación en la toma de decisiones. La atención primaria orientada a la comunidad incluye la atención a la salud comunitaria colectiva y las formas de mejorar la salud desde sus raíces. Un sistema de información de salud puede apoyar el análisis de la salud colectiva y la equidad en salud al presentar las necesidades de salud estratificadas por privación social, etnicidad y circunstancias de la comunidad. CONCLUSIONES: La diferencia en el exceso de mortalidad entre países durante la pandemia de COVID-19 y las experiencias de varios países, demuestran el potencial de las palancas para promover una respuesta de emergencia sanitaria más justa y eficaz. Estas mismas palancas y estrategias pueden promover sistemas de salud más inclusivos y socialmente justos.

Integrated person- and people-centred primary care for diabetes in low- and middle-income countries: The nurses' perspective on patient needs.

AIMS: The aim of this study was to identify what nurses working in primary care settings perceive as necessary to support the life needs of people with type 2 diabetes. Articulate these needs with the needs expressed by people with diabetes in a previous study. Finally, illustrate the potential of the used method. DESIGN: A highly structured qualitative group method for brainstorming and idea sharing was used to generate a participant-owned concept map that can support and evaluate practice change. METHODS: Data were collected between April and May 2022 in two public primary healthcare centres in Sacaba, Bolivia, with 33 professional nurses, technical nurses, nurse trainees and one physician. The concept mapping process by Trochim was used to generate, share and structure ideas, maximizing equality of input. RESULTS: The nurses identified 73 unique needs that were structured in 11 conceptual clusters related to four different stakeholders or domains: organization of care and health policy, strengthening knowledge, skills and attitudes of healthcare providers, empower people living with diabetes and their family, and community-level health promotion and diabetes education. CONCLUSION: The needs and domains identified by nurses and people with type 2 diabetes are very similar and inform a multisectoral and transdisciplinary action plan to jointly monitor and evaluate progress towards people-centred care for people with diabetes. IMPACT: This study demonstrates nurses' important contribution to analysing and designing people-centred care in their community. They identify and act upon social determinants of health related to schools, safety and legislation. Besides global relevance, results inform the municipal health plan and an ongoing research project on cardiometabolic health. PATIENT OR PUBLIC CONTRIBUTION: Data from prior patient consultations were included in the study design, and study results inform the municipal health plan.

[Pillars and lines of action for integrated and people- and community-centered health systemsPilares e linhas de ação para sistemas integrados de saúde centrados nas pessoas e nas comunidades]. / Pilares y líneas de acción para los sistemas de salud integrados y centrados en las personas y las comunidades.

This paper presents the position of the Latin American working group of the International Foundation for Integrated Care (IFIC). The working group brings together various Latin American actors and organizations in support of actions that facilitate the transformation of health systems in the region towards integrated systems that focus on people not as isolated individuals but as subjects of law in the complex social and environmental contexts where they live and interact. The working group proposes nine pillars of integrated care to be used as a conceptual framework for policy development and changes in practices: 1) shared vision and values; 2) population health; 3) people and communities as partners; 4) resilient communities; 5) capacities of human resources for health; 6) governance and leadership; 7) digital solutions; 8) aligned payment systems; and 9) public transparency. Based on these pillars, lines of work are proposed to strengthen alliances and networks, advocacy, research, and capacity-building, in order to help develop health and social systems that are effectively integrated and focused not only on people but also on communities in Latin America.

Este artigo apresenta o posicionamento do grupo de trabalho latino-americano da Fundação Internacional de Cuidados Integrados (1) (IFIC, na sigla em inglês). A IFIC reúne diversos atores e organizações da América Latina com o fim de apoiar ações que facilitem a transformação dos sistemas de saúde na região para sistemas integrados e centrados nas pessoas, não como indivíduos isolados, mas como sujeitos de direito, nos complexos contextos sociais e ambientais em que vivem e participam. O grupo de trabalho propõe nove pilares de atenção integrada a serem utilizados como marco conceitual na elaboração de políticas e de mudanças nas práticas: 1) visão e valores compartilhados, 2) saúde das populações, 3) pessoas e comunidades como parceiros, 4) comunidades resilientes, 5) capacitação de talento humano em saúde, 6) governança e liderança, 7) soluções digitais, 8) sistemas de pagamento alinhados e 9) transparência perante a população. Com base nesses pilares, são propostas linhas de trabalho nas áreas de fortalecimento de alianças e redes, incidência política, pesquisa e capacitação, que contribuam para materializar na América Latina sistemas sociais e de saúde efetivamente integrados e centrados não só nas pessoas, como também nas comunidades.

Pilares y líneas de acción para los sistemas de salud integrados y centrados en las personas y las comunidades

[RESUMEN]. Se presenta el posicionamiento del grupo de trabajo latinoamericano de la Fundación Internacional para los Cuidados Integrados (1) (IFIC, por su sigla en inglés). Este reúne a diversos actores y organizaciones de América Latina, con el objeto de apoyar acciones que faciliten la transformación de los sistemas de salud en la Región hacia sistemas integrados y centrados en las personas, no como individuos aislados, sino como sujetos de derecho, en los contextos sociales y ambientales complejos donde viven y se vinculan. El grupo de trabajo plantea nueve pilares de la atención integrada para ser utilizados como marco conceptual en la elaboración de políticas y de cambios en las prácticas: 1) visión y valores compartidos, 2) salud de las poblaciones, 3) las personas y las comunidades como socias, 4) comunidades resilientes, 5) capacidades del talento humano en salud, 6) gobernanza y liderazgo, 7) soluciones digitales, 8) sistemas de pago alineados, y 9) transparencia ante la ciudadanía. Desde estos pilares se proponen líneas de trabajo en los ámbitos del fortalecimiento de alianzas y redes, la abogacía, la investigación y generación de capacidades, que contribuyan a materializar sistemas de salud y sociales efectivamente integrados y centrados no solo en las personas, sino también en las comunidades en América Latina.

[ABSTRACT]. This paper presents the position of the Latin American working group of the International Foundation for Integrated Care (IFIC). The working group brings together various Latin American actors and organizations in support of actions that facilitate the transformation of health systems in the region towards integrated systems that focus on people not as isolated individuals but as subjects of law in the complex social and environmental contexts where they live and interact. The working group proposes nine pillars of integrated care to be used as a conceptual framework for policy development and changes in practices: 1) shared vision and values; 2) population health; 3) people and communities as partners; 4) resilient communities; 5) capacities of human resources for health; 6) governance and leadership; 7) digital solutions; 8) aligned payment systems; and 9) public transparency. Based on these pillars, lines of work are proposed to strengthen alliances and networks, advocacy, research, and capacity-building, in order to help develop health and social systems that are effectively integrated and focused not only on people but also on communities in Latin America.

[RESUMO]. Este artigo apresenta o posicionamento do grupo de trabalho latino-americano da Fundação Internacional de Cuidados Integrados (1) (IFIC, na sigla em inglês). A IFIC reúne diversos atores e organizações da América Latina com o fim de apoiar ações que facilitem a transformação dos sistemas de saúde na região para sistemas integrados e centrados nas pessoas, não como indivíduos isolados, mas como sujeitos de direito, nos complexos contextos sociais e ambientais em que vivem e participam. O grupo de trabalho propõe nove pilares de atenção integrada a serem utilizados como marco conceitual na elaboração de políticas e de mudanças nas práticas: 1) visão e valores compartilhados, 2) saúde das populações, 3) pessoas e comunidades como parceiros, 4) comunidades resilientes, 5) capacitação de talento humano em saúde, 6) governança e liderança, 7) soluções digitais, 8) sistemas de pagamento alinhados e 9) transparência perante a população. Com base nesses pilares, são propostas linhas de trabalho nas áreas de fortalecimento de alianças e redes, incidência política, pesquisa e capacitação, que contribuam para materializar na América Latina sistemas sociais e de saúde efetivamente integrados e centrados não só nas pessoas, como também nas comunidades.

Pilares y líneas de acción para los sistemas de salud integrados y centrados en las personas y las comunidades / Pillars and lines of action for integrated and people- and community-centered health systems / Pilares e linhas de ação para sistemas integrados de saúde centrados nas pessoas e nas comunidades

RESUMEN Se presenta el posicionamiento del grupo de trabajo latinoamericano de la Fundación Internacional para los Cuidados Integrados (1) (IFIC, por su sigla en inglés). Este reúne a diversos actores y organizaciones de América Latina, con el objeto de apoyar acciones que faciliten la transformación de los sistemas de salud en la Región hacia sistemas integrados y centrados en las personas, no como individuos aislados, sino como sujetos de derecho, en los contextos sociales y ambientales complejos donde viven y se vinculan. El grupo de trabajo plantea nueve pilares de la atención integrada para ser utilizados como marco conceptual en la elaboración de políticas y de cambios en las prácticas: 1) visión y valores compartidos, 2) salud de las poblaciones, 3) las personas y las comunidades como socias, 4) comunidades resilientes, 5) capacidades del talento humano en salud, 6) gobernanza y liderazgo, 7) soluciones digitales, 8) sistemas de pago alineados, y 9) transparencia ante la ciudadanía. Desde estos pilares se proponen líneas de trabajo en los ámbitos del fortalecimiento de alianzas y redes, la abogacía, la investigación y generación de capacidades, que contribuyan a materializar sistemas de salud y sociales efectivamente integrados y centrados no solo en las personas, sino también en las comunidades en América Latina.

ABSTRACT This paper presents the position of the Latin American working group of the International Foundation for Integrated Care (IFIC). The working group brings together various Latin American actors and organizations in support of actions that facilitate the transformation of health systems in the region towards integrated systems that focus on people not as isolated individuals but as subjects of law in the complex social and environmental contexts where they live and interact. The working group proposes nine pillars of integrated care to be used as a conceptual framework for policy development and changes in practices: 1) shared vision and values; 2) population health; 3) people and communities as partners; 4) resilient communities; 5) capacities of human resources for health; 6) governance and leadership; 7) digital solutions; 8) aligned payment systems; and 9) public transparency. Based on these pillars, lines of work are proposed to strengthen alliances and networks, advocacy, research, and capacity-building, in order to help develop health and social systems that are effectively integrated and focused not only on people but also on communities in Latin America.

RESUMO Este artigo apresenta o posicionamento do grupo de trabalho latino-americano da Fundação Internacional de Cuidados Integrados (1) (IFIC, na sigla em inglês). A IFIC reúne diversos atores e organizações da América Latina com o fim de apoiar ações que facilitem a transformação dos sistemas de saúde na região para sistemas integrados e centrados nas pessoas, não como indivíduos isolados, mas como sujeitos de direito, nos complexos contextos sociais e ambientais em que vivem e participam. O grupo de trabalho propõe nove pilares de atenção integrada a serem utilizados como marco conceitual na elaboração de políticas e de mudanças nas práticas: 1) visão e valores compartilhados, 2) saúde das populações, 3) pessoas e comunidades como parceiros, 4) comunidades resilientes, 5) capacitação de talento humano em saúde, 6) governança e liderança, 7) soluções digitais, 8) sistemas de pagamento alinhados e 9) transparência perante a população. Com base nesses pilares, são propostas linhas de trabalho nas áreas de fortalecimento de alianças e redes, incidência política, pesquisa e capacitação, que contribuam para materializar na América Latina sistemas sociais e de saúde efetivamente integrados e centrados não só nas pessoas, como também nas comunidades.

Needs and resources of people with type 2 diabetes in peri-urban Cochabamba, Bolivia: a people-centred perspective.

BACKGROUND: The rising prevalence of type 2 diabetes results in a worldwide public healthcare crisis, especially in low- and middle-income countries (LMICs) with unprepared and overburdened health systems mainly focused on infectious diseases and maternal and child health. Studies regarding type 2 diabetes in LMICs describe specific interventions ignoring a comprehensive analysis of the local factors people see influential to their health. This study aims to meet this research gap by exploring what people with type 2 diabetes in Bolivia need to maintain or improve their health, how important they perceive those identified needs and to what extent these needs are met. METHODS: From March until May 2019, 33 persons with type 2 diabetes from three periurban municipalities of the department of Cochabamba participated in this study. The concept mapping methodology by Trochim, a highly structured qualitative brainstorming method, was used to generate and structure a broad range of perspectives on what the participants considered instrumental for their health. RESULTS: The brainstorming resulted in 156 original statements condensed into 72 conceptually different needs and resources, structured under nine conceptual clusters and four action domains. These domains illustrated with vital needs were: (1) self-management with use of plants and the possibility to measure sugar levels periodically; (2) healthcare providers with the need to trust and receive a uniform diagnosis and treatment plan; (3) health system with opportune access to care and (4) community with community participation in health and safety, including removal of stray dogs. CONCLUSIONS: This study identifies mostly contextual factors like low literacy levels, linguistic problems in care, the need to articulate people's worldview including traditional use of natural remedies with the Bolivian health system and the lack of expertise on type 2 diabetes by primary health care providers. Understanding the needs and structuring them in different areas wherein action is required serves as a foundation for the planning and evaluation of an integrated people centred care program for people with type 2 diabetes. This participative method serves as a tool to implement the often theoretical concept of integrated people centred health care in health policy and program development.

RESUMEN: ANTECEDENTES: La creciente prevalencia de la diabetes tipo 2 resulta en una crisis mundial de salud pública, especialmente en países de ingresos bajos y medianos (PIBM) con sistemas de salud no preparados y sobrecargados, centrados principalmente en las enfermedades infecciosas y la salud materno infantil. Los estudios sobre la diabetes tipo 2 en los PIBM describen intervenciones específicas ignorando un análisis exhaustivo de los factores locales que las personas consideran influyen en su salud. Este estudio tiene como objetivo cubrir esta brecha de investigación al explorar lo que las personas con diabetes tipo 2 en Bolivia necesitan para mantener o mejorar su salud, qué tan importante perciben esas necesidades identificadas y en qué medida estas necesidades son satisfechas. MéTODOS: De marzo a mayo de 2019, 33 personas con diabetes tipo 2 de tres municipios periurbanos del departamento de Cochabamba participaron en este estudio. Se utilizó la metodología de mapeo conceptual de Trochim, un método de lluvia de ideas cualitativo altamente estructurado, para generar y estructurar una amplia gama de perspectivas sobre lo que los participantes consideraron herramientas para su salud. RESULTADOS: La lluvia de ideas resultó en 156 enunciaciones originales condensadas en 72 necesidades y recursos conceptualmente diferentes, estructurados en nueve grupos conceptuales y cuatro dominios de acción. Estos dominios ilustrados con necesidades vitales fueron: (1) autogestión con el uso de plantas y la posibilidad de medir los niveles de azúcar periódicamente; (2) proveedores de salud con la necesidad de confiar y recibir un diagnóstico y plan de tratamiento uniforme; (3) sistema de salud con acceso oportuno a la atención y (4) comunidad con participación comunitaria en salud y seguridad, incluida el control de perros callejeros. CONCLUSIONES: Este estudio identifica principalmente factores contextuales como bajos niveles de alfabetización, problemas lingüísticos en la atención, la necesidad de articular la cosmovisión de las personas incluyendo el uso tradicional de remedios naturales con el sistema de salud boliviano y la falta de pericia en diabetes tipo 2 por parte de los proveedores de atención primaria de salud. Comprender las necesidades y estructurarlas en diferentes áreas en las que se requiere actuar, sirve como base para la planificación y evaluación de un programa de atención integral centrada en la persona para personas con diabetes tipo 2. Este método participativo sirve como una herramienta para implementar el concepto, a menudo teórico, de atención integrada centrada en las personas en el desarollo de políticas y programas de salud.

Using concept mapping to identify policy options and interventions towards people-centred health care services: a multi stakeholders perspective.

BACKGROUND: People-centred health care (PCC) services are identified by the WHO as important building blocks towards universal health coverage. In 2016 the WHO formulated a comprehensive framework on integrated PCC services based on an international expert consultation. Yet, expert opinions may fail to recognize the needs of all health system stakeholders. Therefore, a consultation method that includes the health workforce and laypersons, can be instrumental to elaborate this framework more in-depth. This research sought to identify participants' perspectives on policy options and interventions to achieve people-centred health care services from a multi stakeholder perspective. METHODS: Study participants, both laypersons and health professionals, were recruited in Belgium. A total of 53 participants engaged in one of the seven concept mapping workshops. In this workshop the concept mapping methodology developed by Trochim, a highly structured qualitative group method for brainstorming and idea sharing, was used to generate and structure participants´ perspectives on what is needed to achieve PCC services. The method was validated using the WHO framework. RESULTS: The seven workshops together resulted in 452 different statements that were structured in a framework forming 35 clusters and four overarching domains. The four domains with their most prominent clusters were: (1) governance & policy with intersectoral health policies and affordable health for all; (2) health workforce with excellent communication skills, appreciation of health literacy challenges and respectful attitude based on cultural self-awareness; (3) integrated health services with a greater emphasis on prevention, health promotion and the availability of health education and (4) patient, person and community empowerment and participation with support for informal care, promotion of a healthy lifestyle and contextualised health education. Additionally, this study generated ideas that fitted into every single approach described in the WHO framework. DISCUSSION AND CONCLUSION: This study shows that in order to achieve PCC a participative approach involving all stakeholders at all levels is needed. The concept mapping process is one of these approaches that brings together diverse stakeholders and foments their egalitarian and respectful participation. The framework that resulted from this study can inform future debate regarding planning, implementation and monitoring of PCC.

Armonización iberoamericana de los instrumentos PCAT para la evaluación del primer nivel de atención

Cuarenta años después de Alma Ata, el mundo está reforzando la consciencia sobre la importancia de los atributos y funciones del primer nivel de atención, pero aún queda mucho por hacer para implementarlos, medirlos y aprender de las experiencias exitosas de algunos países. El conjunto de instrumentos Primary Care Assessment Tools (PCAT), desarrollados en los años 90 en Estados Unidos de América por Starfield y Shi (1), se ha mostrado como la herramienta más completa para el análisis de la atención primaria de la salud (APS) y su utilidad fue reconocida en numerosos países y regiones del mundo. El objetivo de esta carta es comunicar preliminarmente el proceso de armonización de las versiones PCAT ya adaptadas en diversos países de Iberoamérica y subrayar la importancia de estas herramientas para evaluar y comparar el primer nivel de atención, particularmente en sistemas de salud fundados en la estrategia de APS.