Characterisation, symptom pattern and symptom clusters from a retrospective cohort of Long COVID patients in primary care in Catalonia.

BACKGROUND: Around 10% of people infected by SARS-COV-2 report symptoms that persist longer than 3 months. Little has been reported about sex differences in symptoms and clustering over time of non-hospitalised patients in primary care settings. METHODS: This is a descriptive study of a cohort of mainly non-hospitalized patients with a persistence of symptoms longer than 3 months from the clinical onset in co-creation with the Long Covid Catalan affected group using an online survey. Recruitment was from March 2020 to June 2021. Exclusion criteria were being admitted to an ICU, < 18 years of age and not living in Catalonia. We focused on 117 symptoms gathered in 18 groups and performed cluster analysis over the first 21 days of infection, at 22-60 days, and ≥ 3 months. RESULTS: We analysed responses of 905 participants (80.3% women). Median time between symptom onset and the questionnaire response date was 8.7 months. General symptoms (as fatigue) were the most prevalent with no differences by sex, age, or wave although its frequency decreased over time (from 91.8 to 78.3%). Dermatological (52.1% in women, 28.5% in men), olfactory (34.9% women, 20.9% men) and neurocognitive symptoms (70.1% women, 55.8% men) showed the greatest differences by sex. Cluster analysis showed five clusters with a predominance of Taste & smell (24.9%) and Multisystemic clusters (26.5%) at baseline and _Multisystemic (34.59%) and Heterogeneous (24.0%) at ≥3 months. The Multisystemic cluster was more prevalent in men. The Menstrual cluster was the most stable over time, while most transitions occurred from the Heterogeneous cluster to the Multisystemic cluster and from Taste & smell to Heterogeneous. CONCLUSIONS: General symptoms were the most prevalent in both sexes at three-time cut-off points. Major sex differences were observed in dermatological, olfactory and neurocognitive symptoms. The increase of the Heterogeneous cluster might suggest an adaptation to symptoms or a non-specific evolution of the condition which can hinder its detection at medical appointments. A carefully symptom collection and patients' participation in research may generate useful knowledge about Long Covid presentation in primary care settings.

Menstrual characteristics and associations with sociodemographic factors and self-rated health in Spain: a cross-sectional study.

BACKGROUND: Evidence on how menstrual characteristics may differ based on socioeconomic factors and self-rated health is significantly scarce. The main aim of this study was to investigate the associations between menstrual characteristics, sociodemographic factors and self-rated health among women and people who menstruate (PWM) aged 18-55 in Spain. METHODS: This cross-sectional study includes data from an online survey collected in March-July 2021 across Spain. Descriptive statistical analyses and multivariate logistic regression models were performed. RESULTS: The analyses included a total of 19,358 women and PWM. Mean age at menarche was 12.4 (SD = 1.5). While 20.3% of our participants experienced a menstrual abundance over 80 ml, 64.1% reported having menstrual blood clots; 6.4% menstruated for longer than 7 days. 17.0% had menstrual cycles that were shorter than 21 days or longer than 35 days. Reports of moderate (46.3%) and high (22.7%) intensity menstrual pain were common. 68.2% of our participants experienced premenstrual symptoms in all or most cycles. The odds for lighter menstrual flow, shorter bleeding days and menstrual cycles were higher as age increased, and amongst participants with less educational attainment. Caregivers presented higher odds for abundant menstrual flow and longer menstruations. Reporting financial constraints and a poorer self-rated health were risk factors for abundant menstrual flow, menstrual blood clots, shorter/longer menstruations and menstrual cycles, premenstrual symptoms, moderate and intense menstrual pain. CONCLUSIONS: This study suggests that age, educational attainment, caregiving, experiencing financial hardship and a poorer self-rated health may shape or mediate menstrual characteristics. It thus highlights the need to investigate and address social inequities of health in menstrual research.

Perspectives on menstrual policymaking and community-based actions in Catalonia (Spain): a qualitative study.

BACKGROUND: Menstrual research and policymaking have become imperative worldwide. It is necessary that these are informed by women and people who menstruate (PWM) alongside expert professionals and activists. METHODS: The main aim of this study was to identify and propose policies and community-based actions to address menstrual inequity and promote menstrual health in Catalonia (Spain). This study consisted of two qualitative studies: (a) 34 individual photoelicitation interviews with women and PWM, (b) a World Café study with 22 professionals and activists. Sampling for both studies was purposive and selective. Recruitment was conducted through healthcare centres, social media, key contacts, and snowball sampling techniques. Data were collected in December 2020-September 2022, and analysed using Framework Analysis. RESULTS: Participants considered the implementation of menstrual policies that address the taboo and stigma of menstruation to be crucial. They stressed the need for menstrual education, which should be integrated into formal education curricula. Participants, and especially women and PWM, highlighted the need to improve the access and quality of healthcare services, so that the menstrual cycle and menstruation are seen as health indicators. Health professionals should encourage agentic informed decisions, hence why both participant groups considered menstrual health education amongst health professionals to be pivotal. Taking action to improve the access and affordability of menstrual products was also imperative for participants, especially for socioeconomically vulnerable populations. Participants agreed on guaranteeing fully equipped menstrual management facilities, and and professionals discussed gender-neutral and sex-segregated bathrooms. Workplace menstrual policies to accommodate and ensure menstrual self-care were also suggested. CONCLUSIONS: Our study highlights the need for multi-dimensional menstrual policies. These should include actions to address menstrual taboo and stigma, to promote menstrual education that goes beyond the hegemonic biomedical prism, to improve the access and quality of menstrual health services, along with policies ensuring adequate menstrual management facilities in public spaces and the access to menstrual products. Policymaking should also focus on how to ensure menstrual management and care in workplaces. Menstrual policies and community-based actions should be framed within intersectionality, to consider how societal structures of power and oppression influence menstrual experiences.

RESUMEN: INTRODUCCIóN: Siendo la investigación y la implementación de políticas menstruales imprescindibles, es necesario que estos procesos estén informados por mujeres y personas que menstrúan (PM), así como por profesionales expertas y activistas. MéTODOS: El objetivo principal de este estudio fue identificar y proponer políticas y acciones comunitarias para abordar la inequidad menstrual y promover la salud menstrual en Cataluña (España). Este estudio consistió en dos estudios cualitativos: (a) 34 entrevistas individuales de fotoelicitación con mujeres y PM, (b) un World Café con 22 profesionales y activistas. El muestreo para ambos estudios fue intencional y selectivo. El reclutamiento se realizó a través de centros de salud, redes sociales, contactos clave y técnicas de bola de nieve. Los datos se recogieron entre diciembre de 2020 y septiembre de 2022 y se analizaron mediante Framework Analysis. RESULTADOS: Las participantes consideraron crucial la implementación de políticas menstruales para abordar el tabú y el estigma menstrual. Destacaron la necesidad de una educación menstrual, que debería integrarse en los currículums escolares. Las participantes, y especialmente las mujeres y PM, resaltaron la necesidad de mejorar el acceso y la calidad de los servicios de salud, de manera que el ciclo menstrual y la menstruación sean consideradas indicadores de salud. Mencionaron que el personal sanitario debe fomentar las decisiones informadas, de ahí que ambos grupos de participantes consideraran fundamental la educación sobre la salud menstrual entre los profesionales de la salud. También, para las participantes fue imperativo asegurar el acceso y asequibilidad de productos menstruales, especialmente para las poblaciones socioeconómicamente vulnerabilizadas. Las participantes estuvieron de acuerdo en la necesidad de garantizar espacios equipadas para el manejo menstrual, y se llevaron a cabo debates entre las profesionales sobre los baños inclusivos y segregados por sexo. También se sugirieron y debatieron políticas menstruales en entornos laborales, para adaptar y garantizar el autocuidado menstrual. CONCLUSIONES: Nuestro estudio destaca la necesidad de políticas menstruales multidimensionales. Estas deberían incluir acciones para abordar el tabú y el estigma menstrual, promover una educación menstrual que vaya más allá de la perspectiva biomédica hegemónica, mejorar el acceso y la calidad de los servicios de salud menstrual, junto con políticas para garantizar la disponibilidad de instalaciones adecuadas para el manejo menstrual en espacios públicos, así como el acceso a productos menstruales. La creación de políticas también debería centrarse en cómo garantizar el manejo y los cuidados menstruales en entornos laborales. Finalmente, estas políticas menstruales y acciones comunitarias deben enmarcarse desde la interseccionalidad, para considerar cómo las estructuras y poderes sociales operan e influyen en las experiencias menstruales.

Impact of a multicomponent healthcare intervention on glycaemic control in subjects with poorly controlled type 2 diabetes: The INTEGRA study.

AIM: To evaluate whether a specially designed multicomponent healthcare intervention improves glycaemic control in subjects with poorly controlled type 2 diabetes. MATERIALS AND METHODS: A cluster, non-randomized, controlled, pragmatic trial in subjects from 11 primary care centres with type 2 diabetes and HbA1c of more than 9% (> 75 mmol/mol) was conducted. The intervention (N = 225 subjects) was professional and patient-centred, including a dedicated monographic visit that encouraged therapeutic intensification by physicians. The sham control (N = 181) was identical to that of the intervention group except that the dedicated visit was omitted. The primary outcome was to compare the reductions in HbA1c values between the groups at 12 months of follow-up. RESULTS: The mean age at baseline was 59.5 years, mean diabetes duration was 10.7 years and mean HbA1c was 10.3% (89.0 mmol/mol). Patients in the intervention arm achieved significantly greater HbA1c reduction than those in the sham control group at 12 months (mean difference -0.62%, 95% CI = -0.2%, -1.04%; P = .002). A larger percentage of intervention participants achieved an HbA1c of less than 8% (44.8% vs. 25.5%; P = .003) and were more frequently treated with more than three antidiabetic therapies (14.4% vs. 3.5%; P = .0008). Intervention was the only variable associated with higher odds of HbA1c less than 8% (odds ratio = 2.52; 95% CI = 1.54-4.12; P < .001). CONCLUSIONS: A multicomponent intervention including a dedicated visit oriented at reducing therapeutic inertia by primary care physicians can improve glycaemic control in poorly controlled patients with type 2 diabetes.

Menstruation and social inequities in Spain: a cross-sectional online survey-based study.

BACKGROUND: Available research suggests that menstrual inequity has an impact on (menstrual) health outcomes and emotional wellbeing. It is also a significant barrier to achieve social and gender equity and compromises human rights and social justice. The aim of this study was to describe menstrual inequities and their associations with sociodemographic factors, among women and people who menstruate (PWM) aged 18-55 in Spain. METHODS: A cross-sectional survey-based study was conducted in Spain between March and July 2021. Descriptive statistical analyses and multivariate logistic regression models were performed. RESULTS: A total of 22,823 women and PWM were included in the analyses (Mean age = 33.2, SD = 8.7). Over half of the participants had accessed healthcare services for menstruation (61.9%). The odds for accessing menstrual-related services were significantly higher among participants with university education (aOR: 1.48, 95% CI, 1.13-1.95). Also, 57.8% reported having had partial or no menstrual education pre-menarche, with odds being higher among participants born in non-European or Latin American countries (aOR: 0.58, 95% CI, 0.36-0.93). Lifetime self-reported menstrual poverty was between 22.2-39.9%. Main risk factors for menstrual poverty were identifying as non-binary (aOR: 1.67, 95% CI, 1.32-2.11), being born in non-European or Latin American countries (aOR: 2.74, 95% CI, 1.77-4.24), and not having a permit to reside in Spain (aOR: 4.27, 95% CI, 1.94-9.38). Completed university education (aOR: 0.61, 95% CI, 0.44-0.84) and no financial hardship < 12 months (aOR: 0.06, 95% CI, 0.06-0.07) were protective factors for menstrual poverty. Besides, 75.2% reported having overused menstrual products due to lack of access to adequate menstrual management facilities. Menstrual-related discrimination was reported by 44.5% of the participants. Non-binary participants (aOR: 1.88, 95% CI, 1.52-2.33) and those who did not have a permit to reside in Spain (aOR: 2.11, 95% CI, 1.10-4.03) had higher odds of reporting menstrual-related discrimination. Work and education absenteeism were reported by 20.3% and 62.7% of the participants, respectively. CONCLUSIONS: Our study suggests that menstrual inequities affect a high number of women and PWM in Spain, especially those more socioeconomically deprived, vulnerabilised migrant populations and non-binary and trans menstruators. Findings from this study can be valuable to inform future research and menstrual inequity policies.

RESUMEN: INTRODUCCIóN: Investigación previa disponible indica que la inequidad menstrual tiene un impacto en los resultados de salud (menstrual) y en el bienestar emocional. Es también una barrera para la equidad social y de género. El objetivo de este estudio es evaluar la inequidad menstrual y las asociaciones con factores sociodemográficos, en mujeres y personas que menstrúan entre 18-55 años en España. MéTODOS: Este es un estudio transversal, basado en una encuesta, llevado a cabo en España entre marzo y julio de 2021. Se realizaron análisis descriptivos y modelos de regresión logística multivariados.  RESULTADOS: Los análisis se realizaron con los datos de 22,823 mujeres y personas que menstrúan. Más de la mitad de las participantes habían accedido a servicios sanitarios para la menstruación (60.5%). La probabilidad de acceder a servicios sanitarios para la menstruación fue significativamente más alta en participantes con educación universitaria (aOR: 1.48, 95% CI, 1.13-1.95). El 57.8% informó no haber tenido educación menstrual o que ésta fuera parcial, pre-menarquia; la probabilidad fue más alta en participantes que no habían nacido en países europeos o latinoamericanos (aOR: 0.58, 95% CI, 0.36-0.93). La pobreza menstrual durante el ciclo vital se reportó en el 22.2-39.9% de las participantes. Los principales factores de riesgo fueron identificarse como persona no binaria (aOR: 1.67, 95% CI, 1.32-2.11), nacer en países fuera de Europa o Latinoamérica (aOR: 2.74, 95% CI, 1.77-4.24), y no tener papeles para residir en España (aOR: 4.27, 95% CI, 1.94-9.38). Tener estudios universitarios (aOR: 0.61, 95% CI, 0.44-0.84) y no haber reportado problemas económicos en los últimos 12 meses (aOR: 0.06, 95% CI, 0.06-0.07) fueron factores protectores para la pobreza menstrual. Además, el 74.6% indicó haber sobreutilizado productos menstruales por no haber tenido acceso a espacios adecuados para el manejo menstrual. El 42.6% de las participantes comunicaron experiencias de discriminación menstrual. Participantes no binarios (aOR: 1.88, 95% CI, 1.52-2.33) y aquellas que no tenían papeles (aOR: 2.11, 95% CI, 1.10-4.03) presentaron una mayor probabilidad de indicar discriminación menstrual. El absentismo laboral y escolar fue indicado por el 18.3% y el 56.6% de las participantes respectivamente. CONCLUSIONES: Nuestro estudio sugiere que la inequidad menstrual afecta a un número significativo de mujeres y personas que menstrúan en España y, especialmente, a aquellas en situaciones de mayor deprivación socioeconómica, algunos colectivos vulnerabilizados de personas migradas, y a personas no binarias y trans que menstrúan. Los resultados de este estudio pueden ser útiles para investigación futura, así como para el desarrollo de políticas públicas de equidad menstrual.

A qualitative exploration of patient safety in a hospital setting in Spain: Policy and practice recommendations on patients' and companions' participation.

INTRODUCTION: Patients' and companions' participation in healthcare could help prevent adverse events, which are a significant cause of disease and disability. Before designing interventions to increase participation, it is first necessary to identify attitudes to patient safety. This study aimed to explore patients' and companions' perceptions, attitudes and experiences of patient safety, taking into account contextual factors, such as cultural background, which are not usually captured in the literature. METHODS: We conducted a qualitative study with a theoretical sampling of 13 inpatients and 3 companions in a university hospital in Barcelona, Spain. Information was obtained from individual and triangular interviews. A descriptive thematic content analysis was conducted by four analysts and a consensus was reached within the research team on the key categories that were identified. We also conducted a card-sorting exercise. RESULTS: All informants emphasized the role of good communication with health professionals, a calm environment and the need for patient education. Discursive positions differed by cultural background. Informants from a Pakistani-Bangladeshi background emphasized language barriers, while those from European and Latin-American backgrounds stressed health professionals' lack of time and the need for more interdisciplinary teamwork. The card-sorting exercise identified several opportunities to enhance participation: checking patient identification and medication dispensation, and maintaining personal and environmental hygiene. CONCLUSION: This exploration of informants' discourse on patient safety identified a wide variety of categories not usually considered from institutional perspectives. The findings of this study could enrich interventions in areas with diverse cultural backgrounds, as well as current frameworks based exclusively on institutional perspectives. PATIENT OR PUBLIC CONTRIBUTION: The results of the study were communicated to patients and accompanying persons via telephone or email. Similarly, a focus group was held with a patient forum to comment on the results. In the design of subsequent interventions to improve patient safety at the hospital, the proposals of patients and companions for their participation will be included together with healthcare professionals' opinions.

[The Research Network on Preventive Activities and Health Promotion (redIAPP): a reference network and promoter of primary care research]. / La Red de Investigación en Actividades Preventivas y Promoción de la Salud (redIAPP): una red de referencia e impulsora de la investigación en atención primaria.

The Research Network on Preventive Activities and Health Promotion (redIAPP), a reference network and promoter of primary care research was created in 2003 thanks to the program Thematic Networks for Cooperative Research in Health (RETICS) of the Instituto de Salud Carlos III (ISCIII). Its creation has meant a radical change in the situation of research in primary care. Throughout its 19 years (2003-2021), different research groups and autonomous communities have participated, and different lines of research have been developed with numerous projects and publications. Despite the difficulties suffered, it has created a collaborative research experience between different autonomous communities with great vitality and with important results for primary care. The redIAPP, therefore, has been a great reference for research in primary care and for the deepening of its area of knowledge. Several lines of improvement are suggested for the future of primary care research.

Experiences of menstrual inequity and menstrual health among women and people who menstruate in the Barcelona area (Spain): a qualitative study.

INTRODUCTION: Menstrual health and menstrual inequity have been neglected in social, economic, healthcare and political spheres. Although available evidence is scarce, it already suggests a link between experiencing menstrual inequity (which refers to the systematic disparities in accessing menstrual health and education, menstrual products and spaces for menstrual management, among other aspects) and menstrual health outcomes. The aim of this study was to explore experiences of menstrual health and menstrual inequity among women and people who menstruate aged 18-55 in Barcelona and surrounding areas (Spain). METHODS: A qualitative study, using a critical feminist perspective, was conducted. Sampling was purposeful and selective. Recruitment was through sexual and reproductive health centres, social media and snowball sampling techniques. Thirty-four semi-structured photo-elicitation interviews were conducted between December 2020 and February 2021. Interviews took place in sexual and reproductive health centres, public spaces, and by telephone. Data were analysed using Reflexive Thematic Analysis. RESULTS: Three themes were identified: "Systemic neglect of menstruation and the menstrual cycle", "When "the private" becomes public: menstrual management" and "Navigating menstrual health: between medicalization and agency". Experiences of menstrual inequity appeared to be widespread among participants. They referred to the impact of having to conceal menstruation and the barriers to managing menstruation in public spaces. Choosing menstrual products was often influenced by price and availability; several participants reported menstrual poverty. A general lack of menstrual education was described. Menstrual education was usually gained through personal experience and self-learnings, or through families and friends. Menstruation and the menstrual cycle had a significant impact on participants' day-to-day. Accessing and navigating the healthcare system was challenging, as participants mostly reported feeling dismissed and almost exclusively offered hormonal contraception as a panacea to address menstrual health. CONCLUSIONS: The impact of menstrual inequity appears to be far-reaching. Multidimensional structural policies should promote agency in individuals and communities to enable opportunities for menstrual education, access to menstrual products, healthcare services and adequate menstrual-management facilities. Health professionals' training is also necessary to improve access to and quality of menstrual healthcare. Policies need to be inclusive of non-binary and trans people, and vulnerable populations.

Effectiveness of a multidisciplinary BIOPSYCHOSOCIAL intervention for non-specific SUBACUTE low back pain in a working population: a cluster randomized clinical trial.

BACKGROUND: Low back pain (LBP) is a multifactorial condition with individual and societal impact that affects populations globally. Current guidelines for the treatment of LBP recommend pharmacological and non-pharmacological strategies. The aim of this study was to compare usual clinical practice with the effectiveness of a biopsychosocial multidisciplinary intervention in reducing disability, severity of pain and improving quality of life in a working population of patients with subacute (2-12 weeks), non-specific LBP. METHODS: Longitudinal cluster randomized clinical trial conducted in 39 Primary Health Care Centres (PHCC) of Barcelona, with patients aged 18-65 years (n = 501; control group = 239; 26 PHCC, intervention group = 262; 13 PHCC). The control group received usual clinical care. The intervention group received usual clinical care plus a biopsychosocial multidisciplinary intervention, which consisted of physiotherapy, cognitive-behavioural therapy and medication. The main outcomes were changes in the Roland Morris Disability Questionnaire (RMDQ), and the minimal clinically important differences. Secondary outcomes were changes in the McGill Pain (MGPQ) and Quality of Life (SF-12) questionnaires. Assessment was conducted at baseline, 3 and 12 months. Analysis was by intention-to-treat and analyst-blinded. Multiple imputations were used. RESULTS: Of the 501 enrolled patients, 421 (84%) provided data at 3 months, and 387 (77.2%) at 12 months. Mean age was 46.8 years (SD: 11.5) and 64.7% were women. In the adjusted analysis of the RMDQ outcome, only the intervention group showed significant changes at 3 months (- 1.33 points, p = 0.005) and at 12 months (- 1.11 points, p = 0.027), but minimal clinically important difference were detected in both groups. In the adjusted analysis of the RMDQ outcome, the intervention group improvement more than the control group at 3 months (- 1.33 points, p = 0.005) and at 12 months (- 1.11 points, p = 0.027). The intervention group presented a significant difference. Both groups presented a minimal clinically important difference, but more difference in the intervention group. The intervention group presented significant differences in the MGPQ scales of current pain intensity and VAS scores at 3 months. No statistically significant differences were found in the physical and mental domains of the SF-12. CONCLUSIONS: A multidisciplinary biopsychosocial intervention in a working population with non-specific subacute LBP has a small positive impact on disability, and on the level of pain, mainly at short-term, but no difference on quality of life. TRIAL REGISTRATION: ISRCTN21392091 (17 oct 2018) (Prospectively registred).

INTEGRA study protocol: primary care intervention in type 2 diabetes patients with poor glycaemic control.

BACKGROUND: The management of hyperglycaemia and associated cardiovascular risk factors in patients with type 2 diabetes mellitus (T2DM) may reduce diabetes-related complications. The strategy to broaden the knowledge base of primary care professionals to improve health care has mainly been prompted by the current reality of limited resources and access to specialized care. The main objective of this study is to assess the effectiveness of comprehensive interventions focused on treatment intensification, decrease clinical inertia and reduce possible barriers to treatment adherence in patients with poorly controlled diabetes in a primary care setting. METHODS: This is a two-phase mixed method study, whose aims are the development of complex interventions and the assessment of their effectiveness. The main study outcome is a change in glycated haemoglobin (HbA1c) levels. The INTEGRA study is divided into two phases. Phase 1: A qualitative study with a phenomenological approach using semi-structured interviews with the objective of determining the factors related to the participants and health care professionals that influence the development and implementation of a specific intervention strategy aimed at patients with poor glycaemic control of T2DM in primary care. Phase 2: Exploratory intervention study to be conducted in Primary Health Care Centres in Catalonia (Spain), including 3 specific health care areas. The intervention study has two arms: Intervention Group 1 and 2. Each intervention group will recruit 216 participants (the same as in the control group) between the ages of 30 and 80 years with deficient glycaemic control (HbA1c > 9%). The control group will be established based on a randomized selection from the large SIDIAP (Sistema d'Informació per al desenvolupament de la Investigació en Atenció Primària) database of patients with comparable socio-demographic and clinical characteristics from the three provinces. DISCUSSION: This study is a comprehensive, pragmatic intervention based on glycaemic treatment intensification and the control of other cardiovascular risk factors. It is also aimed at improving treatment adherence and reducing clinical inertia, which could lead to improved glycaemic control and could likewise be feasible for implementation in the actual clinical practice of primary care. TRIAL REGISTRATION: Clinicaltrials.gov . registration number. NCT02663245; January 25, 2016.

Social Risk and Mortality: A Cohort Study in Patients With Advanced Heart Failure.

BACKGROUND: Heart failure (HF) is a chronic condition that usually leads to death a few years after diagnosis. Although several clinical factors have been found to be related to increased mortality, less is known about the impact of social context, especially at the end stage of the disease. Knowing about social context is important to properly classify risk and provide holistic management for patients with advanced HF. OBJECTIVE: The aim of this study was to determine the impact of social context on mortality in patients with advanced HF. METHODS: A retrospective cohort study was conducted using data from clinical records on community-dwelling patients with HF and with New York Heart Association IV functional class living in Catalonia in northeastern Spain. Clinical data, patient dependency for basic activities of daily living, and social assessments were collected between 2010 and 2013. The primary outcome was all-cause mortality. RESULTS: Data from 1148 New York Heart Association class IV patients were analyzed. Mean (SD) age was 82 (9.0) years, and 61.7% were women. The mean (SD) follow-up was 18.2 (11.9) months. Mortality occurred in 592 patients. Social risk was identified in 63.6% of the patients, and 9.3% acknowledged having social problems. In the adjusted multivariate model, being male (hazard ratio (HR), 1.82; 95% confidence interval [CI], 1.16-2.83), having high dependency on others for basic activities of daily living (HR, 2.16; 95% CI, 1.21-3.85), and presenting with a social problem (HR, 2.46; 95% CI, 1.22-4.97) were related to an increased risk of mortality. CONCLUSIONS: An unfavorable social profile is an independent risk factor for mortality in patients with advanced HF.

Talking to the people that really matter about their participation in pandemic clinical research: A qualitative study in four European countries.

BACKGROUND: Pandemics of new and emerging infectious diseases are unpredictable, recurrent events that rapidly threaten global health and security. We aimed to identify public views regarding provision of information and consent to participate in primary and critical care clinical research during a future influenza-like illness pandemic. METHODS: Descriptive-interpretive qualitative study, using focus groups (n = 10) and semi-structured interviews (n = 16), with 80 members of the public (>18 years) in Belgium, Spain, Poland and the UK. Local qualitative researchers followed a scenario-based topic guide to collect data. Data were transcribed verbatim, translated into English and subject to framework analysis. RESULTS: Public understandings of pandemics were shaped by personal factors (illness during the previous H1N1 pandemic, experience of life-threatening illness) and social factors (historical references, media, public health information). Informants appreciated safeguards provided by ethically robust research procedures, but current enrolment procedures were seen as a barrier. They proposed simplified enrolment processes for higher risk research and consent waiver for certain types of low-risk research. Decision making about research participation was influenced by contextual, research and personal factors. Informants generally either carefully weighed up various approaches to research participation or responded instinctively. They supported the principle of using routinely collected, anonymized clinical biological samples for research without explicit consent, but regarded this as less acceptable if researchers were motivated primarily by commercial gain. CONCLUSIONS: This bottom-up approach to ascertaining public views on pandemic clinical research has identified support for more proportionate research protection procedures for publically funded, low-risk studies.

Health-care users, key community informants and primary health care workers' views on health, health promotion, health assets and deficits: qualitative study in seven Spanish regions.

BACKGROUND: Although some articles have analysed the definitions of health and health promotion from the perspective of health-care users and health care professionals, no published studies include the simultaneous participation of health-care users, primary health care professionals and key community informants. Understanding the perception of health and health promotion amongst these different stakeholders is crucial for the design and implementation of successful, equitable and sustainable measures that improve the health and wellbeing of populations. Furthermore, the identification of different health assets and deficits by the different informants will generate new evidence to promote healthy behaviours, improve community health and wellbeing and reduce preventable inequalities. The objective of this study is to explore the concept of health and health promotion and to compare health assets and deficits as identified by health-care users, key community informants and primary health care workers with the ultimate purpose to collect the necessary data for the design and implementation of a successful health promotion intervention. METHODS: A descriptive-interpretive qualitative research was conducted with 276 participants from 14 primary care centres of 7 Spanish regions. Theoretical sampling was used for selection. We organized 11 discussion groups and 2 triangular groups with health-care users; 30 semi-structured interviews with key community informants; and 14 discussion groups with primary health care workers. A thematic content analysis was carried out. RESULTS: Health-care users and key community informants agree that health is a complex, broad, multifactorial concept that encompasses several interrelated dimensions (physical, psychological-emotional, social, occupational, intellectual, spiritual and environmental). The three participants' profiles consider health promotion indispensable despite defining it as complex and vague. In fact, most health-care users admit to having implemented some change to promote their health. The most powerful motivators to change lifestyles are having a disease, fear of becoming ill and taking care of oneself to maintain health. Health-care users believe that the main difficulties are associated with the physical, social, working and family environment, as well as lack of determination and motivation. They also highlight the need for more information. In relation to the assets and deficits of the neighbourhood, each group identifies those closer to their role. CONCLUSIONS: Generally, participants showed a holistic and positive concept of health and a more traditional, individual approach to health promotion. We consider therefore crucial to depart from the model of health services that focuses on the individual and the disease toward a socio-ecological health model that substantially increases the participation of health-care users and emphasizes health promotion, wellbeing and community participation.

Beyond the consultation room: Proposals to approach health promotion in primary care according to health-care users, key community informants and primary care centre workers.

BACKGROUND: Primary health care (PHC) is the ideal setting to provide integrated services centred on the person and to implement health promotion (HP) activities. OBJECTIVE: To identify proposals to approach HP in the context of primary care according to health-care users aged 45-75 years, key community informants and primary care centre (PCC) workers. METHODS: Descriptive-interpretive qualitative research with 276 participants from 14 PCC of seven Spanish regions. A theoretical sampling was used for selection. A total of 25 discussion groups, two triangular groups and 30 semi-structured interviews were carried out. A thematic interpretive contents analysis was carried out. RESULTS: Participants consider that HP is not solely a matter for the health sector and they emphasize intersectoral collaboration. They believe that it is important to strengthen community initiatives and to create a healthy social environment that encourages greater responsibility and participation of health-care users in decisions regarding their own health and better management of public services and resources. HP, care in the community and demedicalization should be priorities for PHC. Participants propose organizational changes in the PCC to improve HP. PCC workers are aware that HP falls within the scope of their responsibilities and propose to increase their training, motivation, competences and knowledge of the social environment. Informants emphasize that HP should be person-centred approach and empathic communication. HP activities should be appealing, ludic and of proven effectiveness. CONCLUSIONS: According to a socio-ecological and intersectoral model, PHC services must get actively involved in HP together with community and through outreach interventions.

Understanding knee osteoarthritis from the patients' perspective: a qualitative study.

BACKGROUND: No studies of Health Coach Interventions for knee OA sufferers that include patients' perspectives have been published. The study assesses current clinical practice and primary care professionals' advice from the patients' perspective, in order to obtain a participative design for a complex intervention based on coaching psychology. Moreover, wants to analyse the experiences, perceptions, cognitive evaluation, values, emotions, beliefs and coping strategies of patients with knee osteoarthritis, and secondly the impact of these factors in the Self-management of this condition. METHODS: It is an interpretative qualitative study. The study included patients with diagnosis of knee osteoarthritis (OA) from 4 primary health care centres in Barcelona. A theoretical sampling based on a prior definition of participants' characteristics was carried out. Ten semi-structured interviews with knee OA patients were carried out. A content thematic analysis was performed following a mixed-strategy text codification in Lazarus framework and in emerging codes from the data. RESULTS: The results are structured in two blocks: Experiences and perceptions of informants and Experiences of knee osteoarthritis according to the Lazarus model. Regarding experiences and perceptions of informants: Some participants reported that the information was mostly provided by health professionals. Informants know which food they should eat to lose weight and the benefits of weight loss. Moreover, participants explained that they like walking but that sometimes it is difficult to put into practice. Regarding experiences of knee osteoarthritis according Lazarus model: Cognitive evaluation is influenced by cognitive distortions such as obligation, guilt, dramatization and catastrophism. VALUES: Family is the value most associated with wellbeing. Helping others is another recurring value. Emotions: Most participants explain that they feel anxiety, irritability or sadness. Beliefs: To some, physiotherapy helps them feel less pain. However, others explain that it is of no use to them. Participants are aware of the association overweight- pain. Coping strategies: The strategies for coping with emotions aim to reduce psychological distress (anxiety, sadness, anger) and some are more active than others. CONCLUSIONS: The study highlights that patients with knee osteoarthritis require a person-centered approach that provides them with strategies to overcome the psychological distress caused by this condition.

Patients' perceptions and experiences of patient safety in primary care in England.

BACKGROUND: One of the most remarkable features of patient safety research in primary care is the sparse attention paid to patients' own experiences. OBJECTIVE: To explore patient's perceptions and experiences of patient safety in primary care in England. METHODS: We conducted a qualitative study in the South of England with an opportunistic sample of 27 primary care users. Information was obtained from four patient focus groups. A thematic content analysis was conducted by three analysts and consensus reached within the research team on the key themes that emerged. RESULTS: Participants' conceptualizations of patient safety referred to high standards of health care delivery within a relationship of trust. Participants identified four main factors that they believed could potentially affect patient safety. These included factors related to (i) the patient (attitudes, behaviours and health literacy); (ii) the health professional (attitudes, behaviours and accuracy of diagnoses); (iii) the relationship between patients and health professionals (communication and trust); and (iv) the health care system (workload, resources, care coordination, accessibility, interdisciplinary teamwork and accuracy of health care records). Confidentiality, continuity of care and treatment-related safety emerged as cross-cutting major threats to patient safety. CONCLUSIONS: The exploration of participants' perceptions and experiences allowed the identification of a wide variety of themes that were perceived to impact on patient safety in primary care. The findings of this study could be used to enrich current frameworks that are exclusively based on professional or health care system perspectives.

Effectiveness and cost-effectiveness of a health coaching intervention to improve the lifestyle of patients with knee osteoarthritis: cluster randomized clinical trial.

BACKGROUND: The prevalence of osteoarthritis and knee osteoarthritis in the Spanish population is estimated at 17% and 10.2%, respectively. The clinical guidelines concur that the first line treatment for knee osteoarthritis should be non-pharmacological and include weight loss, physical activity and self-management of pain. Health Coaching has been defined as an intervention that facilitates the achievement of health improvement goals, the reduction of unhealthy lifestyles, the improvement of self-management for chronic conditions and quality of life enhancement. The aim of this study is to analyze the effectiveness, cost-effectiveness and cost-utility of a health coaching intervention on quality of life, pain, overweight and physical activity in patients from 18 primary care centres of Barcelona with knee osteoarthritis. METHODS/DESIGN: Methodology from the Medical Research Council on developing complex interventions. Phase 1: Intervention modelling and operationalization through a qualitative, socioconstructivist study using theoretical sampling with 10 in-depth interviews to patients with knee osteoarthritis and 4 discussion groups of 8-12 primary care professionals, evaluated using a sociological discourse analysis. Phase 2: Effectiveness, cost-effectiveness and cost-utility study with a community-based randomized clinical trial. PARTICIPANTS: 360 patients with knee osteoarthritis (180 in each group). Randomization unit: Primary Care Centre. Intervention Group: will receive standard care plus 20-hour health coaching and follow-up sessions. CONTROL GROUP: will receive standard care. MAIN OUTCOME VARIABLE: quality of life as measured by the WOMAC index. Data Analyses: will include standardized response mean and multilevel analysis of repeated measures. Economic analysis: based on cost-effectiveness and cost-utility measures. Phase 3: Evaluation of the intervention programme with a qualitative study. Methodology as in Phase 1. DISCUSSION: If the analyses show the cost-effectiveness and cost-utility of the intervention the results can be incorporated into the clinical guidelines for the management of knee osteoarthritis in primary care. TRIAL REGISTRATION: ISRCTN57405925. Registred 20 June 2014.

The workers opinions have a value in the Code of Ethics: Analysis of the contributions of workers in virtual Forum Catalan Institute of Health.

BACKGROUND: The Catalan Institute of Health (CIH) is the largest health services public provider in Catalonia. "CIH Code of Ethics Virtual Forum" (CEVF), was created within the Intranet of the CIH to facilitate participation among their employees. The current study aims to: a) Analyse the CIH workers' assessment of their own, their colleagues' and the organization's observance of ethical values; b) Identify the opinions, attitudes, experiences and practices related to the ethical values from the discourse of the workers that contributed voluntarily to the CEVF. METHODS: Mixed methods study with convergent parallel design: 1. Cross sectional study by means of a self-administered, ad hoc, anonymous questionnaire to assess the observance of the ethical values of the CIH according to the participants. A total of 712 workers responded to the questionnaire. A descriptive, bivariate analysis of the results was carried out. 2. Qualitative study to determine the meaning for the workers of the ethical values put forward by the organization. Their individual opinions and experiences were explored by means of a thematic contents analysis of 225 comments posted in the CEVF. The study was conducted between May and December 2008. RESULTS: The average score for observance of the CE by the respondents themselves was high (over 4/5), between 3.5-4/5 for the observance by their colleagues and close to 3/5 for the CIH management. These results do not change when we compare by gender, age group and professional discipline. The comments on the values are information-rich, they mirror the ethical environment of the institution and show various ethical dilemmas and suggestions. CONCLUSIONS: Results show that it is feasible for a publicly funded health care organization to develop a CE with the participation of employees and the support of the management. Results underscore the relevance of this strategy for the implementation, improvement and update of the CE as a responsibility shared by all workers. Practices consistent with ethical values are rewarded by social approval, enhance employee's confidence and coherence in decision-making and improve public engagement and institutional policies.

A qualitative exploration of Gestalt therapy and systemic pedagogy paediatric primary healthcare consultations in Agramunt (Spain).

INTRODUCTION: Gestalt therapy (GT) and systemic pedagogy (SP) are useful tools to approach emotional difficulties and mental health problems among children and adolescents. The main objective of this study was to explore the perceptions on GT and SP techniques in paediatric mental health-related consultations in a primary healthcare (PHC) centre in Catalonia in 2018-2019, among families, healthcare, and education professionals. METHODS: Qualitative study, combining semi-structured interviews with families (N = 42) and professionals (N = 15), conducted after a series paediatric PHC consultations including GT and SP techniques. Interviews lasted between 15 and 90 min and were conducted at the PHC centre where GT/SP consultations took place, and at professionals' workplaces. Socio-demographics, reasons for consultation, and quantitative ratings on the perceived effectiveness of GT/SP consultations were also collected to combine these data with the qualitative interviews. Qualitative data were analyzed descriptively using thematic analysis. Quantitative data were analyzed by calculating frequencies (percentages) for categorical variables, and means, medians, and ranges for continuous variables. RESULTS: Narratives from families and healthcare professionals indicate that GT/SP consultations might have been effective in improving children and adolescents' symptomatology and emotional health. Improved well-being within the family context was another main finding, based on families' perceptions and experiences. Besides, GT/SP were considered acceptable for approaching emotional and mental health in PHC services, although barriers for implementation were identified. CONCLUSIONS: This study presents data on the potential usefulness of GT/SP to design and implement services that promote emotional and mental health among children and adolescents in PHC. Also, for the development of health policies and future research in this area.

Building community engagement with caregivers through online interaction and a salutogenic approach in a period of isolation.

Background: Informal caregivers are essential figures that deal with the effects of dependence in the elderly. However, they suffer from poorer health-related quality of life, particularly regarding mental health. Social support is crucial, but this was suspended or dramatically reduced during the Covid-19 pandemic. Salutogenesis theory explores the contributing factors for the promotion and maintenance of health. Considering all these, we offered caregivers the opportunity to join a participatory project aimed at creating communication spaces where they could share experiences, think together about potential solutions, and explore which salutogenic actions they used in their daily basis and how they had changed during Covid-19 restrictions. Methods: We used a qualitative methodology with a socio-constructivist and phenomenological approach and purposive sampling. We organized two focus groups consisting of online semi-structured discussions with seven participants in total. Conversations were videotaped and transcribed and we conducted content thematic analyses using the NVivo software. Results: Caregiving in our setting are primarily women with high levels of education that do not always feel comfortable with this load because it interferes with their personal and professional lives. The pandemic increased caregivers feelings of loneliness, resignation, and burden, directly affecting their mental health. Furthermore, the disappearance of prevention programs and the difficulties to access healthcare services produced negative consequences on the already fragile elderly and their family caregivers. Conclusion: The pandemic and its restrictions exacerbated the problematics affecting informal caregivers. Although these people are aware of their situation and have valued knowledge of how to improve their health, they cannot always put it into practice. We call policymakers to reframe interventions aimed at caregivers by introducing the voice of the community in the planning and to rethink the management of vulnerable people and their carers in other potential health crises.