Validación de cuestionarios para la medición de variables en salud: conceptos fundamentales / Validation of questionnaires for the measurement of health variables: Fundamental concepts

Dentro de la práctica clínica, así como en la salud poblacional, es habitual utilizar cuestionarios que permiten evaluar condiciones o variables que no son directamente observables. No obstante, la construcción y validación de estos instrumentos o cuestionarios suele ser poco conocida. El objetivo de esta revisión narrativa es sintetizar de manera general el proceso de construcción y validación de estos cuestionarios, para así tener una mejor comprensión de este proceso, de los aspectos que se evalúan y de la mejor forma de utilizarlos. La validación de cuestionarios corresponde a un proceso de análisis de este, cuya finalidad es medir una variable latente o constructo, así como sus dimensiones, las que no pueden ser observadas directamente. Una variable latente puede ser inferida a través de un conjunto de atributos específicos que forman parte de ella, como los ítems de un cuestionario y que sí son observables. En este artículo se abordan de manera teórica los conceptos fundamentales de validación de cuestionarios o test, variables latentes o constructos, estudio de la confiabilidad y de la validez, así como los factores que afectan a estas dos últimas características, a través de una revisión narrativa. En el texto, se presentan ejemplos sobre estos conceptos.

In clinical practice and population health, it is common to use questionnaires to assess conditions or variables that are not directly observable. However, the construction and validation of these instruments or questionnaires are often poorly understood. This narrative review aims to summarize in a general way the process of construction and validation of these questionnaires in order to have a better understanding of this process, the aspects that are evaluated, and the best way to use them. The validation of questionnaires corresponds to a process of analysis of the questionnaire, aiming to measure a latent variable and its dimensions, which cannot be observed directly. A latent variable can be inferred through a set of specific attributes that are part of it, such as the items of a questionnaire, which are observable. Through a narrative review, this article addresses the fundamental concepts of questionnaire or test validation, latent variables or constructs, reliability and validity studies, and the factors that theoretically affect the latter two characteristics. Examples of these concepts are presented in the text.

Aspectos generales del uso de métodos mixtos para investigación en salud / General aspects of the use of mixed methods for health research

Tradicionalmente la investigación se ha dividido según su metodología en cuantitativa y cualitativa. La metodología mixta de investigación, que combina ambos métodos, se ha consolidado como una tercera vía, permitiendo abordar de forma integral problemas de investigación de alta complejidad. Aunque existen diversas definiciones sobre la investigación con métodos mixtos, todas ellas comparten aspectos como la recolección y análisis de datos tanto cuantitativos como cualitativos, y la interpretación integrada de los resultados dentro de una misma investigación. Este tipo de investigación es una herramienta importante para abordar la complejidad propia del campo de la salud, permitiendo comprender e integrar los datos cuantitativos con aspectos vivenciales y experienciales. Con ello se logra una perspectiva amplia y profunda de los problemas de salud, dando respuesta a las políticas y servicios sanitarios. Durante el desarrollo de una investigación con métodos mixtos, existen etapas clave donde ambos enfoques pueden integrarse dependiendo de los objetivos planteados por los equipos de investigación. Aunque los estudios con métodos mixtos pueden ser muy diferentes, se han identificado modelos generales que guían el desarrollo de un diseño específico a utilizar. Estos modelos se clasifican según la prioridad de cada enfoque, la secuencia en la que se ejecutará cada enfoque, el nivel y momento de integración de los datos y el propósito de esta integración para el estudio en particular.

Traditionally, research has been divided according to its methodology into quantitative and qualitative. Mixed research methodology combines both methods and has established itself as a third approach, allowing to comprehensively address high-complexity research problems. Although there are various definitions of mixed methods research, they all share aspects such as the collection and analysis of both quantitative and qualitative data and the integrated interpretation of the results within the same research. This type of research is an important tool to address the complexity of health sciences, allowing the understanding and integration of quantitative data with experience-based aspects. In this way, a broad and deep perspective of health problems is achieved, providing a solution to sanitary policies and services. During the development of mixed methods research, there are key stages where both approaches can be integrated depending on the objectives set by the investigators. Although mixed methods studies may differ widely, general models have been identified to guide the development of a single specific design. These models are classified according to the priority of each approach, the sequence in which each approach will be executed, the level and timing of data integration, and the purpose of integrating the data for the study.

Estudio prospectivo descriptivo de las trayectorias de respuesta terapéutica en una cohorte de pacientes con trastorno depresivo mayor

Introducción: El trastorno depresivo mayor (TDM) constituye un problema de salud pública por su alta prevalencia y consecuencias biopsicosociales. Es un desorden clínicamente heterogéneo, complejo y de curso fluctuante. En Chile, no existen estudios sobre trayectorias terapéuticas en TDM. Objetivo: Describir las trayectorias de respuesta clínica en pacientes con TDM en tratamiento en centros de Atención Primaria de Salud (APS) en Chile. Método: Estudio de cohorte prospectiva de cinco meses de seguimiento. Se incluyeron pacientes ingresados en el Programa de Garantías Explícitas en Salud de Depresión de siete centros de APS de la Región de Valparaíso, Chile. Se realizaron cuatro evaluaciones (semanas 0, 4, 12 y 20) para describir variables clínicas y sociodemográficas relacionadas con la evolución. Se elaboraron trayectorias de respuesta en relación con el curso de los síntomas depresivos. Resultados: Se incluyeron 159 participantes (93% fueron mujeres), con un promedio de 43 años de edad. Las condiciones de riesgo para TDM más frecuentemente reportadas fueron el aislamiento social o la escasa red de apoyo y haber presenciado violencia intrafamiliar durante la infancia. Se obtuvo 12 trayectorias de respuesta de un total de 16 patrones posibles. Se observan diferencias al analizar las respuestas terapéuticas entre las semanas 0 y 12 y 0 y 20. Las trayectorias más frecuentes fueron el mantenimiento o empeoramiento de la sintomatología depresiva (37,7%). Conclusiones: Los resultados muestran una variabilidad sintomática durante el transcurso de un TDM. En este seguimiento de cinco meses, más de un tercio de las participantes no mejoraron sus síntomas depresivos.

Introduction: Major depressive disorder (MDD) is a public health problem due to its high prevalence and biopsychosocial consequences. It is a clinically heterogeneous and complex disorder with a fluctuating course. In Chile, there are no studies on clinical trajectories in MDD. Objective: To describe the clinical response trajectories in patients with MDD under treatment in primary care centers (PCC) in Chile. Method: We conducted a prospective cohort study with a five-month follow-up, including patients treated in the Explicit Guarantees in Healthcare program for depression at seven PCC in the Valparaíso Region, Chile. We carried out four evaluations (weeks 0, 4, 12 and 20) to describe various clinical and sociodemographic variables related to the therapeutic evolution. We elaborated response trajectories in relation to the course of depressive symptoms. Results: 159 participants were included (93% women), with an average age of 43 years old. The most frequently reported risk conditions for MDD were social isolation or poor support network and having witnessed domestic violence during childhood. Twelve response trajectories were obtained from a total of 16 possible patterns. Differences were observed when analyzing the therapeutic responses between weeks 0 and 12 and 0 and 20. The most frequent trajectories were the maintenance or worsening of depressive symptoms (37.7%). Conclusions: The results show a symptomatic variability during the course of MDD. In this five-month follow-up, more than a third of the participants did not improve their depressive symptoms.

La salud mental de los trabajadores de salud en Guatemala durante la pandemia de COVID-19: resultados de base del estudio de cohortes HÉROES / Mental health of Guatemalan health care workers during the COVID-19 pandemic: baseline findings from the HEROES cohort study / Saúde mental dos trabalhadores da saúde guatemaltecos durante a pandemia de COVID-19: constatações basais do estudo da coorte HEROES

RESUMEN Objetivos. Evaluar la prevalencia de base de los trastornos de salud mental y exposiciones conexas en una cohorte de trabajadores de salud de Guatemala. Métodos Se analizó la información de base del estudio HÉROES (por COVID-19 HEalth caRe wOrkeRs Study, sobre los trabajadores de salud durante la pandemia) en Guatemala, realizado en línea en el 2020. Las variables de resultado fueron malestar psicológico y síntomas depresivos. Las exposiciones incluyeron experiencias con la COVID-19, características sociodemográficas y características del trabajo. En los análisis se utilizaron modelos de regresión de Poisson brutos y ajustados. Resultados. De los 1801 trabajadores de salud que aceptaron participar, 1522 (84,5%) completaron el cuestionario; 1014 (66,8%) eran mujeres. De los participantes, 59,1% (intervalo de confianza de 95% [IC 95%] = 56,6-61,5) tuvo un tamizaje positivo para malestar psicológico y 23% (IC 95% = 20,9-25,2) para síntomas depresivos de moderados a graves. Las experiencias con la pandemia de COVID-19, las características sociodemográficas y las características del trabajo se correlacionaron con las variables de resultado del estudio. Los participantes que estaban preocupados por el contagio de la COVID-19 tuvieron un mayor riesgo de malestar psicológico (riesgo relativo [RR] = 1,47; IC 95% = 1,30-1,66) y síntomas depresivos (RR = 1,51; IC 95% = 1,17-1,96). Asimismo, los participantes más jóvenes presentaban un riesgo alto de malestar psicológico (RR = 1,80; IC 95% = 1,24-2,63) y síntomas depresivos (razón de posibilidades [OR] = 4,58; IC 95% = 1,51-13,87). Conclusiones. Las afecciones de salud mental tienen una prevalencia sumamente alta en los trabajadores de salud de Guatemala.

ABSTRACT Objectives. To assess the baseline prevalence of mental health conditions and associated exposures in a cohort of health care workers (HCWs) in Guatemala. Methods. We analyzed baseline information from the 2020 Web-based COVID-19 Health Care Workers Study (HEROES)-Guatemala. Outcomes included mental distress and depressive symptoms. Exposures included COVID-19 experiences, sociodemographic characteristics, and job characteristics. We used crude and adjusted Poisson regression models in our analyses. Results. Of the 1801 HCWs who accepted to participate, 1522 (84.5%) completed the questionnaire; 1014 (66.8%) were women. Among the participants, 59.1% (95% confidence interval [CI] = 56.6, 61.5) screened positive for mental distress and 23% (95% CI = 20.9, 25.2) for moderate to severe depressive symptoms. COVID-19 experiences, sociodemographic characteristics, and job characteristics were associated with the study outcomes. Participants who were worried about COVID-19 infection were at higher risk of mental distress (relative risk [RR] = 1.47; 95% CI = 1.30, 1.66) and depressive symptoms (RR = 1.51; 95% CI = 1.17, 1.96). Similarly, the youngest participants were at elevated risk of mental distress (RR = 1.80; 95% CI = 1.24, 2.63) and depressive symptoms (OR = 4.58; 95% CI = 1.51, 13.87). Conclusions. Mental health conditions are highly prevalent among Guatemalan.

RESUMO Objetivos. Avaliar a prevalência basal de condições de saúde mental e exposições associadas em uma coorte de trabalhadores da saúde (TS) na Guatemala. Métodos. Analisamos as informações da linha de base do estudo on-line sobre trabalhadores da saúde e a COVID-19 (HEROES), realizado em 2020 na Guatemala. Os desfechos incluíram angústia debilitante e sintomas de depressão. As exposições incluíram experiências com a COVID-19, características sociodemográficas e características do trabalho. Usamos em nossas análises modelos de regressão bruta e ajustada de Poisson. Resultados. Dos 1801 TS que concordaram em participar, 1522 (84,5%) preencheram o questionário, sendo que 1014 (66,8%) eram mulheres. Dentre esses participantes, 59,1% (intervalo de confiança [IC] de 95%=56,6; 61,5) apresentaram resultado positivo na triagem de angústia debilitante e 23% (IC 95%=20,9, 25,2) apresentaram resultado positivo para sintomas de depressão moderados a graves. Experiências com COVID-19, e características sociodemográficas e de trabalho apresentaram associação com os resultados do estudo. Os participantes que estavam preocupados com infecção por COVID-19 apresentaram maior risco de angústia debilitante (risco relativo [RR]=1,47; IC95%=1,30; 1,66) e sintomas de depressão (RR=1,51; IC 95% =1,17; 1,96). Da mesma maneira, os participantes mais jovens apresentaram alto risco de apresentarem angústia debilitante (RR=1,80; IC 95%=1,24; 2,63) e sintomas de depressão (OR=4,58; IC 95%=1,51; 13,87). Conclusões. Condições de saúde mental são altamente prevalentes entre os guatemaltecos.

El impacto de la pandemia de COVID-19 en la salud mental de los trabajadores de la salud en Chile: datos iniciales de The Health Care Workers Study / Impact of COVID-19 pandemic on the mental health of healthcare workers

Background: Healthcare workers' mental health was affected by SARS-CoV-2 pandemic. Aim: To evaluate healthcare workers' mental health and its associated factors during the pandemic in Chile. Material and Methods: An online self-reported questionnaire was designed including the Goldberg Health Questionnaire, the Patient Health Questionnaire, (PHQ-9), and the Columbia-Suicide Severity Rating Scale among other questions. It was sent to 28,038 healthcare workers. Results: The questionnaire was answered by 1,934 participants, with a median age of 38 years (74% women). Seventy five percent were professionals, and 48% worked at a hospital. Fifty nine percent of respondents had a risk of having a mental health disorder, and 73% had depressive symptoms. Significant associations were found with sex, workplace, and some of the relevant experiences during the pandemic. Fifty one percent reported the need for mental health support, and 38% of them received it. Conclusions: There is a high percentage of health workers with symptoms of psychological distress, depression, and suicidal ideas. The gender approach is essential to understand the important differences found. Many health workers who required mental health care did not seek or received it.

Estudio descriptivo de mortalidad en sobrevivientes de tortura y prisión política en el período de la dictadura militar en Chile, 1973-1990

Background: Studies on the long-term consequences of torture in survivors in Chile have only addressed the consequences for mental health, leaving aside the physical consequences. Aim: To report the causes of death in the universe of victims of the Chilean civic-military dictatorship recognized by the Reports of the National Commission for Political Prison and Torture (CNPPT) and the Advisory Commission for the qualification of Disappeared Detainees, Politically Executed individuals and Victims of Political Prison and Torture. Material and Methods: The causes of death, age at the time of death, sex, political context of death and opportunity of repair up to June 2016 are described in 38,254 victims of the Chilean civic-military dictatorship. Results: Of the universe of 38,254 victims, 9,152 (23.9%) died until June 2016. The median age at death was 68 years. The main causes of death were malignant tumors in 28%, cardiovascular diseases in 27%, respiratory diseases in 10%, digestive diseases in 9% and external causes in 8%. Conclusions: These results can inform prevention and treatment strategies for victims of the Chilean dictatorship.

Stigma towards people with mental disorders: perceptions of devaluation and discrimination in a sample of Chilean workers / Estigma hacia personas con trastornos mentales: percepciones de devaluación y discriminación en una muestra de trabajadores chilenos

Abstract Introduction Mental disorders represent one of the main causes of disease burden in the adult population. Negative public attitudes and behaviors toward people with mental disorders negatively affect the treatment, recovery, and social inclusion of those affected. Chile laks surveys on workers that address this issue. Objective To describe the perceptions of devaluation and discrimination towards people with mental disorders in a sample of Chilean workers. Method A cross-sectional study was carried out with 1 516 workers in the formal sector of four regions of Chile (Metropolitan Region [RM], Bío Bio [VIII], Valparaíso [V] and Coquimbo [IV]). The perception of discrimination and devaluation was explored through a modified version of the The perceived Devaluation-Discrimination Scale (PDD) comprising 15 questions. The relationship of each question with sociodemographic variables (age, sex, years of study, and region) and type of economic activity was assessed. Results The study found a high percentage of perceptions of devaluation and discrimination in most aspects considered, particularly those related to hiring a person who has been hospitalized due to a mental illness (85%), feeling sorry for people with severe mental illnesses (80%), and the unwillingness to marry a person with a mental illness (78%). Significant differences were observed in the opinions by sociodemographic variables and region of residence. Discussion and conclusion The perception of Chilean workers has high levels of stigma towards people living with mental disorders. It is necessary and urgent to develop effective anti-stigma public policies to promote a more inclusive, tolerant society.

Resumen Introducción Los trastornos mentales representan una de las principales causas de carga de morbilidad en la población adulta. Las actitudes y conductas públicas negativas hacia las personas con trastornos mentales inciden negativamente en el tratamiento, la recuperación e inclusión social de las personas afectadas. Chile no cuenta con encuestas en trabajadores que aborden este tema. Objetivo Describir las percepciones de devaluación y discriminación hacia personas con trastornos mentales en una muestra de trabajadores chilenos. Método Se realizó un estudio transversal con 1 516 trabajadores del sector formal de cuatro regiones de Chile (Región Metropolitana [RM], de Bío Bio [VIII], de Valparaíso [V] y de Coquimbo [IV]). Se exploró la percepción de discriminación y devaluación por medio de una versión modificada de la Perceived Devaluation-Discrimination Scale (PDD) con 15 preguntas. Se analizó la relación de cada pregunta con variables sociodemográficas (edad, sexo, años de estudio y región) y tipo de actividad económica. Resultados Se detectó un alto porcentaje de percepción de devaluación y discriminación en la mayoría de los aspectos considerados, destacándose los relacionados con la contratación de una persona que ha sido hospitalizada por una enfermedad mental (85%), sentir pena por las personas con enfermedades mentales graves (80%) y el rechazo a casarse con una persona que tenga una enfermedad mental (78%). Se observaron diferencias significativas en las percepciones, según las variables sociodemográficas y las relativas a la región de residencia. Discusión y conclusión La percepción de los trabajadores en Chile muestra altos niveles de estigma social hacia personas con trastornos mentales. Es necesario y urgente desarrollar políticas públicas antiestigma efectivas, promoviendo al mismo tiempo una sociedad más inclusiva y tolerante.

Implementing the protocol of a pilot randomized controlled trial for the recovery-oriented intervention to people with psychoses in two Latin American cities / Implementação de um protocolo para um estudo piloto randomizado e controlado sobre uma intervenção voltada para a recuperação em pessoas com psicoses em duas cidades latino-americanas / Implementando un protocolo para una prueba piloto controlada aleatorizada en una intervención orientada a la recuperación de personas con psicosis en dos ciudades latinoamericanas

Several Latin American countries have made remarkable strides towards offering community mental health care for people with psychoses. Nonetheless, mental health clinics generally have a very limited outreach in the community, tending to have weaker links to primary health care; rarely engaging patients in providing care; and usually not providing recovery-oriented services. This paper describes a pilot randomized controlled trial (RCT) of Critical Time Intervention-Task Shifting (CTI-TS) aimed at addressing such limitations. The pilot RCT was conducted in Santiago (Chile) and Rio de Janeiro (Brazil). We included 110 people with psychosis in the study, who were recruited at the time of entry into community mental health clinics. Trial participants were randomly divided into CTI-TS intervention and usual care. Those allocated to the intervention group received usual care and, in addition, CTI-TS services over a 9-month period. Primary outcomes include quality of life (WHO Quality of Life Scale - Brief Version) and unmet needs (Camberwell Assessment of Needs) at the 18-month follow-up. Primary outcomes at 18 months will be analyzed by Generalized Estimating Equations (GEE), with observations clustered within sites. We will use three-level multilevel models to examine time trends on the primary outcomes. Similar procedures will be used for analyzing secondary outcomes. Our hope is that this trial provides a foundation for planning a large-scale multi-site RCT to establish the efficacy of recovery-oriented interventions such as CTI-TS in Latin America.

Diversos países latino-americanos já alcançaram avanços notáveis na oferta de assistência em saúde mental para pessoas com psicoses. No entanto, as clínicas de saúde mental geralmente realizam atividades de extensão muito limitadas dentro das comunidades, tendem a ter vínculos fracos com a assistência primária, raramente envolvem os próprios pacientes nos cuidados e poucas vezes prestam serviços orientados para a recuperação. O artigo descreve um estudo piloto randomizado e controlado sobre a Critical Time Intervention-Task Shifting (CTI-TS), que teve como objetivo analisar essas limitações. O estudo piloto foi realizado em Santiago (Chile) e no Rio de Janeiro (Brasil). Teve como meta a inclusão de 110 pessoas com psicose, recrutadas no momento da entrada em clínicas comunitárias de saúde mental. Os participantes foram randomizados para o CTI-TS ou para os cuidados usuais. Aqueles alocados ao grupo da intervenção receberam os cuidados usuais e os serviços de CTI-TS ao longo de 9 meses. Os desfechos primários incluíram a qualidade de vida (WHO Quality of Life Scale - Brief Version) e as necessidades não atendidas (Camberwell Assessment of Needs) no acompanhamento aos 18 meses. Os desfechos primários aos 18 meses serão analisados com a técnica de Equações de Estimação Generalizadas (GEE), com as observações agrupadas dentro dos locais do estudo. Serão utilizados modelos em três níveis para examinar as tendências temporais nos desfechos primários. Procedimentos semelhantes serão utilizados para analisar os resultados secundários. Espera-se que o estudo forneça uma base para planejar um estudo randomizado e controlado em grande escala e em múltiplos locais para estabelecer a eficácia da intervenção orientada para a recuperação, a exemplo da CTI-TS, na América Latina.

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Efecto de acciones de equipos de Atención Primaria de Salud para proteger la salud mental después de desastres naturales / Effect of Primary Health Care team actions to protect mental health after natural disasters

Resumen Introducción Existe alta prevalencia de alteraciones emocionales en la población expuesta a desastres y los centros de atención primaria de salud (APS) podrían contribuir a su prevención. Objetivo Analizar asociaciones post-catástrofe entre variables de APS y variables de salud mental de la población. Método Estudio efectuado en Chile un año después de un terremoto de 8,8° Richter. Se aplicó un cuestionario de intensidad de acciones de salud mental en 16 centros APS y las escalas GHQ-12 y SF-36 para malestar psicológico y calidad de vida en una muestra basada en hogares y otra de consultantes a APS. Se efectuó un análisis de regresión lineal múltiple para las dos poblaciones y los dos instrumentos. Resultados Ninguna de las variables sobre intensidad de acciones de APS mostró relación con GHQ-12 o SF-36 en ambas muestras. Las variables asociadas significativamente a mayor puntaje en GHQ-12 y menor puntaje en SF-36 fueron sexo femenino, baja escolaridad, baja situación económica, menor apoyo social y daños producidos por el terremoto. Conclusión El equipo APS podría lograr un mayor efecto preventivo post-catástrofe trabajando con otros sectores que incluyan la dimensión salud mental en el abordaje de los problemas sociales críticos en situaciones de desastres, y reservando el trabajo preventivo directo para las personas con alta vulnerabilidad psicológica.

Abstract Background There is a high prevalence of emotional disturbances in the population exposed to disasters, and primary health care centers (PHC) could contribute to their prevention. Objective To analyze post-catastrophe associations between PHC variables and population mental health variables. Method Study conducted in Chile one year after an 8.8° Richter earthquake. We applied a questionnaire on the intensity of mental health actions in 16 PHC centers, and scales GHQ-12 and SF-36 for psychological distress and quality of life, in a sample based on households and consultants of the PHCs. We used multiple linear regression analysis for the two samples and the two instruments. Results The variables on PHC intensity of actions showed no association with the GHQ-12 or SF-36 scores in both samples. The main variables significantly associated with higher scores on GHQ-12 and lower scores on SF-36 were female gender, fewer years of schooling, negative economic situation, less social support and physical damages caused by the earthquake. Conclusion The PHC teams could achieve greater preventive post-disaster outcome working with other sectors, including mental health dimensions, while addressing the critical disaster social issues, and focusing direct preventive work on those psychologically vulnerable.

Primary care consultation liaison and the rate of psychiatric hospitalizations: a countrywide study in Chile / Las consultorías de salud mental en atención primaria y la tasa de hospitalización psiquiátrica: estudio nacional en Chile / Consultoria em saúde mental na atenção primária e taxa de internação psiquiátrica: estudo nacional no Chile

ABSTRACT Objectives To assess the quality of consultation liaison across all primary health care centers in Chile, and its potential relationship with the psychiatric hospitalization rate. Methods We carried out a countrywide ecological cross-sectional study on 502 primary health centers in 275 municipalities (87.3% of total primary health centers in Chile) during 2009. We characterized the presence of consultation liaison using four criteria: availability, frequency, continuity of participants, and continuity across care levels. We also created a dichotomous variable called "optimal consultation liaison" for when all four criteria were met. A quasi-Poisson regression model was used to estimate the rate of hospitalization due to different psychiatric disorders, adjusting by population attributes. Results Of the primary health centers, 28.3% of them had had optimal consultation liaison during the preceding year, concentrated in the poorest and richest municipalities. Continuity of care was the criterion that was met least often (38.3%). The presence of optimal consultation liaison at the municipal level was associated with fewer psychiatric discharges, with the following incidence rate ratios and 95% confidence intervals (CIs): schizophrenia, 0.65 (95% CI: 0.49-0.85); other psychoses, 0.68 (95% CI: 0.52-0.89); and personality disorders, 0.66 (95% CI: 0. 49-0.89). Municipalities with optimal consultation liaison showed 2.44 fewer total psychiatric discharges per 10 000 inhabitants, although without reaching statistical significance (-0.85 to 5.70). Conclusions Using a nationally representative sample, we found that consultation liaison in primary care was associated with having fewer psychiatric hospitalizations. More studies are required to understand the role of each component of consultation liaison.

RESUMEN Objetivos Evaluar la calidad de las consultorías de salud mental en todos los centros de atención primaria de salud en Chile y su posible relación con la tasa de hospitalización psiquiátrica. Métodos Se llevó a cabo un estudio transversal ecológico a nivel nacional sobre los 502 centros de atención primaria de salud en 275 municipios (87,3 % del total de los centros de atención primaria de salud en Chile) durante el 2009. Las consultorías de salud mental se caracterizaron por medio de cuatro criterios: disponibilidad, frecuencia, continuidad de los participantes y continuidad en los distintos niveles de atención. Además, se creó una variable dicótoma llamada "consultoría óptima" para cuando se cumplían los cuatro criterios. Se utilizó un cuasimodelo de regresión de Poisson para calcular la tasa de hospitalización a causa de distintos trastornos psiquiátricos, ajustada por los atributos de la población. Resultados De los centros de atención primaria de salud, el 28,3 % había presentado consultorías óptimas durante el año anterior, concentradas en los municipios más pobres y más ricos. La continuidad de la atención fue el criterio que se cumplió con menos frecuencia (38,3 %). La presencia de consultorías óptimas a nivel municipal estuvo asociada con menos altas médicas psiquiátricas, con la siguiente razón de tasa de incidencia e intervalos de confianza (IC) del 95 %: esquizofrenia, 0,65 (IC del 95%: 0,49-0,85); otras psicosis, 0,68 (IC del 95%: 0,52-0,89); y trastornos de la personalidad, 0,66 (IC del 95%: 0,49-0,89). Los municipios con consultorías óptimas registraron 2,44 menos altas médicas psiquiátricas totales por 10 000 habitantes, aunque sin alcanzar significación estadística (-0,85 a 5,70). Conclusiones Por medio de una muestra representativa a nivel nacional, encontramos que las consultorías de salud mental en centros de atención primaria de salud estaban asociadas con la disminución de hospitalizaciones psiquiátricas. Se requieren más estudios para comprender la función de cada componente de las consultorías de salud mental.

RESUMO Objetivos Avaliar a qualidade da consultoria em saúde mental nos centros de atenção primária à saúde e possível relação com a taxa de internação psiquiátrica. Métodos Um estudo de delineamento transversal ecológico foi conduzido em nível nacional em 502 centros de atenção primária à saúde (87,3% do número total no país) em 275 municípios no Chile em 2009. A prática de consultoria em saúde mental foi caracterizada de acordo com quatro critérios: disponibilidade, frequência, continuidade dos participantes e continuidade nos níveis de atenção. Também foi criada uma variável dicotômica, denominada "consultoria ideal", quando os quatro critérios eram satisfeitos. Foi usado um modelo de regressão de quase-Poisson para estimar a taxa de internação por diferentes transtornos psiquiátricos, ajustada segundo as características da população. Resultados Ao todo, 28,3% dos centros de atenção primária à saúde tiveram uma prática de consultoria ideal no ano anterior, concentrada nos municípios pertencentes aos quartis mais pobre e mais rico. A continuidade da atenção foi o critério satisfeito com menor frequência (38,3%). A prática de consultoria ideal ao nível de município foi associada a um número menor de altas psiquiátricas, com as seguintes razões de taxas de incidência e intervalos de confiança de 95% (IC 95%): 0,65 para esquizofrenia (IC 95% 0.49-0.85); 0,68 para outras psicoses (IC 95% 0.52-0.89) e 0,66 para transtornos de personalidade (IC 95% 0.49-0.89). Os municípios com prática de consultoria ideal tiveram 2,44 menos altas psiquiátricas por 10 mil habitantes, embora não seja estatisticamente significativo (-0.85 a 5,70). Conclusões O estudo de uma amostra representativa da população nacional revelou que a consultoria em saúde mental na atenção primária esteve associada a um número menor de internações psiquiátricas. Outros estudos são necessários para entender o papel de cada componente da consultoria em saúde mental.

Stigma toward mental illness in Latin America and the Caribbean: a systematic review

Objective: Stigma toward individuals with mental disorders has been studied extensively. In the case of Latin America and the Caribbean, the past decade has been marked by a significant increase in information on stigma toward mental illness, but these findings have yet to be applied to mental health services in Latin America. The objective of this study was to conduct a systematic review of studies relating to stigma toward mental illness in Latin America and the Caribbean. The authors specifically considered differences in this region as compared with manifestations reported in Western European countries. Methods: A systematic search of scientific papers was conducted in the PubMed, MEDLINE, EBSCO, SciELO, LILACS, Imbiomed, and Bireme databases. The search included articles published from 2002 to 2014. Results: Twenty-six studies from seven countries in Latin America and the Caribbean were evaluated and arranged into the following categories: public stigma, consumer stigma, family stigma, and multiple stigmas. Conclusion: We identified some results similar to those reported in high-income settings. However, some noteworthy findings concerning public and family stigma differed from those reported in Western European countries. Interventions designed to reduce mental illness-related stigma in this region may benefit from considering cultural dynamics exhibited by the Latino population.

Respeto a los derechos de las personas que se atienden en Servicios de Psiquiatría Ambulatoria en Chile / A survey about quality of care and user’s rights in Chilean psychiatric services

Background: Quality of care and respect for the rights of users are critical to achieve positive health outcomes and respond appropriately to the expectations of people, particularly if they have mental illnesses. Aim: To carry out a baseline diagnosis of quality of care and respect for rights in public outpatient psychiatric services. Material and Methods: Quality of care and respect for patients’ rights was assessed by a mental health professional and a trained psychiatric service user in 15 ambulatory psychiatric services. The WHO QualityRights instrument was used, reviewing documentation and making observations in each facility, as well as interviewing 146 patients, 148 health care workers and 64 relatives of patients. Results: A high level of achievement was accomplished in terms of discrimination-free health care, availability of psychotropic medications, lack of abuse or neglect and use of informed consents. A low level of achievement was found in terms of user support to cope with community living, access to education or work and participation in community activities, respect for user treatment preferences and preventive measures to avoid maltreatment and cruelty. Conclusions: Chile could improve the performance of psychiatry services having laws based on the “Convention of Rights of Persons with Disabilities” and standards of the World Health Organization, having national policies about quality of care and rights of users, reinforcing the community work of mental health care teams, reinforcing and informing users about their rights and promoting research on interventions to improve the respect of their rights.

Adaptación y validación de un cuestionario para evaluar contratransferencia en una sesión / Adaptation and validation of a questionnaire to asses countertransference in a session

Despite the clinical importance of the concept of countertransference there are few instruments to evaluate it; one of them is the Countertransference Questionnaire (CQ), which measures countertransference during a therapeutic process. The CQ is a self-report questionnaire, composed of a set of items that refer to a wide range of ideas, feelings and behaviors that therapists develop towards their patients. It is written in common language, without the use of technical terms, allowing the instrument to be used and compared by clinicians of any theoretical orientation. The following paper shows the translation to Spanish, an adapted version for its application in one interview or session, and its validation in a population of Chilean psychiatrists and psychologists in a sample of 333 completed questionnaires. Three versions of the questionnaire were created: Interviewer, Observer and Observer of the Interviewer. We conducted an exploratory factor analysis wich grouped the items on a total of seven factors with good or very good internal consistency (Cronbach’s alpha between 0.66 and 0.89) Results showed that the instrument is valid for its application in Chilean psychiatrists and psychologists.

A pesar de la importancia clínica del concepto de la contratransferencia hay pocos instrumentos para evaluarla, uno de ellos es el Countertransference Questionnaire que mide la contratransferencia durante un proceso terapéutico. Este cuestionario es de autoreporte, sus ítems se refieren a un amplio rango de ideas, sentimientos y conductas hacia sus pacientes expresados por los terapeutas. Está redactado en lenguaje cotidiano, sin términos técnicos, lo que permite que el instrumento pueda ser usado y comparado por clínicos de cualquier orientación teórica. En este artículo presentamos su traducción, adaptación para ser aplicado en una entrevista o sesión y la validación en una población de psiquiatras y psicólogos chilenos que realizamos con una muestra de 333 cuestionarios. Hicimos tres versiones del cuestionario: Entrevistador, Observador y Observador del entrevistador. Realizamos un análisis factorial exploratorio que agrupó los ítems en siete factores con consistencia interna buena o muy buena (alfa de Cronbach entre 0,66y 0,89). Los resultados arrojaron que este instrumento es válido para ser aplicado en psiquiatras y psicólogos chilenos.

Validación de la escala de bienestar mental de Warwick - Edingurgo, en Chile / Validação da escala de bem-estar mental de Warwick Edimburgo, no Chile / Validation of Warwick-Edinburgh mental wellbeing scale in Chile

Introducción: El bienestar mental es un constructo relevante,pero ha sido poco estudiado y existen muy pocos cuestionariospara su valoración. Objetivo: Adaptar y validar la versiónespañola de la Escala de Bienestar Mental de WarwickEdimburgo.Material y Método: Se realizó un procedimientode validación semántica, seguido de una aplicación a 220personas adultas para estudiar sus propiedades psicométricas.Resultados: Se introdujeron cambios semánticos mínimos.Se utilizó un análisis factorial de componentes principales,con buenos resultados (KMO= 0,897) y una muy buenaconsistencia interna para un factor(∝ = 0,875). Estecuestionario mostró una buena correlación con el GHQ-12 y el cuestionario de calidad de vida WHOQOL-BREF.La correlación test - retest fue positiva y estadísticamentesignificativa (r = 0,556, p < 0,001). Conclusión: Esta escalamostró buenos indicadores psicométricos, siendo unaherramienta útil y fácil de aplicar para la evaluación delbienestar mental en adultos.

Introduction: Mental well-being is a relevant construct,but it has not been thoroughly studied and there are very few assessment questionnaires. Objective: Adapt and validate the Spanish version of theWarwick-Edinburgh Mental Well-Being Scale. Material and Method: A process of semanticvalidation was performed, followed by the application to 220 adults in order to study theirpsychometric properties. Results: Minimal semantic changes were introduced. Factorialanalysis of the main components was used, with good results (KMO= 0.897) and verygood internal consistency for a factor (∝ = 0.875). This questionnaire showed very goodcorrelation with questionnaire GHQ-12 and the one on life quality WHOQOL-BREF.The correlation test-retest was positive and statistically significant (r = 0.556, p < 0.001).Conclusion: This scale showed good psychometric indicators, being a simple and easy toapply tool to assess mental well-being in adults.

La salud como derecho en la misión fundacional de la Escuela de Salud Pública de la Facultad de Medicina de la Universidad de Chile: un análisis histórico / Health as a right in the founding mission of the School Of Public Health, School Of Medicine, University Of Chile: a historical analysis / A saúde como direito na missão fundacional da Escola De Saúde Pública Da Faculdade De Medicina Da Universidade de Chile: uma análise histórica

Este trabajo explora el contexto histórico en el cual se origina la Escuela de Salud Pública de la Universidad de Chile (ESP). Se estudia un periodo de tiempo comprendido entre fines del siglo XIX y mediados del siglo XX. En primer lugar, se analizan las posiciones de cuatro actores claves (la élite, los médicos y profesionales de la salud, las capas populares, y el Estado) y sus conflictos. En segundo lugar, se estudia el cambio de paradigma en el rol del Estado frente a los problemas de salud, desde una posición de “Estado subsidiario y gendarme” a una de “Estado asistencial de compromiso”. La ESP surge como producto de estos procesos históricos, para cubrir la necesidad de formar especialistas en el campo de la salud pública, obteniendo un apoyo externo de la Fundación Rockefeller que se resulta fundamental en su inicio. Desde sus inicios tiene un fuerte involucramiento en la vida pública del país, asumiendo la salud de la población como un derecho social.

The historical context in which the School of Public Health of the University of Chile was born is explored in this work. The period studied goes from the end of the 19th century to middle of the 20th Century. In the first place, the position of the four key actors - the elite, doctors and health professionals, popular layers, and the State - and their conflicts are analyzed. In the second place, the change of paradigm in the role of the State regarding health problems, from a position of “Subsidiary Gendarme State” to a new position of “Welfare Committed State” is studied. The School of Public Health was born as a result of these historical processes, to cover the need to train specialists in the field of public health, getting external support from the Rockefeller Foundation which was essential in its beginnings. Since its origin it has been greatly involved in the country´s public life, understanding people´s health as a social right.

Este trabalho analisa o contexto histórico no qual teve origem a Escola de Saúde Pública da Universidade do Chile (ESP). Estuda-se um período de tempo que varia entre finais do século XIX e meados do século XX. Em primeiro lugar, são analisadas as posições dos quatro jogadores-chave (a elite, os médicos e profissionais de saúde, os setores populares, e o Estado) e seus conflitos. Em segundo lugar, analisa-se a mudança de paradigma no papel do Estado a partir dos problemas de saúde, a partir de uma conceição de “Estado subsidiário e gendarme” para uma de “Estado assistencial de compromisso” A ESP surge como resultado desses processos históricos, para atender a necessidade de formação de especialistas no domínio da saúde pública, obtendo um apoio externo da Fundação Rockefeller, que é essencial no início. Desde a sua criação tem uma forte participação na vida pública do país, assumindo a saúde da população como um direito social.

Respuesta de los centros de atención primaria en salud mental después del terremoto y tsunami del 2010 en la Región del Maule / Response of primary care teams to manage mental health problems after the 2010 earthquake

Background: Thirty to 50% of people exposed to a natural disaster suffer psychological problems in the ensuing months. Aim: To characterize the activities in mental health developed by Primary Health Care centers after the earthquake that affected Chile on february 27th, 2010. Material and Methods: A cross-sectional study analyzing 16 urban centers of Maule Region, was carried out. A questionnaire was developed to know the preparatory and supportive activities directed to the community and the training and self-care activities directed to Health Care personnel that were made during the 12 months following the catastrophe. In addition, a questionnaire evaluating structural aspects was designed. Results: Only 1/3 of the centers made some preparatory activity and none of them made a diagnosis of population vulnerability. The average of protective Mental Health interventions coverage reached 35% of the population estimated to be most affected. The activities lasted 31 to 62% of the optimal duration standards set by experts (according to the type of action). Important differences between centers in economic and geographical accessibility, construction and professional resources were found. Conclusions: This study shows the difficulties faced by urban centers of Maule Region to deal with mental health problems caused by the earthquake, which were attributable to the absence of local planning and drills, and to the lack of intra and inter sectorial coordination.

Programa colaborativo a distancia para el tratamiento de la enfermedad depresiva / Assessment of a distant collaborative program for the treatment of depression in primary care

Background: In the treatment of depression, primary care teams play an important role, whose effectiveness improves when inserted into a collaborative model of disease management. Aim: To report the results of a clinical trial carried out to test the effectiveness of a collaborative program between primary health teams and specialists supported by an electronic platform. Material and Methods: Physicians from four community hospitals belonging to the Reloncavi Health Service network, recruited 81 patients with depression aged 37 to 43 years, 84% of whom were female. Participants were divided in an active group, which participated in the collaborative program and a control group, which received the usual care, according to the Ministry of Health’s Guidelines for Depression. The main outcome was the Beck Depression Inventory (BDI-I) score at three months of intervention. Results: Participants had an average of 29.6 points (95% CI: 27.6-31.6) in the BDI-I and 38% of them had a high suicide risk. There were no statistically significant baseline differences between active and control group. In the intervention group, the BDI-I score changed from 30.0 (95% CI 27.0 to 32.8) to 15.3 (95% CI 11.8 to 18.8). In the control group the score changed from 29.2 (95% CI: 26.4-31.9) points to 20.8 (95% CI 16.8 to 24.7). The decrease was significantly higher in the intervention groups. Conclusions: A program of this kind may be useful to assist primary care teams in remote areas of the country to improve treatment outcomes for depression.

A theoretical and empirical framework for constructing culture-specific stigma instruments for Chile / Uma estrutura teórica e empírica para a construção de instrumentos de estigma específicos para a cultura chilena

Different cultural contexts contribute to substantial variation in the stigma faced by people with psychosis globally. We propose a new formulation of how culture affects stigma to create psychometrically-validated tools to assess stigma's culture-specific effects. We propose to construct culture-specific stigma measures for the Chilean context via: 1) open-ended administration of 'universal' stigma scales to a sample of individuals with psychosis, relatives, and community respondents; 2) qualitative analyses to identify how culture shapes stigma and to derive initial 'culture-specific' stigma items; 3) construction and pilot-testing of final 'culture-specific' stigma measures; 4) initial psychometric validation among a sample of individuals with psychosis. We identify initial hypotheses for how stigma might threaten the capacities to participate in fundamental activities that 'matter most' in the Chilean context. These include mental illness stigma threatening the man's ability to protect the honor of the family, and the woman's ability to be a 'holy and pure' mother. Mental illness stigma may further endanger the ability of the family to uphold reciprocal obligations within their social network. Developing such measures promises to aid efforts to address culture-specific forms of stigma, and to facilitate implementation of community mental health services, in Chile and other Latin American contexts.

Diferentes contextos culturais contribuem para a variação substancial do estigma enfrentado por pessoas com psicose globalmente. Nós propomos uma nova formulação de como a cultura afeta o estigma para criar instrumentos validados psicometricamente a fim de avaliar os efeitos específicos do estigma cultural. Propomos a construção de medidas específicas de estigma cultural no contexto chileno através de: 1) administração aberta de escalas "universais" de estigma em uma amostra de indivíduos com psicose, parentes e entrevistados da comunidade; 2) análise qualitativa para identificar as formas de estigma cultural e extrair itens específicos de stigma cultaral; 3) construção e testes-piloto de medidas finais específicos de estigma cultural; 4) validação psicométrica inicial entre uma amostra de indivíduos com psicose. Identificamos hipóteses iniciais de como o estigma pode ameaçar as capacidades de participar em atividades fundamentais mais importantes no contexto chileno. Estes incluem o estigma de a doença mental ameaçar a capacidade do homem para proteger a honra da família, e da capacidade da mulher para ser uma "santa e pura" mãe. O estigma da doença mental pode comprometer ainda mais a capacidade da família para sustentar as obrigações recíprocas dentro de sua rede social. Desenvolvimento de tais medidas promete ajudar os esforços para abordar formas específicas de estigma cultural, e para facilitar a implementação de serviços comunitários de saúde mental, no Chile e em outros contextos latino-americanos.

Transmisión transgeneracional del trauma psicosocial en comunidades indígenas de Argentina: percepción del daño en el pasado y presente y acciones autoreparatorias / Transmissão transgeracional do trauma psicossocial em comunidades indígenas na Argentina: a percepção de dano no passado, presente e ações autorreparatórias

El presente artículo indagó desde la perspectiva de los sujetos, con respecto a la transmisión transgeneracional del trauma psicosocial sufrido por comunidades Wichí del Norte Argentino. Se propuso identificar las experiencias percibidas como traumáticas por las comunidades Wichí, tanto pasadas como presentes, describiendo los relatos respecto a la vivencia del trauma y a las formas de socialización generadas en dicha comunidad. Esto tuvo presente las situaciones o acciones llevadas adelante en los últimos años, que pudieran ser consideradas como autoreparatorias. Se trata de un trabajo exploratorio de tipo cualitativo, realizado en comunidades Wichí de la Provincia de Salta, durante los años 2009, 2010, y 2011. Fueron realizadas 30 entrevistas a caciques, mujeres, dirigentes y personas de las comunidades Wichí. Entre los resultados se reconoce la permanencia del daño en los grupos originarios y los mecanismos utilizados tanto por el Estado como por la sociedad para mantener esta situación, también se advierte un comportamiento de aislamiento y evasión ante el trauma, además se identifican secuelas y la manera en que éstas reproducen la situación de trauma. Fue también observado en la comunidad Wichí mecanismos de autoreparación en torno a la situación de trauma. La experiencia específica en relación con el pueblo Wichí reafirma los mecanismos de la transmisión transgeneracional del trauma psicosocial, surgiendo nuevas formas de organización de manera espontánea que develan el camino hacia la superación del trauma.

O presente artigo investigou, a partir da perspectiva do sujeito, a transmissão transgeracional do trauma psicossocial sofrido pelas comunidades Wichí no Norte Argentino. Pretendeu-se identificar as experiências percebidas como traumáticas pelas comunidades Wichí, tanto no passado como no presente, descrevendo os relatos sobre a experiência do trauma e os modos de socialização gerados em tal comunidade. Foram levadas em conta as situações ou ações realizadas nos últimos anos, que poderiam ser consideradas como autorreparatórias. Tratou-se de um trabalho qualitativo exploratório, realizado nas comunidades Wichí da Província de Salta, durante 2009, 2010 e 2011. Foram realizadas 30 entrevistas com chefes, mulheres, líderes e pessoas das comunidades Wichí. Entre os resultados, é possível reconhecer a influência dos danos nos grupos originais e os mecanismos utilizados pelo Estado e pela sociedade para manter esta situação. Também destacam-se o comportamento de isolamento e a fuga perante o trauma. Foram identificadas as sequelas e a maneira que tais pessoas reproduzem a situação de trauma. Também mostraram-se, na comunidade Wichí, os mecanismos de autorreparação sobre a situação de trauma. A experiência específica com relação ao povo Wichí reafirma os mecanismos da transmissão transgeracional do trauma psicossocial, surgindo novas formas de organização emergente espontaneamente que revelam o caminho para superar o trauma.

Estudio multicéntrico para la validación de la versión en español del Eating Disorder Diagnostic Scale / Validation of the Spanish version of the Eating Disorders Diagnostic Scale

Background: The Eating Disorders Diagnostic Scale (EDDS) is a self-administered low cost psychometric instrument with excellent levels of temporal reliability and validity. Aim: To adapt and validate the EDDS in Chile. Material and Methods: Thefactorial structure, internal consistency and test-retest reliability ofthe Spanish-language version of the EDDS was analyzed in a sample of1964 university and high school students. The concurrent validity was tested in a sample of 50 primary care patients with ED and 59 controls, comparing its results with those of a structured psychiatric interview (CIDI). Results: The EDDS showed a high internal consistency, moderate test-retest reliability, an appropriate factorial structure (in women) and an excellent convergent validity. Also, the diagnosis of ED obtained with the EDDS is moderately consistent with the structured psychiatric interview. Conclusions: The Spanish-language version of the EDDS showed a satisfactory psychometric behavior and a good capacity for detecting ED, according to the DSM criterion.