Quality improvement collaborative to optimize heart failure care in patients from a network of clinics in Argentina during the COVID-19 pandemic.

Heart failure (HF) is a major clinical and public health problem associated with significant mortality, morbidity, and health-care costs. Despite the existence of evidence-based guidelines for the optimal treatment of HF, the quality of care remains suboptimal. Our aim was to increase the use a care bundle in 50% of enrolled subjects during their hospitalization and discharge and to reduce their readmission for HF causes by 10%. We conducted an uncontrolled before-after study in eight hospitals in Argentina to evaluate the effect of a quality improvement intervention on the use of an HF care bundle in patients with HF New York Heart Association (NYHA) Class II-III. The HF bundle of care included medication, continuum of care, lifestyle habits, and predischarge examinations. Training and follow-up of multidisciplinary teams in each center were performed through learning sessions and plan-do-study-act improvement cycles. Data collectors reviewed bundle compliance in the health records of recruited patients after their hospital discharge and verified readmissions through phone calls to patients within 30-40 days after discharge. We recruited 200 patients (83 before and 127 during the intervention phase), and bundle compliance increased from 9.6% to 28.3% [odds ratio 3.71, 95% confidence interval (8.46; 1.63); P = .002]. Despite a slow improvement during the first months, bundle compliance gained momentum near the end of the intervention surpassing 80%. We observed a non-significant decreased readmission rate within 30 days of discharge due to HF in the postintervention period [8.4% vs. 5.5%, odds ratio 0.63, 95% CI (1.88; 0.21); P = .410]. Qualitative analysis showed that members of the intervention teams acknowledged the improvement of work organization and standardization of care, teamwork, shared mental model, and health record completeness as well as the utility of training fellows. Despite the challenges related to the pandemic, better care of patients with HF NYHA Class II-III was possible through simple interventions and collaborative work. Graphical abstract.

[Strategy to improve access to etiological treatment of Chagas disease at the first level of care in Argentina]. / Estrategia para mejorar el acceso al tratamiento etiológico para la enfermedad de Chagas en el primer nivel de atención en Argentina.

OBJECTIVE: Improve distribution of etiological treatment of Chagas disease by identifying barriers to the decentralization of treatment to the first level of care in Argentina. METHODS: A qualitative, exploratory, and descriptive study was conducted using semi-structured interviews of key actors belonging to the National Chagas Program and members of health teams at the first level of care, for the purpose of identifying barriers to diagnosis and treatment of Chagas disease at different levels (administrative, health agents, and community) that could affect a decentralized distribution strategy. Additionally, pilot decentralization was instituted in 10 primary health care centers in an Argentine province. RESULTS: Semi-structured interviews were conducted with 22 program heads and health professionals. Principal obstacles found were lack of systematic case-finding, poor coordination among levels of care and health system actors, lack of health team training on treatment, patient monitoring, and patient-related barriers. A pilot decentralization program was carried out and strategies were evaluated to optimize large-scale intervention. CONCLUSIONS: The results made it possible to improve implementation of the plan to decentralize treatment through better inter-program coordination, capitalization on existing monitoring and communication tools, and sensitization of health teams. Furthermore, recommendations were developed to improve diagnosis and treatment of Chagas disease.

Barriers and facilitators to vaccination in Latin America: a thematic synthesis of qualitative studies.

Vaccines are often undervalued or underused for a variety of reasons, and vaccine hesitancy is a global challenge that threatens vaccine acceptance and the goals of immunization programs. This review aimed to describe the barriers and facilitators to vaccination in Latin America. The study design was a systematic review and thematic synthesis of qualitative studies reporting on the knowledge or attitudes of adults, parents of children at vaccination age, adolescents and health professionals towards vaccination in Latin America. The databases searched were PubMed, CENTRAL, Scopus, LILACS, SciELO, and CINAHL. A total of 56 studies were included. Facilitators included vaccination being recognized as an effective strategy for preventing infectious diseases and as a requirement for access to social assistance programs, schooling or employment. Recommendations from health professionals and positive experiences with health services were also identified as facilitators. The main barriers were lack of information or counseling, structural problems such as shortages of vaccines and limited hours of operation, the inability to afford over-the-counter vaccines or transportation to health facilities, certain religious beliefs, misconceptions and safety concerns. Qualitative research can contribute to understanding perceptions and decision-making about vaccination and to designing policies and interventions to increase coverage.

Amyotrophic lateral sclerosis in Argentina: unveiling the burden of treatment through patient and caregiver perspectives.

PURPOSE: To examine the burden of treatment (BoT) experienced by people with Amyotrophic Lateral Sclerosis (ALS) in Argentina. METHODS: Qualitative methodological design based on semi-structured interviews. Nineteen semi-structured interviews were conducted (PwALS = 7, informal caregivers= 12). The interview guides were designed based on the literature and BoT theory. Data were analysed following a framework analysis approach. RESULTS: The research highlighted the arduous journey toward obtaining a diagnosis, marked by delays influenced by healthcare system inefficiencies, lack of disease awareness and pandemic-related anxiety. Receiving the diagnosis was a destabilising experience, triggering the need to reframe self-identity, a new reality. As the disease progressed, patients encountered significant challenges in their daily activities and basic tasks, affecting their ability to work, communicate, and manage personal care. The burden extended beyond the patients to their primary caregivers. Access to specialised care, bureaucratic complexities in securing treatment, and the financial impact of managing the disease posed substantial challenges. CONCLUSION: The findings offer valuable insights into the experiences of PwALS and their caregivers in Argentina. They underscore the need for increased disease awareness, improved access to specialised care, and enhanced support networks to alleviate the burdens PwALS and their families face.

Streamlined pathways for patients with amyotrophic lateral sclerosis in Argentina are necessary to ensure timely access to comprehensive support and interventions, laying the foundation for holistic rehabilitation.There is a need to encourage clear communication between healthcare providers and patients to establish ongoing dialogue incorporating emotional, social, and psychological aspects into rehabilitation, aligning with patient-centric approaches.There is a need to develop and implement adaptive rehabilitation strategies to sustain independence and enhance quality of life for amyotrophic lateral sclerosis patients, addressing the physical, emotional, and social implications of the disease's progression.Rehabilitation professionals should advocate for systemic improvements to ensure equitable access to therapies and support alleviate financial burdens, enabling a comprehensive, patient-focused approach to rehabilitation.

Development of a core outcome set for maternal and perinatal health research and surveillance in light of emerging and ongoing epidemic threats.

Background: Maternal and perinatal health is often directly and indirectly affected during infectious disease epidemics. Yet, a lack of evidence on epidemics' impact on women and their offspring delays informed decision-making for healthcare providers, pregnant women, women in the post-pregnancy period and policy-makers. To rapidly generate evidence in these circumstances, we aim to develop a Core Outcome Set (COS) for maternal and perinatal health research and surveillance in light of emerging and ongoing epidemic threats. Methods: We will conduct a Systematic Review and a four-stage modified Delphi expert consensus. The systematic literature will aim to inform experts on outcomes reported in maternal and perinatal research and surveillance during previous epidemics. The expert consensus will involve two individual, anonymous online surveys to rate outcomes' importance and suggest new ones, one virtual meeting to discuss disagreements, and one in-person meeting to agree on the final COS, outcomes definitions and measurement methods. Four panels will be established to participate in the modified Delphi with expertise in (a) maternal and perinatal health, (b) neonatal health, (c) public health and emergency response, and (d) representation of civil society. We will recruit at least 20 international experts for each stakeholder group, with diverse backgrounds and gender, professional, and geographic balance. Only highly-rated outcomes (with at least 80% of ratings being 7-9 on a 9-point Likert scale) and no more than 10% of low ratings (1-3) will be included in the final COS. Conclusions: Implementing this COS in future maternal and perinatal research and surveillance, especially in the context of emerging and ongoing epidemic threats, will facilitate the rapid and systematic generation of evidence. It will also enhance the ability of policy-makers, healthcare providers, pregnant women and women in the post-pregnancy period and their families to make well-informed choices in challenging circumstances.

Kidney failure, status passage, and the transitional nature of living with the disease: A qualitative study in Argentina.

The span of kidney failure (KF) has been extended by advances in treatment. To elucidate the lived experiences of people with KF, we draw on Glaser and Strauss's theory of status passage. Semi-structured interviews were conducted with 50 patients with KF and 14 health professionals, from two healthcare facilities in Buenos Aires, Argentina. The theory informed on the temporal dimensions of people's passages and dimensions related to what actors know of this passage. We described the status passage as a sequence of transitions (starting dialysis, receiving a transplant, returning to dialysis) that have devastating effects on patient's roles, and are accompanied with fear and experience of wasting time. Temporal aspects were crucial and planning was useless; indeed, timing of statuses was uncertain. With a transplant, certain roles and capacities could be regained. Some patients were not aware of the chronic nature of the disease and the ultimate reversibility of the transplant. Control over the passage was minimal because of the unpredictable prognosis of the disease but patients employed strategies to regain it. Control was even more limited for people who migrated to receive a treatment; whose lives were completely altered. Status passage theory signaled the overwhelming impact of the passage on all aspects of people's lives, the uncertainty of the transitions, lack of control and awareness of essential aspects, and unexpected aspects of desirability, adding to our understanding of how people experience this disease and its treatments.

[Strategies for health services in women, newborns, children, and adolescents during the COVID-19 pandemic in countries of Americas]. / Estrategias de servicios de salud en mujeres, recién nacidos/as, niños/as y adolescentes durante la pandemia de COVID-19 en países de las Américas.

The article analyzes the perceived challenges and strategies implemented in five Latin American and Caribbean countries to ensure continuity of care and access to health services for women, newborns, children, and adolescents during the COVID-19 pandemic. The study corresponds to a quick assessment based on semi-structured interviews with key informants in countries selected by convenience: Colombia, Ecuador, Guatemala, Grenada, and the Dominican Republic. Interviews were conducted with 23 key informants: (a) decision makers at the national and/or subnational level, (b) healthcare professionals, and (c) representatives of civil society organizations; from December 2020 to January 2021. Among the findings, at the beginning of the pandemic, priority was given to the COVID-19 care, with measures to limit the flow of people to health facilities in the countries involved, closing or limiting outpatient visits and restricting care schedule. For women, this affected family planning services and access to contraceptive methods, implying a reduction in prenatal check-ups. As a result of this deinstitutionalization of care, among newborns, a decrease in pediatric check-ups, a decrease in timely immunization and late detection of pathologies or growth problems were reported. Among adolescents, a strong restriction of family planning services, the limitation of other friendly counseling spaces and difficulties in accessing contraceptives were observed.

El artículo analiza los desafíos percibidos y las estrategias implementadas en cinco países de América Latina y el Caribe para garantizar la continuidad de los cuidados y el acceso a servicios de salud de mujeres, recién nacidos/as, niños/as y adolescentes durante la pandemia por COVID-19. El estudio corresponde a una evaluación rápida basada en entrevistas semi-estructuradas a informantes clave de países seleccionados por conveniencia: Colombia, Ecuador, Guatemala, Granada y República Dominicana. Se realizaron entrevistas con 23 informantes clave: (a) referentes de la toma de decisión a nivel nacional y/o subnacional, (b) referentes de servicios de salud, y (c) representantes de organizaciones de la sociedad civil, durante diciembre de 2020 y enero de 2021. Entre los hallazgos, al inicio de la pandemia se priorizó la atención del COVID-19, con medidas para limitar la afluencia de personas a los establecimientos de salud en los países involucrados, procediendo al cierre o limitación de consultas externas y restricción de horarios de atención. Para las mujeres, esto impactó en los servicios de planificación familiar y el acceso a métodos anticonceptivos, e implicó una reducción de los controles prenatales. Por esta desinstitucionalización de la atención, entre recién nacidos/as fue reportada una disminución de los controles pediátricos, una disminución de su vacunación oportuna y una detección tardía de patologías o problemas de crecimiento. Entre adolescentes, se señaló una fuerte restricción de los servicios de planificación familiar, la limitación de otros espacios amigables de consejería y dificultades para acceder a anticonceptivos.

O artigo analisa os desafios observados e as estratégias implementadas em cinco países da América Latina e do Caribe para garantir a continuidade do atendimento e o acesso aos serviços de saúde para mulheres, recém-nascidos/as, crianças e adolescentes durante a pandemia de COVID-19. O estudo é uma avaliação rápida baseada em entrevistas semiestruturadas com informantes-chave em países selecionados por conveniência: Colômbia, Equador, Guatemala, Granada e República Dominicana. Foram realizadas entrevistas com 23 informantes-chave: (a) tomadores de decisão em nível nacional e/ou subnacional, (b) prestadores de serviços de saúde e (c) representantes de organizações da sociedade civil; durante dezembro de 2020 e janeiro de 2021. Entre as conclusões encontrou-se que, no início da pandemia, foi dada prioridade à COVID-19, com medidas para limitar o fluxo de pessoas às instalações de saúde nos países envolvidos, fechando ou limitando as consultas ambulatoriais e restringindo o horário de atendimento. Para as mulheres, a medida impactou os serviços de planejamento familiar e o acesso à contracepção, significando uma redução nos check-ups pré-natais. Como resultado desta desinstitucionalização dos cuidados, uma diminuição dos check-ups pediátricos, uma diminuição das vacinações no período correto e uma detecção tardia de patologias ou problemas de crescimento foram relatados entre os/as recém-nascidos/as. Entre os adolescentes, foi observada uma restrição severa dos serviços de planejamento familiar, a limitação de acesso a espaços de aconselhamento amigável e dificuldades de acesso a contraceptivos.

How do social and economic vulnerabilities shape the work of participating in care? Everyday experiences of people living with kidney failure in Argentina.

BACKGROUND: A new chronic patient has emerged, with a burden of symptoms and treatment. Patients with kidney failure (KF) require complex and expensive treatments, and in underresourced contexts, they struggle to obtain quality and timely care, even in countries with universal health coverage. We describe how, in such a setting, social structural factors and control over services placed by the system affect the burden of treatment of patients. METHOD: This qualitative study was undertaken in Buenos Aires, Argentina. Semistructured interviews were conducted with patients with KF (n = 50) and health professionals (n = 14) caring for these patients. Additionally, three types of health coverage were included: public health, social security and private healthcare, with diverse socioeconomic backgrounds. FINDINGS: Patients' agency to meet demands is extended by relational networks with redistributed responsibilities and roles. Networks provided logistical, financial, emotional support; indeed, patients with limited networks were susceptible to rapid health deterioration, as treatment interruptions could not be identified in time. Control over services translated into scarce information about treatment options, changing dialysis schedules, lack of contact with transplant teams, and new rules to access medication or make requests. For any type of coverage, there was an economic burden related to noncovered medication, copayments, travel, caregivers, specialized diets, and moving to a city offering treatment. Many patients reported economic difficulties that prevented them from even affording meals. Hardships worsened by unemployment because of the disease. Some patients had migrated seeking treatment, leaving everything behind, but could not return without risking their life. Transplanted patients often needed to re-enter the labor market against a background of high unemployment rates. CONCLUSION: While health policy and practices encourage self-management, the patient may not have the capacity to meet the system's demands. A better understanding of BoT could contribute to improving how patients experience their illness.

Promoting immunization equity in Latin America and the Caribbean: Case studies, lessons learned, and their implication for COVID-19 vaccine equity.

In 2020, the World Health Organization launched the Immunization Agenda 2030: A Global Strategy to Leave No One Behind, which prioritizes high equitable immunization coverage at the national level and in all districts. Achieving high and homogenous immunization coverage, which is all the more important within the current context of the COVID-19 pandemic and vaccine rollout, requires the strengthening of existing immunization activities and innovative approach to immunization promotion. This research applied a descriptive case study methodology to document the implementation of strategic multi-level alliances to promote equitable immunization access and demand in Colombia, Guyana, and Sucre, Bolivia. Data collection, carried out between September 2019 and March 2020, included documentary reviews, semi-structured interviews, focus groups, and site visits accompanied by discussions with relevant stakeholders. Case studies provide valuable examples of people-centered, partnership-based, country-owned, and data-guided approaches to promoting equitable immunization coverage, including multi-level partnerships to build technical capacity for the identification and measurement of social inequalities impacting immunization in Colombia; intersectoral and community collaboration for pro-equity emergency response to regional vaccine preventable disease outbreaks in Guyana; and strategic alliances with the education sector and civil society organizations for the introduction of the human papilloma virus (HPV) vaccine in Sucre, Bolivia. Lessons learned highlight avenues for improving the impact of multi-level, equity-focused capacity building, particularly at the local level; optimizing the use of data and resources, partnerships, and community and stakeholder education and empowerment. While impact studies are needed to better understand the quantitative contributions of such strategic alliances, these case studies illustrate their practical significance and reinforce the value of multi-level, intersectoral collaboration for enhancing equitable immunization access and demand. The experiences of Colombia, Guyana, and Sucre, Bolivia provide evidence-based insight to support pro-equity immunization program planning to ensure that no one is left behind and that everyone, everywhere receives the benefits of vaccines, both routine and for COVID-19.

Implementing Strategies at the Workplace Level to Increase Colorectal Cancer Screening Uptake in Argentina: A Controlled Interrupted Time-series Study.

Colorectal cancer is the third most common neoplasm. The immunochemical fecal occult blood test (iFOBT) is recommended for screening. The worksite setting has great potential to deliver preventive interventions. We aimed to design and evaluate the feasibility and potential impact of a multicomponent strategy in a workplace [Internal Revenue Agency of the Province of Buenos Aires (ARBA from its acronym in Spanish "Agencia de Recaudación de Buenos Aires") in Argentina].We used a quasi-experimental research design, a controlled interrupted time-series (ITS). The study involved: (i) a preintervention period (July 2015-September 2018); and (ii) an intervention period (October 2018-February 2019). We used semi-structured interviews and focus groups to design the intervention and to ensure feasibility and implementability. We fitted segmented linear regression models to evaluate changes in the monthly rates per 10,000 tests done in ARBA employees and controlling for the proportion of tests done in non-ARBA workers. A total of 1,552 ARBA employees aged 50 or more participated. Overall, iFOBT mean uptake rates were 16 times higher in the intervened during the five-month intervention period, remaining statistically significant after adjusting by the proportion of tests done in the control group (P < 0.001). The effect was higher in women aged 50 to 59 years. Activities were suspended due to the COVID-19 pandemic. A multifaceted workplace-based intervention proved to be feasible and acceptable to increase the uptake of colorectal cancer screening in employees of Argentina. Achieving high implementation rates requires building a healthy relationship with the partner organization, adding their values and views, and establishing agreed-upon mechanisms. PREVENTION RELEVANCE: Employee-facing multifaceted worksite cancer screening interventions are a valuable means to increase knowledge and utilization of workers. The controlled ITS showed that colorectal cancer screening mean uptake rates were 16 times higher in the intervened versus the control population during the intervention period, particularly among women aged 50 to 75.

Design and feasibility of an implementation strategy to address Chagas guidelines engagement focused on attending women of childbearing age and children at the primary healthcare level in Argentina: a pilot study.

BACKGROUND: Chagas is a public health problem, especially in Latin America, exacerbated by migratory movements and increasing urbanization. Argentina is among the countries with the highest estimated prevalence in the region, with 1,500,000 people infected, with mother to child as the main mode of transmission. Vertical transmission has been significantly reduced by treating women of childbearing age; several guidelines in the region recommend treatment as a primary prevention strategy for the child and a secondary prevention strategy for women and their families. Despite recommendations, women of childbearing age are not always treated, and children do not receive timely diagnosis and treatment. The objective of this research was to design an implementation strategy to improve using Chagas guidelines focused on attending women of childbearing age and children at the primary healthcare level and pilot it in three primary health care centers in Argentina. METHODS: We conducted a pilot feasibility study using the Consolidated Framework for Implementation Research. A qualitative process evaluation was conducted using semi-structured interviews with health care providers and observations in primary health care centers. RESULTS: We developed a multifaceted implementation strategy including training, flowcharts and reminders, a register of suspected and confirmed cases, and the selection of a management facilitator. The pilot study took place between September 2019 and May 2020. The implementation level was heterogeneous and varied depending on the components, being the facilitating factors, the simplicity of the intervention, professionals' willingness to expand the indication of serologic tests, and staff commitment to the adoption of intervention components. The main barriers found were the change of authorities at the local level, some professionals´ reluctance to administer etiological treatment, staff shortages, lack of diagnostic supplies, and the health emergency caused by the COVID-19 pandemic. CONCLUSIONS: Behavioral change strategies should be applied to improve implementation to address some of the main barriers, including support actions offered by opinion leaders, medical experts, and local health authorities. Rapid diagnostic tests should be readily available to maintain behavior changes. We suggest further refinement of the strategy and its implementation in more centers to assess outcomes prospectively with a hybrid implementation research design.

[Formative research for the design and implementation of a strategy to increase colorectal cancer screening in the workplace in Argentina]. / Investigación formativa para el diseño e implementación de una estrategia para aumentar el rastreo de cáncer colorrectal en el ámbito laboral en Argentina.

The workplace has great potential to disseminate information and implement health promotion activities such as cancer prevention and early detection. Due to the challenges of deploying health interventions in this setting, formative studies are needed to adjust the design and implementation of successful strategies. To inform the intervention's design and implementation and improve the adherence rate to screening with fecal occult blood test in a workplace in Argentina, a formative study was conducted to identify potential barriers and facilitators. The formative study adopted a qualitative methodological design. Interviews were held with 10 individuals in charge of key areas in the institution where the main study was conducted, besides 8 focus groups with workers over 50 years of age. Challenges were identified at the institutional level for the intervention's implementation, such as workers' geographic dispersion and the complexity of the institution's flowchart, as well as at the population level, such as low knowledge about colorectal cancer and diagnostic tests and low risk perception. The facilitators featured the intervention's acceptability and the availability of human and material resources to proceed with the intervention, such as institutional communications channels for disseminating the information and logistics for distribution of diagnostic kits. The formative study allowed identifying resources and potential barriers that informed the intervention's design and implementation.

El ámbito laboral tiene un gran potencial para difundir información e implementar actividades de promoción de la salud, como la prevención y detección temprana del cáncer. Debido al desafío de implementar intervenciones sanitarias en este ámbito, se necesitan investigaciones formativas para adecuar el diseño y la implementación de las estrategias para que sean exitosas. Con el objetivo de informar el diseño e implementación de la intervención, para mejorar la tasa de adherencia al tamizaje con el test de sangre oculta en materia fecal, en un ámbito laboral en Argentina, se realizó una investigación formativa para identificar potenciales barreras y facilitadores. La investigación formativa siguió un diseño metodológico cualitativo. Se realizaron entrevistas con 10 responsables de áreas clave de la institución en que se desarrolló el estudio y 8 grupos focales con trabajadores mayores de 50 años. Se identificaron desafíos para la implementación de la intervención en el nivel institucional, como la dispersión geográfica de los trabajadores y la complejidad del organigrama de la institución, y en el nivel de la población objetivo, como el bajo conocimiento del cáncer colorrectal y de los test diagnósticos, así como la baja percepción de riesgo. Entre los facilitadores se destacaron la aceptabilidad de la intervención, además de la disponibilidad de recursos humanos y materiales para llevar adelante la intervención, como canales de comunicación institucional para la diseminación de información, así como la logística para la distribución de kits diagnósticos. La investigación formativa permitió relevar recursos e identificar potenciales barreras que informaron el diseño y la implementación de la intervención.

O local de trabalho possui grande potencial para divulgar informação e implementar atividades de promoção da saúde, como a prevenção e detecção precoce do câncer. Frente ao desafio de implementar ações sanitárias naquele ambiente, são necessárias pesquisas formativas para adequar a estruturação e a implementação das estratégias para que sejam bem-sucedidas. Com o objetivo de subsidiar a concepção e a implementação da ação, visando melhorar a taxa de aderência ao screening com o teste de sangue oculto nas fezes no ambiente de trabalho na Argentina, foi desenvolvida uma pesquisa formativa para identificar potenciais barreiras e facilitadores. A pesquisa formativa seguiu um formato metodológico qualitativo. Foram realizadas entrevistas com 10 gerentes de áreas chaves da entidade onde foi desenvolvido o estudo e 8 grupos focais, com trabalhadores acima de 50 anos de idade. Foram identificados alguns desafios para a implementação de uma ação em nível institucional, como a dispersão geográfica dos trabalhadores e a complexidade do organograma da entidade, e em termos de população objetiva, como o baixo conhecimento a respeito do câncer colorretal e dos testes diagnósticos, além da baixa percepção de risco. Entre os facilitadores, destacaram-se a aceitabilidade da ação e a disponibilidade de recursos humanos e materiais para levar a cabo a ação, como canais de comunicação institucional, para a divulgação da informação e a logística, para a distribuição dos kits diagnósticos. A pesquisa formativa revelou recursos e identificou potenciais barreiras, ajudando na estruturação e implementação da ação.

Health care providers perspectives about maternal immunization in Latin America.

BACKGROUND: Antenatal care providers have a key role in providing appropriate information and immunization recommendations to improve pregnant women's vaccine uptake. The objective of this study is to describe health care providers' perspectives and experience regarding the implementation of maternal immunization programs in Latin America. METHODS: We conducted 33 in-depth interviews of health care providers from Argentina, Brazil, Honduras, Mexico, and Peru (6-7 per country). Qualitative data analysis was conducted using a combination of both manual techniques and the computer software program NVivo. We identified and coded main themes related to maternal immunization. RESULTS: The main themes identified in this analysis were practices related to maternal immunization, knowledge and training, resource availability and interactions with pregnant women. Healthcare providers knew that recommendations exists but some did not know their content; they expressed concerns about insufficient training. Providers from all five countries expressed the need for additional human resources and supplies. They also expressed a desire for women to be more proactive and ask more questions during the health visits. CONCLUSION: This is the first multi-country study assessing the perspectives of health care providers about maternal immunization practices at the facility level in Latin America. Recommendations based on the results from this study include implementing additional trainings around maternal immunization, especially targeting obstetricians and midwives. These trainings should be conducted in coordination with improvements to supply chain and other structural issues.

Barriers and facilitators to vaccination in Latin America: a thematic synthesis of qualitative studies / Barreras y facilitadores de la vacunación en América Latina: síntesis temática de estudios cualitativos / Barreiras e facilitadores para a vacinação na América Latina: síntese temática de estudos qualitativos

Vaccines are often undervalued or underused for a variety of reasons, and vaccine hesitancy is a global challenge that threatens vaccine acceptance and the goals of immunization programs. This review aimed to describe the barriers and facilitators to vaccination in Latin America. The study design was a systematic review and thematic synthesis of qualitative studies reporting on the knowledge or attitudes of adults, parents of children at vaccination age, adolescents and health professionals towards vaccination in Latin America. The databases searched were PubMed, CENTRAL, Scopus, LILACS, SciELO, and CINAHL. A total of 56 studies were included. Facilitators included vaccination being recognized as an effective strategy for preventing infectious diseases and as a requirement for access to social assistance programs, schooling or employment. Recommendations from health professionals and positive experiences with health services were also identified as facilitators. The main barriers were lack of information or counseling, structural problems such as shortages of vaccines and limited hours of operation, the inability to afford over-the-counter vaccines or transportation to health facilities, certain religious beliefs, misconceptions and safety concerns. Qualitative research can contribute to understanding perceptions and decision-making about vaccination and to designing policies and interventions to increase coverage.

Las vacunas suelen estar subvaloradas o desaprovechadas por diversas razones. La vacilación ante las vacunas es un desafío global y representa una amenaza para la aceptación de las vacunas y para los objetivos de los programas de inmunización. El objetivo de esta revisión es describir las barreras y los facilitadores de la vacunación en América Latina. El diseño del estudio fue una revisión sistemática y una síntesis temática de estudios cualitativos sobre conocimientos o actitudes de adultos, padres de niños en edad de vacunación, adolescentes y profesionales de la salud sobre la vacunación en América Latina. Las bases de datos analizadas fueron PubMed, CENTRAL, Scopus, LILACS, SciELO y CINAHL. Se incluyeron 56 estudios. Los facilitadores incluyeron la idea de que la vacunación era reconocida como una estrategia eficaz para prevenir enfermedades infecciosas y un requisito para el acceso a la asistencia social, la escolaridad o el empleo. También se identificaron como factores facilitadores las recomendaciones de los profesionales de la salud y las experiencias positivas con los servicios de salud. Los principales obstáculos fueron la falta de información o asesoramiento, problemas estructurales como la escasez de vacunas y los horarios de funcionamiento limitados, la imposibilidad de pagar vacunas no provistas de forma gratuita o de desplazarse a los centros de salud, ciertas creencias religiosas, conceptos erróneos sobre las vacunas y preocupaciones por la seguridad. La investigación cualitativa puede contribuir a la comprensión de las percepciones y a la toma de decisiones sobre la vacunación y al desarrollo de políticas e intervenciones para aumentar la cobertura de vacunación.

As vacinas são frequentemente subvalorizadas ou subutilizadas por uma série de razões. A hesitação vacinal é um desafio global, sendo uma ameaça à aceitação das vacinas e aos objetivos dos programas de imunização. O objetivo desta revisão é descrever barreiras e facilitadores para a vacinação na América Latina. O desenho do estudo foi uma revisão sistemática e síntese temática de estudos qualitativos sobre conhecimento ou atitudes de adultos, pais de crianças em idade de vacinação, adolescentes e profissionais de saúde sobre vacinação na América Latina. As bases de dados analisadas foram PubMed, CENTRAL, Scopus, LILACS, SciELO e CINAHL. Foram incluídos 56 estudos. Os facilitadores incluíram a ideia de que a vacinação era reconhecida como uma estratégia eficaz para prevenir doenças infecciosas e um requisito para o acesso à assistência social, escolaridade ou emprego. Além disso, recomendações de profissionais de saúde e experiências positivas com serviços de saúde também foram identificados como fatores facilitadores. Os principais obstáculos foram a falta de informação ou aconselhamento, problemas estruturais como escassez de vacinas e horário limitado de funcionamento, incapacidade de comprar vacinas pagas ou se transportar para unidades de saúde, certas crenças religiosas, concepções erradas sobre vacinas e preocupações de segurança. A pesquisa qualitativa pode contribuir para a compreensão das percepções e tomadas de decisão sobre a vacinação e para o desenvolvimento de políticas e intervenções para aumentar a cobertura vacinal.

Work of being an adult patient with chronic kidney disease: a systematic review of qualitative studies.

INTRODUCTION: Chronic kidney disease (CKD) requires patients and caregivers to invest in self-care and self-management of their disease. We aimed to describe the work for adult patients that follows from these investments and develop an understanding of burden of treatment (BoT). METHODS: Systematic review of qualitative primary studies that builds on EXPERTS1 Protocol, PROSPERO registration number: CRD42014014547. We included research published in English, Spanish and Portuguese, from 2000 to present, describing experience of illness and healthcare of people with CKD and caregivers. Searches were conducted in MEDLINE, Embase, CINAHL Plus, PsycINFO, Scopus, Scientific Electronic Library Online and Red de Revistas Científicas de América Latina y el Caribe, España y Portugal. Content was analysed with theoretical framework using middle-range theories. RESULTS: Searches resulted in 260 studies from 30 countries (5115 patients and 1071 carers). Socioeconomic status was central to the experience of CKD, especially in its advanced stages when renal replacement treatment is necessary. Unfunded healthcare was fragmented and of indeterminate duration, with patients often depending on emergency care. Treatment could lead to unemployment, and in turn, to uninsurance or underinsurance. Patients feared catastrophic events because of diminished financial capacity and made strenuous efforts to prevent them. Transportation to and from haemodialysis centre, with variable availability and cost, was a common problem, aggravated for patients in non-urban areas, or with young children, and low resources. Additional work for those uninsured or underinsured included fund-raising. Transplanted patients needed to manage finances and responsibilities in an uncertain context. Information on the disease, treatment options and immunosuppressants side effects was a widespread problem. CONCLUSIONS: Being a person with end-stage kidney disease always implied high burden, time-consuming, invasive and exhausting tasks, impacting on all aspects of patients' and caregivers' lives. Further research on BoT could inform healthcare professionals and policy makers about factors that shape patients' trajectories and contribute towards a better illness experience for those living with CKD. PROSPERO REGISTRATION NUMBER: CRD42014014547.

Parliamentary debates on death with dignity in Argentina: the rights of terminal patients on the legislative agenda, 1996-2012. / Debates parlamentarios sobre la muerte digna en Argentina: los derechos de los pacientes terminales en la agenda legislativa, 1996-2012.

This article examines the regulation on terminal patients' rights in Argentina at two points in time: the first attempts to regulate end-of-life rights (1996), and the "death with dignity" law passed by the National Congress (2011-2012). Comparative analysis allows us to observe variations among the individuals and situations included in the legislation, as well as in the conceptualization of autonomy and the interventions that is considered lawful refuse. The political context and the differential way that "death with dignity" entered the legislative agenda in each period determined the public's construction of the problem and thus the extent and result of the debates.

El artículo examina la producción legislativa sobre derechos de los pacientes terminales en Argentina en dos momentos: los primeros intentos de regular los derechos en el final de la vida (1996) y la sanción de la ley de "muerte digna" en el Congreso Nacional (2011-2012). El análisis comparativo permite observar variaciones en torno a las personas y situaciones incluidas en la legislación, la forma en que se conceptualiza la autonomía y las intervenciones que se considera legítimo rechazar. El contexto político y la forma diferencial en que la "muerte digna" ingresó en la agenda legislativa en cada periodo determinaron la construcción pública del problema y con ello los alcances y el resultado de los debates.

Estrategias de servicios de salud en mujeres, recién nacidos/as, niños/as y adolescentes durante la pandemia de COVID-19 en países de las Américas / Strategies for health services in women, newborns, children, and adolescents during the COVID-19 pandemic in countries of Americas / Estratégias de serviços de saúde para mulheres, recém-nascidos/as, crianças e adolescentes durante a pandemia de COVID-19 nos países das Américas

El artículo analiza los desafíos percibidos y las estrategias implementadas en cinco países de América Latina y el Caribe para garantizar la continuidad de los cuidados y el acceso a servicios de salud de mujeres, recién nacidos/as, niños/as y adolescentes durante la pandemia por COVID-19. El estudio corresponde a una evaluación rápida basada en entrevistas semi-estructuradas a informantes clave de países seleccionados por conveniencia: Colombia, Ecuador, Guatemala, Granada y República Dominicana. Se realizaron entrevistas con 23 informantes clave: (a) referentes de la toma de decisión a nivel nacional y/o subnacional, (b) referentes de servicios de salud, y (c) representantes de organizaciones de la sociedad civil, durante diciembre de 2020 y enero de 2021. Entre los hallazgos, al inicio de la pandemia se priorizó la atención del COVID-19, con medidas para limitar la afluencia de personas a los establecimientos de salud en los países involucrados, procediendo al cierre o limitación de consultas externas y restricción de horarios de atención. Para las mujeres, esto impactó en los servicios de planificación familiar y el acceso a métodos anticonceptivos, e implicó una reducción de los controles prenatales. Por esta desinstitucionalización de la atención, entre recién nacidos/as fue reportada una disminución de los controles pediátricos, una disminución de su vacunación oportuna y una detección tardía de patologías o problemas de crecimiento. Entre adolescentes, se señaló una fuerte restricción de los servicios de planificación familiar, la limitación de otros espacios amigables de consejería y dificultades para acceder a anticonceptivos.

The article analyzes the perceived challenges and strategies implemented in five Latin American and Caribbean countries to ensure continuity of care and access to health services for women, newborns, children, and adolescents during the COVID-19 pandemic. The study corresponds to a quick assessment based on semi-structured interviews with key informants in countries selected by convenience: Colombia, Ecuador, Guatemala, Grenada, and the Dominican Republic. Interviews were conducted with 23 key informants: (a) decision makers at the national and/or subnational level, (b) healthcare professionals, and (c) representatives of civil society organizations; from December 2020 to January 2021. Among the findings, at the beginning of the pandemic, priority was given to the COVID-19 care, with measures to limit the flow of people to health facilities in the countries involved, closing or limiting outpatient visits and restricting care schedule. For women, this affected family planning services and access to contraceptive methods, implying a reduction in prenatal check-ups. As a result of this deinstitutionalization of care, among newborns, a decrease in pediatric check-ups, a decrease in timely immunization and late detection of pathologies or growth problems were reported. Among adolescents, a strong restriction of family planning services, the limitation of other friendly counseling spaces and difficulties in accessing contraceptives were observed.

O artigo analisa os desafios observados e as estratégias implementadas em cinco países da América Latina e do Caribe para garantir a continuidade do atendimento e o acesso aos serviços de saúde para mulheres, recém-nascidos/as, crianças e adolescentes durante a pandemia de COVID-19. O estudo é uma avaliação rápida baseada em entrevistas semiestruturadas com informantes-chave em países selecionados por conveniência: Colômbia, Equador, Guatemala, Granada e República Dominicana. Foram realizadas entrevistas com 23 informantes-chave: (a) tomadores de decisão em nível nacional e/ou subnacional, (b) prestadores de serviços de saúde e (c) representantes de organizações da sociedade civil; durante dezembro de 2020 e janeiro de 2021. Entre as conclusões encontrou-se que, no início da pandemia, foi dada prioridade à COVID-19, com medidas para limitar o fluxo de pessoas às instalações de saúde nos países envolvidos, fechando ou limitando as consultas ambulatoriais e restringindo o horário de atendimento. Para as mulheres, a medida impactou os serviços de planejamento familiar e o acesso à contracepção, significando uma redução nos check-ups pré-natais. Como resultado desta desinstitucionalização dos cuidados, uma diminuição dos check-ups pediátricos, uma diminuição das vacinações no período correto e uma detecção tardia de patologias ou problemas de crescimento foram relatados entre os/as recém-nascidos/as. Entre os adolescentes, foi observada uma restrição severa dos serviços de planejamento familiar, a limitação de acesso a espaços de aconselhamento amigável e dificuldades de acesso a contraceptivos.

[The rights of the dying: the refusal of medical treatments in Argentine courts]. / Derechos en el final de la vida: el rechazo de tratamientos médicos en los tribunales argentinos.

This paper addresses the judicialization of end of life medical decision-making, as part of the advance of the justice system in the regulation of medical practice and the rise of recognition of patient autonomy. The article analyzes, from a sociological standpoint, legal decisions regarding treatment refusal at the end of life produced by the Argentine courts between 1975 and 2015. Based on a qualitative design, 38 sentences collected from jurisprudential databases using key terms were analyzed. First, judicialized cases during the period are described; these are characterized by a high proportion of claims presented by health institutions, a pro-treatment bias in the legal actions requested, and a high percentage of unnecessary litigation in the absence of conflicts or in situations that do not require court intervention. Second, legal and extralegal factors affecting the justiciability of decisions to refuse or withdraw medical treatments, such as changes in the law and processes of politicization of claims, are analyzed.

Intervenciones en ámbito laboral para incrementar el rastreo de cáncer colorrectal evaluación de tecnología sanitaria / Workplace interventions to increase colorectal cancer screening: health technology assessment

INTRODUCCIÓN: El cáncer de colon y recto (CCR) es la tercera neoplasia más frecuente y la cuarta causa de muerte por cáncer a nivel mundial. En Argentina es la segunda neoplasia maligna más frecuente, con el 11,8% de los casos. El objetivo del informe fue evaluar la evidencia sobre la eficacia de intervenciones efectuadas en el ámbito laboral para incrementar el rastreo de CCR. MÉTODOS: Se realizó una búsqueda en bases de datos bibliográficas, buscadores genéricos de Internet y sitios ministeriales de salud y educación nacionales. RESULTADOS: Se incluyeron dos estudios clínicos aleatorizados (ECA) por conglomerados, un ECA, cinco estudios de implementación sin grupo control, reportes de programas y guías de prácticas clínicas de rastreo del CCR desarrollados en países de América y una guía europea. Las intervenciones en el ámbito laboral son eficaces para aumentar la tasa de rastreo. La entrega de kits para test de sangre oculta en materia fecal (TSOMF) fue la intervención más utilizada, seguida por distribución de información y sesiones educativas. Se vio mayor eficacia de las intervenciones en quienes contaban con historia familiar de CCR o recibían información sobre el riesgo individual de desarrollar la enfermedad. Los encuentros educativos en ámbitos laborales son un entorno aceptable para difundir información y distribuir kits para TSOMF. DISCUSIÓN: Un abordaje compuesto por intervenciones en el ámbito laboral podría incrementar la tasa de rastreo de CCR en la población general

Investigación formativa para el diseño e implementación de una estrategia para aumentar el rastreo de cáncer colorrectal en el ámbito laboral en Argentina / Formative research for the design and implementation of a strategy to increase colorectal cancer screening in the workplace in Argentina / Pesquisa formativa para a estruturação e implementação de uma estratégia para aumentar o rastreamento do câncer colorretal no local de trabalho na Argentina

Resumen: El ámbito laboral tiene un gran potencial para difundir información e implementar actividades de promoción de la salud, como la prevención y detección temprana del cáncer. Debido al desafío de implementar intervenciones sanitarias en este ámbito, se necesitan investigaciones formativas para adecuar el diseño y la implementación de las estrategias para que sean exitosas. Con el objetivo de informar el diseño e implementación de la intervención, para mejorar la tasa de adherencia al tamizaje con el test de sangre oculta en materia fecal, en un ámbito laboral en Argentina, se realizó una investigación formativa para identificar potenciales barreras y facilitadores. La investigación formativa siguió un diseño metodológico cualitativo. Se realizaron entrevistas con 10 responsables de áreas clave de la institución en que se desarrolló el estudio y 8 grupos focales con trabajadores mayores de 50 años. Se identificaron desafíos para la implementación de la intervención en el nivel institucional, como la dispersión geográfica de los trabajadores y la complejidad del organigrama de la institución, y en el nivel de la población objetivo, como el bajo conocimiento del cáncer colorrectal y de los test diagnósticos, así como la baja percepción de riesgo. Entre los facilitadores se destacaron la aceptabilidad de la intervención, además de la disponibilidad de recursos humanos y materiales para llevar adelante la intervención, como canales de comunicación institucional para la diseminación de información, así como la logística para la distribución de kits diagnósticos. La investigación formativa permitió relevar recursos e identificar potenciales barreras que informaron el diseño y la implementación de la intervención.

Abstract: The workplace has great potential to disseminate information and implement health promotion activities such as cancer prevention and early detection. Due to the challenges of deploying health interventions in this setting, formative studies are needed to adjust the design and implementation of successful strategies. To inform the intervention's design and implementation and improve the adherence rate to screening with fecal occult blood test in a workplace in Argentina, a formative study was conducted to identify potential barriers and facilitators. The formative study adopted a qualitative methodological design. Interviews were held with 10 individuals in charge of key areas in the institution where the main study was conducted, besides 8 focus groups with workers over 50 years of age. Challenges were identified at the institutional level for the intervention's implementation, such as workers' geographic dispersion and the complexity of the institution's flowchart, as well as at the population level, such as low knowledge about colorectal cancer and diagnostic tests and low risk perception. The facilitators featured the intervention's acceptability and the availability of human and material resources to proceed with the intervention, such as institutional communications channels for disseminating the information and logistics for distribution of diagnostic kits. The formative study allowed identifying resources and potential barriers that informed the intervention's design and implementation.

Resumo: O local de trabalho possui grande potencial para divulgar informação e implementar atividades de promoção da saúde, como a prevenção e detecção precoce do câncer. Frente ao desafio de implementar ações sanitárias naquele ambiente, são necessárias pesquisas formativas para adequar a estruturação e a implementação das estratégias para que sejam bem-sucedidas. Com o objetivo de subsidiar a concepção e a implementação da ação, visando melhorar a taxa de aderência ao screening com o teste de sangue oculto nas fezes no ambiente de trabalho na Argentina, foi desenvolvida uma pesquisa formativa para identificar potenciais barreiras e facilitadores. A pesquisa formativa seguiu um formato metodológico qualitativo. Foram realizadas entrevistas com 10 gerentes de áreas chaves da entidade onde foi desenvolvido o estudo e 8 grupos focais, com trabalhadores acima de 50 anos de idade. Foram identificados alguns desafios para a implementação de uma ação em nível institucional, como a dispersão geográfica dos trabalhadores e a complexidade do organograma da entidade, e em termos de população objetiva, como o baixo conhecimento a respeito do câncer colorretal e dos testes diagnósticos, além da baixa percepção de risco. Entre os facilitadores, destacaram-se a aceitabilidade da ação e a disponibilidade de recursos humanos e materiais para levar a cabo a ação, como canais de comunicação institucional, para a divulgação da informação e a logística, para a distribuição dos kits diagnósticos. A pesquisa formativa revelou recursos e identificou potenciais barreiras, ajudando na estruturação e implementação da ação.