Aspects that facilitate access to care for viral hepatitis: An evaluative research

ABSTRACT BACKGROUND: Viral hepatitis is a major public health concern worldwide. OBJECTIVES: This study aimed to analyze the factors that facilitate access to care for viral hepatitis. DESIGN AND SETTING: Using a sequential mixed method, this evaluation research was conducted in the state of Mato Grosso, Brazil. METHODS: Mapping of references and selection of regions were made based on the quantity and heterogeneity of services. The stakeholders, including the managers of the State Department of Health and professionals from reference services, were identified. Nine semi-structured interviews were conducted using content analysis and discussions guided by the dimensions of the analysis model of universal access to health services. RESULTS: In the political dimension, decentralizing services and adhering to the Intermunicipal Health Consortium are highly encouraged. In the economic-social dimension, a commitment exists to allocate public funds for the expansion of referral services and subsidies to support users in their travel for appointments, medications, and examinations. In the organizational dimension, the availability of inputs for testing, definition of user flow, ease of scheduling appointments, coordination by primary care in testing, collaboration following the guidelines and protocols, and engagement in extramural activities are guaranteed. In the technical dimension, professionals actively commit to the service and offer different opening hours, guarantee the presence of an infectious physician, expand training opportunities, and establish intersectoral partnerships. In the symbolic dimension, professionals actively listen to the experiences of users throughout their care trajectory and demonstrate empathy. CONCLUSIONS: The results are crucial for improving comprehensiveness, but necessitate managerial efforts to enhance regional governance.

Health System Resilience as the Basis for Explanation Versus Evaluation Comment on "The COVID-19 System Shock Framework: Capturing Health System Innovation During the COVID-19 Pandemic".

The onset and impacts of COVID-19 have prompted attention to national health system preparedness for, and capacity to adapt in response to, public health emergencies and other shocks. This preparedness and adaptive capacity are often framed as 'health system resilience' a concept previously associated more with assessments of health systems in conflict-affected and fragile states. Yet health system resilience remains a slippery concept, defined and applied in multiple ways. Reflecting on the Hodgins and colleagues' study "the COVID-19 system shock framework: capturing health system innovation during the COVID-19 pandemic," this article restates the limitations of health systems resilience as a concept capable of anchoring evaluative assessments of health system performance but stresses its value in the context of explanatory research investigating how and why health systems adapt, with due attention to the power of actors' whose choices inform the nature and direction of change.

[Roles and impacts of the pharmacist in the management of insomnia: A literature review]. / Rôles et impacts du pharmacien dans la prise en charge de l'insomnie : une revue de la littérature.

BACKGROUND: Insomnia is a common sleep disorder that affects a large portion of the population in a situational, recurrent, or chronic way. In Canada, it is estimated that 13% of the population suffers from it. OBJECTIVE: The primary objective of this literature review is to identify and describe studies dealing with the role and impact of the management of insomnia by a pharmacist. METHOD: PubMed®, EMBASE® and CINALH Complete were searched to extract articles published between January 1st, 1990 and May 28, 2020. Studies on the role and impact of management of insomnia by a pharmacist, in French and English, descriptive or quantitative, with or without control group were included. Articles that did not deal with insomnia as the primary topic or where insomnia is a secondary condition were excluded, conference abstracts and studies showing no concrete results. The following variables were extracted: author, type of study, duration, location, sample size and characteristics of participants, description of pharmacist interventions, limits and biases, outcomes assessed and results. The quality of the pharmacists' interventions description was evaluated with DEPICT2. RESULTS: Our review identified eight articles published from 2006 to 2018 evaluating 14 types of outcomes and 41 separate outcomes. A total of 37% (7/19) of the quantitative outcomes had statistically significant positive results, regarding insomnia qualification, symptoms and adequate use. Six studies were conducted in community pharmacy. The quality score varied between 8 and 10 out of 11. CONCLUSION: There is little data on the role and impact of the management of insomnia by a pharmacist. The pharmacist can have a positive impact, particularly when practicing in a community pharmacy. Given the limited data and the prevalence of insomnia, it appears relevant to invest in pharmaceutical evaluative research for this condition.

The Fairy Tale Model: Secure Facility Therapist Perceptions.

The current exploratory qualitative study sought to investigate novice therapist experience of implementing a phased trauma recovery approach, the Fairy Tale Model (FTM), in secure accommodation in Scotland. Participants were ten therapists trained and supervised in FTM over a 6 month period. Therapists delivered FTM to 37 youth. Individual interviews with therapists were based on the objectives of FTM, and explored the benefits, challenges and facilitating factors for both youth and therapists. Perceived benefits for therapists included increases in trauma-informed knowledge, skills, and confidence. Youth were perceived by therapists, to be less emotionally dysregulated and more motivated, hopeful, and communicative. Challenges for therapists involved the complexity of youth difficulties, competing work demands, difficulties unlearning established approaches, and short duration placements. Prioritizing therapy, intensive sessions, and frequent communication with care staff were seen as facilitating factors. Recommendations are made for FTM delivery and more robust mixed methods evaluative research including therapist, youth and other stakeholder perspectives.

Os (des)encontros da pesquisa no tempo-espaço amazônico: um ensaio sobre produção de conhecimento como abertura à aprendizagem / Research encounters in the amazon time-space: an essay on the production of knowledge as permanent learning / I (dis)incontri della ricerca nello spazio-tempo amazzonico: un saggio sulla produzione di conoscenza come apertura all'apprendimento

Narrativa da experiência do trabalho de campo de pesquisa avaliativa sobre o Programa Mais Médicos realizada no Município de São Gabriel da Cachoeira, no Estado do Amazonas. Por meio da narrativa, busca-se refletir sobre a necessidade de abertura à aprendizagem a partir da diversidade do local na metodologia das pesquisas que analisam contextos diversos, em particular no âmbito das análises de políticas públicas. A diversidade de situações encontradas no campo empírico é utilizada para refletir sobre aspectos operacionais, questões metodológicas e relações entre teoria e prática nas pesquisas sociais. Utilizando a metáfora do embrenhar, com sentido de estar em situação diversa do habitual, foram sendo analisadas questões singulares da pesquisa que destacam a contribuição do campo empírico de implementação de políticas no território amazônico para o fazer da pesquisa. Entre as questões que o empírico levantou para a pesquisa, quando colocado em diálogo transversal com a teoria e com a metodologia da pesquisa, está o desenvolvimento da atenção básica a partir do encontro entre perspectivas diversas dos profissionais do Programa e os profissionais vinculados anteriormente às equipes. Sugere-se que a pesquisa, para articular o geral e o específico, a teoria e as práticas, seja compreendida como educação permanente dos pesquisadores. (AU)

The article refers to the experience of evaluative research on the 'More Doctors' Program in São Gabriel da Cachoeira, Amazonas, Brazil. The methodology was based on the narrative, as well as learning by the diversity of research methodologies used to analyze public policies in the specific context. Thus, the research field was used to reflect on operational aspects, methodological issues and relations between theory and practice in social research. The metaphor of "embarrassing", which means "being in a different context than usual" was used to analyze specific research themes, highlighting ways of conducting research on public policies in the Amazonian territory. The research in the territory produced a transversal dialogue between the results and the theoretical and methodological references, as well as the development of the primary health care from the meeting of the professionals of the More Doctors Program and the others previously linked to the teams. Therefore, it is suggested that the research process that articulated general and specific, as well as theory and practice, can be understood the educational actions for researchers. (AU)

L'articolo si riferisce all'esperienza di ricerca valutativa realizzata nel municipio di São Gabriel da Cachoeira, nello stato di Amazonas, Brasile, nell'ambito del Programma Mais Médicos. L'articolo si focalizza sull'apprendimento mediato della diversità e dalla diversificazione delle metodologie di ricerca basate sul contesto, e si sofferma sulle possibili ripercussioni sul "campo" delle analisi delle politiche pubbliche svolte attraverso questa prospettiva. Nella ricerca, la peculiarità delle condizioni presenti nel "campo" , viene utilizzata per riflettere sia su aspetti operativi, sia sulle questioni metodologiche e sia sugli effetti sul campo delle relazioni tra teoria e pratica. Utilizzando la metafora del "embrenhar" ovvero "essere in un contesto differente da quello abituale" sono stati collocati in analisi temi specifici della ricerca nel tentativo di mettere in risalto quali contributi alla ricerca stessa sono apportati dallo studio dell'implementazione delle politiche nel contesto reale del territorio. Tra le questioni sollevate dall'incrocio tra le informazioni raccolte ed i quadri teorico-metodologici della ricerca sottolineamo il potenziale, in termini di sviluppo delle cure primarie, rappresentato dall'incontro tra le diverse prospettive dei professionisti legati al Programma Mais Medicos e quelli precedentemente legati alle equipes. Infine si suggerisce che la ricerca, per ricostruire le articolazioni tra generale e specifico, tra teoria e pratiche, debba essere intesa come una attività di educazione permanente dei ricercatori.(AU)

Research encounters in the amazon time-space: an essay on the production of knowledge as permanent learning / Os (Des)Encontros da Pesquisa no tempo-espaço amazônico: um ensaio sobre a produção do conhecimento como abertura à aprendizagem

Narrativa da experiência do trabalho de campo de pesquisa avaliativa sobre o Programa Mais Médicos realizada no Município de São Gabriel da Cachoeira, no Estado do Amazonas. Por meio da narrativa, busca-se refletir sobre a necessidade de abertura à aprendizagem a partir da diversidade do local na metodologia das pesquisas que analisam contextos diversos, em particular no âmbito das análises de políticas públicas. A diversidade de situações encontradas no campo empírico é utilizada para refletir sobre aspectos operacionais, questões metodológicas e relações entre teoria e prática nas pesquisas sociais. Utilizando a metáfora do embrenhar, com sentido de estar em situação diversa do habitual, foram sendo analisadas questões singulares da pesquisa que destacam a contribuição do campo empírico de implementação de políticas no território amazônico para o fazer da pesquisa. Entre as questões que o empírico levantou para a pesquisa, quando colocado em diálogo transversal com a teoria e com a metodologia da pesquisa, está o desenvolvimento da atenção básica a partir do encontro entre perspectivas diversas dos profissionais do Programa e os profissionais vinculados anteriormente às equipes. Sugere-se que a pesquisa, para articular o geral e o específico, a teoria e as práticas, seja compreendida como educação permanente dos pesquisadores.

The article refers to the experience of evaluative research on the 'More Doctors' Program in São Gabriel da Cachoeira, Amazonas, Brazil. The methodology was based on the narrative, as well as learning by the diversity of research methodologies used to analyze public policies in the specific context. Thus, the research field was used to reflect on operational aspects, methodological issues and relations between theory and practice in social research. The metaphor of "embarrassing", which means "being in a different context than usual" was used to analyze specific research themes, highlighting ways of conducting research on public policies in the Amazonian territory. The research in the territory produced a transversal dialogue between the results and the theoretical and methodological references, as well as the development of the primary health care from the meeting of the professionals of the More Doctors Program and the others previously linked to the teams. Therefore, it is suggested that the research process that articulated general and specific, as well as theory and practice, can be understood the educational actions for researchers.

Indicadores sobre o cuidado a crianças e adolescentes com autismo na rede de CAPSi da região metropolitana do Rio de Janeiro / Indicators on the mental health care of autistic children and adolescents in the CAPSi of Rio de Janeiro's metropolitan region

Os Centros de Atenção Psicossocial Infanto-juvenis (CAPSi) são equipamentos estratégicos para o atendimento de crianças e adolescentes com problemas mentais, incluindo os transtornos do espectro do autismo. Esta pesquisa visou à criação de indicadores sobre o tratamento de autistas nos CAPSi, a partir do discurso de trabalhadores e familiares de 14 CAPSi da região metropolitana do Rio de Janeiro. A metodologia participativa envolveu a realização de 14 grupos focais com trabalhadores de cada CAPSi e três grupos focais com familiares de crianças e adolescentes com autismo atendidos nesses serviços. A transcrição dos registros em áudio dos grupos focais deu origem a cinco "temas ordenadores", reunindo os argumentos produzidos por todos os CAPSi e grupos de familiares. Esse material foi trabalhado numa oficina final, gerando cerca de 130 indicadores, os quais foram agrupados em cinco eixos temáticos: organização do CAPSi; projeto terapêutico individual; atendimento e mobilização dos familiares; rede, território e direitos; formação dos profissionais e processos de trabalho. Tais indicadores podem servir de guias e referências às boas práticas no cuidado com as pessoas com autismo e suas famílias, podendo ser usados para futuras iniciativas de avaliação do atendimento oferecido pelos CAPSi a essa população...

The Centers of Psychosocial Care for Children and Adolescents (CAPSi) are strategic services for treatment of children and adolescents with mental problems, including autism spectrum disorders. This research aimed at creating indicators on the treatment of autistic children and adolescents in CAPSi. The participative research involved mental health workers and parents of children from 14 CAPSi in Rio de Janeiro's metropolitan region. The methodology involved 14 focal groups with workers and three focal groups with parents of patients. The transcriptions of audio recordings of focal groups engendered five "organizers themes", that were elaborated in a final workshop, generating about 130 indicators, which were grouped around five axis: service organization; individual therapeutic project; territorial network and advocacy; family support and organization; professional training and work process. These indicators can serve as guides and references to best practices in caring for people with autism and their families, and can be used in future evaluations of the treatment offered in the CAPSi...

Empoderamento de usuários e familiares em saúde mental e em pesquisa avaliativa/interventiva: uma breve comparação entre a tradição anglo-saxônica e a experiência brasileira / Empowerment of users and family members in mental health care and in evaluative/interventional research: a brief comparison between the Anglo-Saxon tradition and the Brazilian experience

O objeto deste artigo são as principais características das tradições e experiências de empoderamento de usuários e familiares em abordagens e serviços de saúde mental em países anglo-saxônicos e no Brasil, e suas repercussões e estratégias no campo da pesquisa avaliativa e interventiva em saúde mental. O objetivo é comparar, através de uma breve revisão bibliográfica da literatura, como as tradições de empoderamento se desenvolveram nos dois cenários, a partir de características do contexto econômico, político, social e particularmente cultural. A revisão mostrou como estes contextos geram diferentes perspectivas de valorização da autonomização e empoderamento de usuários e familiares nas políticas sociais em geral e em saúde mental, como também nas apropriações no campo da pesquisa avaliativa e interventiva em saúde mental. Nos países anglo-saxônicos, esta tradição vem se desenvolvendo fortemente há cerca de 4 décadas, e no Brasil as estratégias participacionistas enfatizam mecanismos mistos - profissionais, usuários e familiares juntos -, com a presença dominante dos profissionais, e as iniciativas mais diretamente desenhadas para os usuários e familiares são muito recentes, a partir de 2005.

The scope of this article is to assess the main characteristics of the traditions and experiences of empowerment of users and family members in mental health treatment and services in Anglo-Saxon countries and in Brazil and the repercussions and strategies thereof in the field of evaluative and interventional research in mental health. Based on a brief bibliographical review of the literature, the aim is to compare how the empowerment tradition has developed in the two realities, based on the characteristics of the economic, political, social - and especially cultural - context. The review revealed how these contexts induce different perspectives on how to foster the autonomy and empowerment of users and family members in social policies and mental health, as well as their appropriation in the field of evaluative and interventional research. In Anglo-Saxon countries, this tradition has been vigorously promoted over the past four decades, and in Brazil the participative strategies emphasize mixed mechanisms - professionals, users and family members together - with the dominant presence of the professionals. The strategies in Brazil more directly designed for users and family members are recent and have been implemented from 2005 onwards.

Concepciones y prácticas sobre la violencia en el ámbito escolar / Concepts and practises of violence in school settings

Tras una aproximación al concepto de Violencia Escolar, se efectúa una exposición de dos paradigmas de abordaje vigentes aún en las instituciones educativas: el de la disciplina y el de la convivencia, señalando los dispositivos y acciones que han devenido de ambos modelos. Seguidamente se presentan los objetivos, la estrategia metodológica y los resultados obtenidos en la investigación realizada en el marco del proyecto "Investigación evaluativa de un proyecto de promoción de la salud en establecimientos educativos" (convocatoria UBACYT 2010-2012) y en la cual una de las autoras participó como becaria en la categoría estímulo. El informe realiza un análisis y discusión en torno a los principales hallazgos, y las transferencias establecidas a los miembros de la comunidad educativa que participaron en el presente estudio.(AU)

After introducing the concept of school violence, we display two paradigms: one from the discipline and other from the coexistance, both taking place in the scholar institutions, remainding the actions and devices from each other. It will be shown the aims, the methodological estrategy and the results gotten by the research curried out by the "Evaluative research of a promoting health in scholar institutions project" project (UBACYT 2010-2012 call), and in which one of the authors worked as a stimulus category fellow. The paper makes an analysis and discusion about the main indings and the transfer throught the educational community members, who took part in this study.(AU)

Concepciones y prácticas sobre la violencia en el ámbito escolar / Concepts and practises of violence in school settings

Tras una aproximación al concepto de Violencia Escolar, se efectúa una exposición de dos paradigmas de abordaje vigentes aún en las instituciones educativas: el de la disciplina y el de la convivencia, señalando los dispositivos y acciones que han devenido de ambos modelos. Seguidamente se presentan los objetivos, la estrategia metodológica y los resultados obtenidos en la investigación realizada en el marco del proyecto "Investigación evaluativa de un proyecto de promoción de la salud en establecimientos educativos" (convocatoria UBACYT 2010-2012) y en la cual una de las autoras participó como becaria en la categoría estímulo. El informe realiza un análisis y discusión en torno a los principales hallazgos, y las transferencias establecidas a los miembros de la comunidad educativa que participaron en el presente estudio.

After introducing the concept of school violence, we display two paradigms: one from the discipline and other from the coexistance, both taking place in the scholar institutions, remainding the actions and devices from each other. It will be shown the aims, the methodological estrategy and the results gotten by the research curried out by the "Evaluative research of a promoting health in scholar institutions project" project (UBACYT 2010-2012 call), and in which one of the authors worked as a stimulus category fellow. The paper makes an analysis and discusion about the main indings and the transfer throught the educational community members, who took part in this study.

Avaliação em saúde e avaliação econômica em saúde: introdução ao debate sobre seus pontos de interseção / Health assessment and economic assessment in health: introduction to the debate on the points of intersection

O estudo pretende inferir a existência, ou não, de um continuum entre a Avaliação em Saúde e a Avaliação Econômica em Saúde ao evidenciar os pontos de interseção entre essas formas de avaliação. Para tanto se realizou uma revisão bibliográfica no que concerne à fundamentação teórica, métodos e enfoques de ambas as formas de avaliação. Tomando por base a fundamentação teórica dos modelos de avaliação em saúde, normativa e pesquisa avaliativa, como referida por Hartz et al., e as abordagens teóricas da avaliação econômica, welfarista e extrawelfarista, referidas por Brouwer et al., concluiu-se que há um continuum, entre o modelo da pesquisa avaliativa, adotada na avaliação em saúde, e a abordagem teórica extrawelfarista da avaliação econômica em saúde e entre a abordagem normativa da avaliação em saúde e o enfoque welfarista da avaliação econômica em saúde. No que tange, entretanto, à prática avaliativa no dia a dia das instituições, os estudos realizados, em geral, ainda são concebidos sob um enfoque normativo e sob uma abordagem welfarista.

The study aims to infer the existence of a continuum between Health Assessment and Economic Assessment in Health, by highlighting points of intersection of these forms of appraisal. To achieve this, a review of the theoretical foundations, methods and approaches of both forms of assessment was conducted. It was based on the theoretical model of health evaluation as reported by Hartz et al and economic assessment in health approaches reported by Brouwer et al. It was seen that there is a continuum between the theoretical model of evaluative research and the extrawelfarist approach for economic assessment in health, and between the normative theoretical model for health assessment and the welfarist approaches for economic assessment in health. However, in practice the assessment is still conducted using the normative theoretical model and with a welfarist approach.

Salud mental y atención primaria. Accesibilidad, integralidad y continuidad del cuidado en centros de salud de grandes centros urbanos en Argentina / Mental health and primary health care. Care accessibility, integrality and continuity in health centers of large urban areas in Argentina

INTRODUCCION: La atención primaria representa la forma más integral, positiva y democrática de construir el cuidado de la salud y favorecer la equidad.OBJETIVO: Evaluar la accesibilidad a los servicios de salud mental en grandes centros urbanos de la Argentina.METODOS: Se realizó un estudio multicéntrico (Ciudad de Buenos Aires, Córdoba, Paraná y Rosario) en 2010, que articuló abordajes cuanti-cualitativos.RESULTADOS: El estudio mostró que la expansión de los servicios de salud mental en la atención primaria y su integración en servicios de salud general tienen una dirección consistente asumida en las políticas sanitarias. Los procesos de territorialización contribuyen a facilitar el acceso a los cuidados requeridos. Las políticas del sector marcan su carácter universal y su condición de gratuidad para los usuarios. Las acciones asistenciales se complementan con las intervenciones de prevención y promoción de la salud, aun cuando estas últimas adquieren menor magnitud. La facilitación del contacto inicial, la acogida, la continuación de la atención y la búsqueda de integralidad presentan desarrollos desiguales en cada uno de los contextos estudiados. La circulación de los usuarios entre los niveles del sistema de salud es fluida y significativa.CONCLUSIONES: En las ciudades analizadas se ha sostenido en los últimos un incentivo estratégico para favorecer el acceso de la población a los cuidados de salud mental y se ha impulsado, según el contexto político-sanitario y bajo diversas modalidades, la expansión de la red de servicios, la ampliación de las prestaciones y la integración de los cuidados específicos a la atención primaria. No obstante, siguen existiendo desafíos y deudas. Por tanto, es necesario realizar intervenciones políticas y sanitarias efectivas que consoliden dicho proceso. El diagnóstico elaborado constribuye a lograr un conocimiento sistemático, orientado al diseño de acciones particulares en cada una de las jurisdicciones.

INTRODUCTION: Primary care represents the most integral, positive and democratic way to build health care and promote equity.OBJECTIVE: To evaluate the accessibility to mental health services of large urban centers in Argentina.METHODS: A multicenter study (Buenos Aires City, Córdoba, Paraná and Rosario) was conducted in 2010. It linked qualitative and quantitative approaches.RESULTS: The study showed that the expansion of mental health services in primary care and their integration ino general health services are consistent with the current health policy. Territorialization processes contribute to facilitate the access to required care. Health policies establish its universal character and its status as provided for free to the users. Care actions are complemented by interventions towards prevention and health promotion, even though the latter take place on a smaller scale. The easy initial contact, acceptance, continuity of care and pursuit of integrity are components that have an unequal development in each of the contexts studied. The circulation of users between the different levels of the health system is smooth and meaningful.CONCLUSIONS: During the last years there has been a strategic incentive to promote accessibility of population to mental health care in the studied cities. Depending on the health-political context and under various forms, it included expansion of service networks, extension of benefits and integration of specific care to primary care. However, the remaining challenges and debts require effective health policies and interventions that strengthen the process. Through this diagnosis the study contributes to achieve a systematic knowledge, which is useful to design specific actions in each of the jurisdictions.

Salud mental y atención primaria. Accesibilidad, integralidad y continuidad del cuidado en centros de salud de grandes centros urbanos en Argentina / Mental health and primary health care. Care accessibility, integrality and continuity in health centers of large urban areas in Argentina

INTRODUCCION: La atención primaria representa la forma más integral, positiva y democrática de construir el cuidado de la salud y favorecer la equidad.OBJETIVO: Evaluar la accesibilidad a los servicios de salud mental en grandes centros urbanos de la Argentina.METODOS: Se realizó un estudio multicéntrico (Ciudad de Buenos Aires, Córdoba, Paraná y Rosario) en 2010, que articuló abordajes cuanti-cualitativos.RESULTADOS: El estudio mostró que la expansión de los servicios de salud mental en la atención primaria y su integración en servicios de salud general tienen una dirección consistente asumida en las políticas sanitarias. Los procesos de territorialización contribuyen a facilitar el acceso a los cuidados requeridos. Las políticas del sector marcan su carácter universal y su condición de gratuidad para los usuarios. Las acciones asistenciales se complementan con las intervenciones de prevención y promoción de la salud, aun cuando estas últimas adquieren menor magnitud. La facilitación del contacto inicial, la acogida, la continuación de la atención y la búsqueda de integralidad presentan desarrollos desiguales en cada uno de los contextos estudiados. La circulación de los usuarios entre los niveles del sistema de salud es fluida y significativa.CONCLUSIONES: En las ciudades analizadas se ha sostenido en los últimos un incentivo estratégico para favorecer el acceso de la población a los cuidados de salud mental y se ha impulsado, según el contexto político-sanitario y bajo diversas modalidades, la expansión de la red de servicios, la ampliación de las prestaciones y la integración de los cuidados específicos a la atención primaria. No obstante, siguen existiendo desafíos y deudas. Por tanto, es necesario realizar intervenciones políticas y sanitarias efectivas que consoliden dicho proceso. El diagnóstico elaborado constribuye a lograr un conocimiento sistemático, orientado al diseño de acciones particulares en cada una de las jurisdicciones.

INTRODUCTION: Primary care represents the most integral, positive and democratic way to build health care and promote equity.OBJECTIVE: To evaluate the accessibility to mental health services of large urban centers in Argentina.METHODS: A multicenter study (Buenos Aires City, Córdoba, Paraná and Rosario) was conducted in 2010. It linked qualitative and quantitative approaches.RESULTS: The study showed that the expansion of mental health services in primary care and their integration ino general health services are consistent with the current health policy. Territorialization processes contribute to facilitate the access to required care. Health policies establish its universal character and its status as provided for free to the users. Care actions are complemented by interventions towards prevention and health promotion, even though the latter take place on a smaller scale. The easy initial contact, acceptance, continuity of care and pursuit of integrity are components that have an unequal development in each of the contexts studied. The circulation of users between the different levels of the health system is smooth and meaningful.CONCLUSIONS: During the last years there has been a strategic incentive to promote accessibility of population to mental health care in the studied cities. Depending on the health-political context and under various forms, it included expansion of service networks, extension of benefits and integration of specific care to primary care. However, the remaining challenges and debts require effective health policies and interventions that strengthen the process. Through this diagnosis the study contributes to achieve a systematic knowledge, which is useful to design specific actions in each of the jurisdictions.

La inclusión de la perspectiva de la sociedad civil popular en VIH/SIDA: sistematización de experiencias como enfermera en Brasil y Canadá / Inclusion of popular civil society perspective in HIV/AIDS: sistematization of experiences as a nurse in Brazil and Canada

La enfermera en Salud Pública tiene como misión movilizar las organizaciones de base de su país para implantar los programas de salud. Este trabajo implica un acercamiento que le permita captar el detalle de la realidad concreta, pero que sólo una cierta distancia crítica le permitirá situarlo en un contexto de significación global. Una sistematización de experiencias presenta la investigación evaluable comunitaria como una oportunidad metodológica para las ciencias de la salud en general y de enfermería. La perspectiva es especialmente pertinente para las prácticas profesionales de salud, específicamente en contextos imprevisibles y de conflictos de verticalidad sociopolítica entre los diversos actores implicados en un programa de salud pública. La inclusión en barrios periféricos y el trabajo con grupos comunitarios favorece la inclusión desde el punto de vista de la sociedad civil popular dentro de la evaluación de las acciones preventivas del Sida y de otros programas de salud pública.

A intersubjetividade no cuidado à Saúde Mental: narrativas de técnicos e auxiliares de enfermagem de um Centro de Atenção Psicossocial / Intersubjectivity in Mental Health care: narratives of nursing technicians at a Psychosocial Care Center

Diante da demanda por atenção em Saúde Mental e na tentativa de se renovar o tratamento psiquiátrico destinado a portadores de transtornos mentais severos, surgiram os Centros de Atenção Psicossocial (Caps). Este artigo visa à análise de repercussões subjetivas do trabalho nos Caps nos profissionais de nível médio, buscandose contribuir para o planejamento em saúde. Realizaram-se dois grupos focais com trabalhadores de um Caps III. A metodologia utilizada para análise alicerça-se na abordagem hermenêutico-crítica proposta por Ricoeur e na filosofia gadameriana. Revelou-se como principal desencadeante de sofrimento a desvalorização do trabalho. Destacaram-se temas como dificuldade de cooperação com familiares de usuários, a fraca interligação do Caps com a rede de saúde, a responsabilização pelo plantão noturno, controvérsias sobre a liberação de pacientes em leito-noite e excesso de carga horária. Propõe-se adequado planejamento de estrutura e de organização institucional quando da abertura de novos Caps, visando diminuir impacto de trabalho nos técnicos e melhorar o desempenho clínico da equipe.

Psychosocial Care Centers (Caps) were established as a result of the demand for Mental Health care and were an attempt to update psychiatric treatment for those afflicted with severe mental disorders. This article seeks to analyze subjective repercussions of work conducted in Caps on mid-level professionals and to contribute to healthcare planning. Two focal groups were conducted with workers of a Caps III. The methodology applied to the analysis was based on the critical hermeneutical approach proposed by Ricoeur and espoused by Gadamerian philosophy. Lack of appreciation in the workplace was revealed as being the main cause of suffering. Several themes stood out including the difficulty of obtaining the cooperation of users'; relatives, the tenuous interconnection between Caps and the health network, the attribution of responsibility for the night shift, controversies regarding overnight-stay patients and an excessive workload. Adequate structural planning and institutional organization is proposed when opening new Caps in order to reduce the workload of technicians and improve the clinical performance of the team.

La práctica de la investigación evaluativa en un programa de promoción de la salud con instituciones escolares / The practice of evaluative research in a program of health promotion in educational institutions

El presente trabajo informa acerca de los aspectos metodológicos y operativos de la investigación evaluativa que se está llevando a cabo en relación al Programa de Escuelas Promotoras de Salud que desarrolla la Cátedra I de Salud Pública y Salud Mental. Se efectúa una breve reseña acerca de ciertos determinantes sociales que impactan sobre las Instituciones educativas del nivel secundario desde una perspectiva que destaca distintos niveles sistémicos para su comprensión y posterior intervención. Mediante ejemplos e ilustraciones se exponen las características fundamentales del programa de Escuelas Promotoras de Salud y las de la investigación evaluativa que permiten pensar el uso de esta modalidad de investigación asociada a programas de intervención en promoción y educación para la salud, destacando las siguientes dimensiones: a) Componentes de la evaluación desde una perspectiva sistémica; b) La complementariedad de métodos y técnicas de investigación; c) Participación y empoderamiento de los actores; d) Fortalecimiento del vínculo institucional.

This work informs about evaluative methodology research that is carried out in association to the Health-Promoting Schools Programme developed by Public Health and Mental Health I. This paper is a brief overview of how certain social determinants impact on educational institutions of high school from a perspective that highlights different systems and levels for their understanding and later intervention. Through of examples and illustrations it will be exposed the fundamental characteristics of the Health promoting schools program and the of qualitative research that allow us to think about the use of this type of research associated with intervention in health, education and promotion programmes, highlighting the following dimensions: a) components of the evaluation from a systemic point of view; b) combination of methods and research techniques; c) participation and empowerment of the participants involved; d) empowerment institutionals merge.

Contribuição teórico-conceitual para a pesquisa avaliativa no contexto de vigilância da saúde / Theoretical and conceptual contribution to evaluative research in health surveillance context

O presente artigo revisita inicialmente alguns dos elementos conceituais e operacionais sobre pesquisa avaliativa, em consonância com uma concepção ampliada de qualidade, reunindo saberes e campos de ação no âmbito das práticas de Saúde Pública. Em seguida, buscamos viabilizar o desenho de um modelo teórico tendo em vista a proposta de implementação das ações de vigilância da saúde, como na definição de uma imagem-objetivo da organização e integração das políticas e práticas de saúde sob uma lógica hierarquizada e regionalizada. Por fim, refletimos sobre os devires e desafios em torno da importância da teoria no campo da avaliação em saúde, produzindo saberes e abordagens para construção de modelos lógicos que relevem a complexidade dos objetos de intervenção e sua natureza de prática social transformadora.

Initially this article revises some of the conceptual and operational elements on evaluative research by gathering knowledge and action fields on public health practices. Such concepts are taken according to a wider conception of quality. Then, the article intends to arrange a theoretical model design considering the proposition for implementation of health surveillance actionsAn image-objective definition of organization and integration of health polices and practices based on hierarchic and local logic also take place. Finally, becomings and challenges around the theory in the health evaluation field turn to be the aim of our reflection in order to enable the production of knowledge and approaches to construct logic models which reveals the complexity of interventionist objects as well as its transforming nature of social practices.

Investigación evaluativa de una estrategia de promoción de la salud en el ámbito escolar: An evaluative research / A health promoting schools strategy

El presente trabajo informa acerca de la investigación evaluativa que se está llevando a cabo en relación al Programa de Escuelas Promotoras de Salud que desarrolla la Cátedra I de Salud Pública y Salud Mental. Basado en las evidencias científicas relevadas, la investigación desarrolla un diseño de tipo antes-después, con aplicación de técnicas cuantitativas y cualitativas en distintas fases del proceso de evaluación (prediagnóstico, línea de base, proceso y resultados). Se describen los resultados obtenidos hasta la fecha y los instrumentos a ser aplicados para el establecimiento de una línea de base acorde a las necesidades de evaluar los cuatro objetivos del Programa, a saber: a) Transformar las escuelas como ámbito físico y psicosocial saludable; b) Incidir positivamente en los comportamientos de salud de los estudiantes; c) Insertar la promoción de la salud en el proyecto educativo institucional; d) Mejorar las articulaciones entre la escuela y los servicios de salud.

This paper reports an evaluative research being carried out in relation to the Program of Health-Promoting Schools developed by the Department I of Public Health and Mental Health -Psychology, UBA-. Based on the evidence about health promotion in schools, this research uses an "ex - ante" type design, using quantitative and qualitative techniques that are applied in different stages (pre-diagnosis, baseline, process and outputs). Here are described the results so far and the instruments to be applied to establish a consistent baseline adjusted to the needs of the four objectives of the Program. Those are: a) Transforming schools into physical and psychosocial health field, b ) Impinge positively on health behaviors of students, c) Insert the health promotion in the educational institutions projects; d) Improve the link between schools and health services.

Control prenatal y su impacto en la mortalidad materna: Análisis de una tendencia, 1994-2004: Cali, Colombia / Prenatal control and its impact on reducing maternal deaths: Trend analysis, 1994-2004: Cali, Colombia

Objetivo: analizar el comportamiento de las razones de mortalidad materna en la ciudad de Cali (Colombia) durante dos décadas, 1985 a 2004, a la luz de indicadores de desarrollo social y organización de los servicios de atención a la gestante. Metodología: se utiliza como marco conceptual el modelo canadiense propuesto por Laframboise y Lalonde en 1974, para explicar la contribución de los servicios de salud en la disminución de las tasas de mortalidad materna. Resultados: a partir de 1994 se inició un descenso sostenido de la mortalidad materna, que se ha mantenido hasta el 2004. Durante este período no se evidenció un mejoramiento cuantitativo significativo de los indicadores de desarrollo social y económico de la ciudad de Cali. Las altas coberturas de atención prenatal (97%) y del parto institucional (98%), junto con un sistema eficiente de referencia y contrareferencia, se mantuvieron estables. El control de los procesos de mejoramiento de la calidad de la atención prenatal, con evaluaciones y ajustes periódicos, y la participación permanente de ginecobstetras en el nivel primario de atención, constituyeron los hitos primordiales de las intervenciones realizadas en la red de servicios públicos de atención. Discusión: los factores de riesgo intervenidos en la atención prenatal, la alta cobertura institucional de atención del parto y una red de referencia y contrareferencia de pacientes, oportuna y eficiente, parecen ser responsables de la disminución del 80% de las muertes, según el cálculo de Guzmán en 1986.

Objective: analysing the statistical data regarding maternal deaths in Cali (Colombia) during two consecutive decades (1985-2004) and correlating outcomes with environmental and social indicators. Methodology: the Canadian Laframboise conceptual model was used for explaining how health service organisation and other aspects of medical care play a part in decreasing maternal mortality rates. Results: maternal deaths in Cali have been decreasing since 1994. No significant quantitative variations in environmental and/or social indicators for Cali were detected from 1994-2004. High prenatal control (97%) and institutional delivery coverage (98%) remained stable, together with an efficient referral and counter-referral system. Improving prenatal attention quality through periodic evaluation and adjustment and obstetrician/gynaecologists’ ongoing participation in first-level attention were the highlights of public attention service network intervention. Discussion: prenatal risk factors, broad institutional coverage for a quality motherhood care programme and an efficient referral system have all contributed towards reducing maternal deaths by nearly 80 (taking Guzmán’s 1986 calculation as reference point).