Ética médica y atención a pacientes en estadio terminal en el nivel primario de atención / Medical Ethics and End-stage Patient Care at the Primary Care Level

Introducción: El artículo reflexiona sobre la naturaleza multidimensional y compleja de la ética y su relación con las ciencias médicas. Objetivo: Reflexionar sobre la atención a pacientes en estadio terminal desde el punto de vista de la ética médica para una atención médica integral en el primer nivel de atención. Métodos: estudio cualitativo; se emplearon análisis documental, sistematización, análisis y síntesis de publicaciones sobre la temática estudiada como métodos teóricos, para ello se valoran los criterios de autores y resultados que se expresan en artículos publicados. Se realizaron búsquedas, tanto en bases de datos estudiadas como en las plataformas de productos del Nacional Council for Biotechnology Information de la Nacional Library of Medicine of United States of America; y de Elsevier, esta última productora de Embase y Scopus, a través del motor de búsqueda Google Académico, en español e inglés, y sin límite de tiempo. Se emplearon los términos: ética médica, deontología médica, relación médico-paciente, paciente terminal y cuidados paliativos. Se excluyeron aquellos artículos que no habían sido revisados por pares o no mostraban el texto completo. Se revisó la información suministrada por cada fuente y se sintetizó. Conclusiones: En Cuba, la bioética avanza en la medida que lo permite la estrategia de Atención Primaria de Salud, con un Programa del Médico y Enfermera de la Familia resiliente y de valores humanos demostrados nacional e internacionalmente. Como reto se plantea estimular el debate entre saberes para generar cambios a favor de los pacientes, las familias, las comunidades y la sociedad(AU)

Introduction: The article reflects on the multidimensional and complex nature of ethics and its relationship to the medical sciences. Objective: To reflect on the care of terminally ill patients from the point of view of medical ethics for comprehensive medical care at the primary level of care. Methods: A qualitative study was carried out using documentary analysis, systematization, analysis and synthesis of publications on the subject studied as theoretical methods. For this purpose, the criteria of authors and results expressed in published articles were evaluated. Searches were carried out in Spanish and English through Google Scholar, and without time limit, both in the databases studied and in the product platforms of the National Council for Biotechnology Information of the National Library of Medicine of the United States of America and Elsevier. The terms: medical ethics, medical deontolog, physician-patient relationship, terminal patient and palliative care were used. Articles that were not peer-reviewed and those that did not show the full text were excluded. The information provided by each source was reviewed and synthesized. Conclusions: In Cuba, bioethics advances to the extent allowed by the Primary Health Care strategy, with a resilient Family Physician and Nurse Practitioner Program and human values demonstrated nationally and internationally. The challenge is to stimulate the debate between knowledge to generate changes in favor of patients, families, communities and society(AU)

Pilot implementation of a community-based, eHealth-enabled service delivery model for newborn hearing screening and intervention in the Philippines

Objectives@#This study explores the potential of the HeLe Service Delivery Model, a community-based newborn hearing screening (NHS) program supported by a web-based referral system, in improving provision of hearing care services. @*Methods@#This prospective observational study evaluated the HeLe Service Delivery Model based on records review and user perspectives. We collected system usage logs from July to October 2018 and data on patient outcomes. Semi-structured interviews and review of field reports were conducted to identify implementation challenges and facilitating factors. Descriptive statistics and content analysis were used to analyze quantitative and qualitative data, respectively. @*Results@#Six hundred ninety-two (692) babies were screened: 110 in the RHUs and 582 in the Category A NHS hospital. Mean age at screening was 1.4±1.05 months for those screened in the RHU and 0.46±0.74 month for those in the Category A site. 47.3% of babies screened at the RHU were ≤1 month old in contrast to 86.6% in the Category A hospital. A total of 10 babies (1.4%) received a positive NHS result. Eight of these ten patients were referred via the NHS Appointment and Referral System; seven were confirmed to have bilateral profound hearing loss, while one patient missed his confirmatory testing appointment. The average wait time between screening and confirmatory testing was 17.1±14.5 days. Facilitating factors for NHS implementation include the presence of champions, early technology adopters, legislations, and capacity-building programs. Challenges identified include perceived inconvenience in using information systems, cost concerns for the patients, costly hearing screening equipment, and unstable internet connectivity. The lack of nearby facilities providing NHS diagnostic and intervention services remains a major block in ensuring early diagnosis and management of hearing loss in the community. @*Conclusion@#The eHealth-enabled HeLe Service Delivery Model for NHS is promising. It addresses the challenges and needs of community-based NHS by establishing a healthcare provider network for NHS in the locale, providing a capacity-building program to train NHS screeners, and deploying health information systems that allows for documentation, web-based referral and tracking of NHS patients. The model has the potential to be implemented on a larger scale — a deliberate step towards universal hearing health for all Filipinos.

(Sobre)viver na rua: narrativas das pessoas em situação de rua sobre a rede de apoio / (About) living on the street: narratives of homeless people about the support network / (Sobre)vivir en la calle: narrativas de personas en situación de calle sobre la red de apoyo

A população em situação de rua (PSR), em seu cotidiano, se relaciona com diferentes pessoas, grupos e/ou coletivos ligados à execução das políticas públicas, às organizações não governamentais, familiares ou a membros da sociedade civil. Pensar nessas dinâmicas de trabalho, cooperação e auxílio remete a pensar sobre uma rede de apoio que constrói estratégias com essa população. Tendo presente essas problematizações, este estudo teve como objetivo analisar as narrativas das pessoas em situação de rua sobre como é produzida sua rede de apoio. Para tanto, foi realizado um estudo qualitativo, de orientação etnográfica, sendo utilizada a observação participante, registros em diário de campo e entrevistas narrativas. Participaram seis pessoas em situação de rua que recebem alimentação ofertada por projetos sociais em uma cidade do interior do Rio Grande do Sul. Os dados produzidos foram analisados a partir da Análise Temática. As análises expressam as especificidades das narrativas das trajetórias de vida associadas à chegada às ruas e à composição de uma rede de apoio na rua. Ao conhecer como se produz e opera essa rede de apoio, a partir das narrativas das pessoas em situação de rua, problematiza-se a complexidade dessa engrenagem e o desafio de produzir ações integradas entre as diferentes instâncias da rede. Nisso, destaca-se a potencialidade de práticas que levem conta à escuta, ao diálogo e à articulação na operacionalização de políticas públicas atentas às necessidades dessa população.(AU)

The street population, in their daily lives, relates to different people, groups and/or collectives linked to the execution of public policies, to non-governmental organizations, family members, or to members of civil society. Thinking about these dynamics of work, cooperation, and assistance leads to thinking about a support network that builds strategies with this population. Having these problematizations in mind, this study aims to analyze the narratives of homeless people about how their support network is produced. To this end, a qualitative study was carried out, with ethnographic orientation, using participant observation, records in a field diary, and narrative interviews. Participated in the research six homeless people who receive food offered by social projects in a municipality in the interior of Rio Grande do Sul. The data produced were analyzed using the Thematic Analysis. The analyzes express the specifities of the narratives of life trajectories associated with the arrival on the streets and the composition of a support network on the street. By knowing how the support network is produced and operated, the complexity of this gear and the challenge of producing integrated actions between the different instances of the network are problematized. Thus, it highlights the potential of practices that consider listening, dialogue, and articulation in the operationalization of public policies that are attentive to the needs of this population.(AU)

Las personas en situación de calle en su cotidiano se relacionan con distintas personas, grupos y/o colectivos, que están vinculados a la ejecución de políticas públicas, organizaciones no gubernamentales, familiares o miembros de la sociedad civil. Pensar en estas dinámicas de trabajo, cooperación y ayuda nos lleva a una red de apoyo que construye estrategias con estas personas. Teniendo en cuenta esta problemática, este estudio tiene como objetivo analizar las narrativas de las personas en situación de calle acerca de cómo se produce su red de apoyo. Con este fin, se realizó un estudio cualitativo, etnográfico, utilizando observación participante, registros de diario de campo y entrevistas narrativas. Este estudio incluyó a seis personas en situación de calle que reciben alimentos ofrecidos por proyectos sociales en una ciudad del interior de Rio Grande do Sul (Brasil). Se utilizó el Análisis Temático. Los análisis expresan las especificidades de las narrativas de las trayectorias de vida asociadas con la llegada a las calles y la composición de una red de apoyo en la calle. Al saber cómo se produce y opera la red de apoyo, a partir de las narrativas de las personas en la calle, se problematizan la complejidad de este equipo y el desafío de producir acciones integradas entre las diferentes instancias de la red. Destaca el potencial de las prácticas que tienen en cuenta la escucha, el diálogo y la articulación en la implementación de políticas públicas que estén atentas a las necesidades de esta población.(AU)

Paradigma manicomial e proibicionismo como operadores da guerra de raças no Brasil / Asylum paradigm and prohibitionism operating the racial war in Brazil / Paradigma asilar y prohibicionismo como operadores de la guerra racial en Brasil

Este artigo relaciona o paradigma manicomial, relativo à assistência psiquiátrica, à compreensão e ao manejo do campo da saúde mental, ao paradigma proibicionista, referente ao porte, uso e à circulação de drogas, como duas séries de políticas e práticas sociais que operam a guerra de raças que está na base do Estado brasileiro. Com isso, propomos uma investigação arqueogenealógica acerca do emaranhado de condições de emergência das práticas e objetos de saber-poder mobilizados por esses dois paradigmas, atentando ao caráter político das verdades que as sustentam. Dedicamo-nos especialmente ao período entre o final do século XIX e o começo do XX ao interrogar as dinâmicas de forças que constituem as práticas sociais e seus efeitos de subjetivação, produzidos pela sujeição de corpos por meio de uma diversidade de mecanismos morais, disciplinares, eugênicos, higienistas e biopolíticos que articulam os anseios de modernização e produtividade do Estado brasileiro à gestão dos problemas de saúde e segurança do país, colocando a pobreza, o vício e a doença como desdobramento da sua constituição racial. Concluímos, por fim, que o conflito de raças aparece como fundo intrínseco que se atualiza no cerne e a partir dos campos problemáticos da saúde mental e das drogas, colocando como saída dos impasses sociais e políticos eliminar ou pelo menos diluir, via miscigenação ou submissão para integração, o elemento físico e cultural do negro do Brasil.(AU)

This article puts in relation the asylum paradigm, associated to psychiatric care, to the understanding and management of the mental health field, to the prohibitionist paradigm, that refers to the possession, use and circulation of drugs, as two series of social policies and practices that operate racial war that is in the base of the Brazilian State. So on, we propose an archeogenealogical investigation about the emergency conditions of the practices and objects of knowledge-power organized by these two paradigms, paying attention to the political character of the truths that support them. Looking especially at the period between the end of the 19th century and the beginning of the 20th, we questioned the dynamics of forces that constitute social practices and their effects of subjectivation, produced by the subjection of bodies through moral, disciplinary, eugenic, hygienist and biopolitics mechanisms that articulate the modernization and productivity aspirations of the Brazilian State to the management of the country's health and safety problems, understanding poverty, addiction and disease as consequences of its racial constitution. We conclude that the conflict of races is an intrinsic background that is updated at the heart of the problematic fields of mental health and drugs. Considering this, the solution for social and political impasses is the elimination or at least dilution, through miscegenation or submission for integration, of the physical and cultural element of black people in Brazil.(AU)

Este artículo relaciona el paradigma asilar de atención psiquiátrica, comprensión y manejo del campo de la salud mental, con el paradigma prohibicionista, referente a al uso y circulación de drogas, como dos series de políticas y prácticas sociales que operan la guerra racial que está en el fundamento del Estado brasileño. Así, proponemos una investigación arqueogenealógica sobre las condiciones de emergencia de prácticas y objetos de saber-poder movilizados por estos dos paradigmas, prestando atención al carácter político de las verdades que los sustentan. Nos dedicamos especialmente al período entre finales del siglo XIX y principios del XX buscando la dinámica de fuerzas que constituyen a las prácticas sociales y sus efectos de subjetivación, producidos por la sujeción de los cuerpos a través de una diversidad de mecanismos morales, disciplinarios, eugenésicos, higienistas y biopolíticos que articulan las aspiraciones de modernización y productividad del Estado brasileño a la gestión de los problemas de salud y seguridad del país, comprendiendo la pobreza, la adicción y la enfermedad como resultado de su constitución racial. Finalmente, concluimos que el conflicto racial aparece como un trasfondo intrínseco que se actualiza en el cerne y desde los campos problemáticos de la salud mental y de las drogas, tomando como soluciones a los impasses sociales y políticos nacionales, la eliminación o al menos la dilución, a través del mestizaje o de la sumisión para fines de integración, del elemento físico y cultural del negro en Brasil.(AU)

Centro especializado ambulatorio de Cienfuegos: una mirada desde la gestión hospitalaria en su primera década / Specialized ambulatory center of Cienfuegos province: a view to hospital management in its first decade

La celebración en el 2019 de una década de trabajo ininterrumpido del primer hospital ligero diseñado en Cuba fue motivo para la realización de este trabajo, que tuvo como objetivo describir los principales resultados en los aspectos de meso y microgestión hospitalaria del Centro Especializado Ambulatorio Héroes de Playa Girón de Cienfuegos, desde el 2009 hasta el 2019. Múltiples investigaciones mostraron la utilidad de la gestión por procesos para garantizar la calidad de la atención médica y la integración de los programas de seguridad institucional y del paciente en las funciones gerenciales y asistenciales. La primera gestión hospitalaria del Centro Especializado Ambulatorio, sobre la base de las mejores experiencias nacionales e internacionales, cumplió con los objetivos del diseño para el cual fue creado al integrar calidad, racionalidad y eficiencia. Esta experiencia puede ser ejemplo para otras instituciones que precisen de un centro de atención ambulatoria y muy corta estadía en la concepción de un hospital universitario(AU)

The celebration in 2019 of a decade of continuous work of the first ambulatory hospital designed in Cuba motivated the production of this work, that had as an objective to describe the main results in the aspects of hospital meso and micro-management of Héroes de Playa Girón Specialized Ambulatory Center of Cienfuegos province, from 2009 to 2019. Several research works showed the usefulness of management by processes to guarantee the quality of medical care and the integration of institutional and patients safety programs in management and care functions. The first hospital management of the Specialized Ambulatory Center, based on the best national and international experiences, accomplished the objectives for what it was design to by integrating quality, rationality and efficiency. This experience would be an example for other institutions that need an ambulatory care center and a short time in the creation of a university hospital(AU)

O papel da estratégia da saúde da família e comunidade na rede de urgências e emergências / The role of the family and community health strategy in the urgency and emergency care network

Introdução: A Estratégia de Saúde da Família e Comunidade (ESFC) é parte da Rede de Atenção às Urgências e Emergências (RAUE). Embora a ESFC seja um ponto da RAUE, essa temática é pouco estudada, mesmo com a atenção a casos de urgência e emergência (U/E) estando cada vez mais presente em seu cotidiano. Isso aponta para a importância em investigá-la. Objetivo: Analisar o papel da ESFC na atenção a usuários em situações de U/E. Metodologia: trata-se aqui, de estudo de caso, qualitativo, exploratório, desenvolvido nas sete unidades de ESFC de um município do centro-oeste paulista, Brasil. Foram realizadas entrevistas semiestruturadas com 38 profissionais, analisadas segundo descrição temática. Resultados: Os dados foram agrupados em três núcleos temáticos: estrutura, processo de trabalho e articulação da ESFC com a RAUE. A estrutura mostrou-se deficiente, em relação à capacitação profissional e à disponibilidade de medicamentos, materiais e insumos. A ESFC tem importante papel no atendimento a casos de U/E, entretanto o processo de trabalho não está organizado para abordar adequadamente esses casos, e a articulação com a RAUE é deficiente. Os resultados apontam para questões que representam um desafio ao aprimoramento da ESFC em contextos semelhantes e servem como embasamento preliminar para pesquisas futuras.

Introduction: The Family and Community Health Strategy (ESFC, in Portuguese) is part of the Emergency Care Network (RAUE). Although it is part of RAUE and the attention to emergency cases is increasingly present in the daily routine of the ESFC, this themeis little studied, which points out the importance of investigating it. Objective: To analyze the role of ESFC in the care of users in emergency situations. Methodology: Qualitative and exploratory case study, developed in the seven ESFC units of a municipality in the Midwest of São Paulo, Brazil. Semi-structured interviews were conducted with 38 professionals and analyzed according to the thematic description. Results: The data were grouped into three thematic nuclei: structure, work process, and ESFC articulation with RAUE. The structure was deficient in relation to professional training and the availability of medicines, materials, and supplies.ESFC plays an important role in the care of emergency cases. However, the work process is not organized to adequately address these cases and the articulation with RAUE is deficient. The results point to issues that represent a challenge for the improvement of ESFC in similar contexts and serve as a preliminary basis for future research.

Contribución de una estrategia de atención centrada en la persona con multimorbilidad al Modelo de Atención Integral de Salud Familiar y Comunitario en Chile / Contribution of a multimorbidity person-centered care strategy to the Comprehensive Family and Community Healthcare Model in Chile

BACKGROUND: The Multimorbidity Person-Centered Care Model allows to customize care according the needs of each person. AIM: To characterize the perception of health teams about the contribution of the Multimorbidity Person-Centered Care Model (MACEP) to the development of the key principles of the Comprehensive Family and Community Health Care Model (MAIS). MATERIAL AND METHODS: A qualitative collaborative study with 35 interviews and the participation of 67 professionals from the primary healthcare network. Content analysis using mixed code system with MAXQDA2020 program. RESULTS: The innovations and complex interventions that positively affect the development and implementation of the essential principles of MAIS were recognized by participants as a contribution of the central elements of MACEP. CONCLUSIONS: This contribution is an opportunity for the expeditious implementation of Family Health principles in the health network. Incorporating the vision of implementers and users, who are part of these changes, is essential. It is necessary to establish, project and evaluate innovations to identify, implement and promote learning at Health Services throughout the country.

Satisfação no trabalho de trabalhadores da atenção primária à saúde: um estudo exploratório / Satisfacción laboral de los trabajadores de atención primaria de salud: un estudio exploratorio / Job satisfaction of primary health care workers: an exploratory study

RESUMO Objetivo: identificar os fatores relacionados à (in)satisfação no trabalho de trabalhadores da Atenção Primária à Saúde (APS). Métodos: estudo exploratório com abordagem quantitativa, conduzido em 23 unidades da APS no estado de São Paulo. Foi utilizada a Escala de Satisfação no Trabalho, que abrange o grau de contentamento com chefia, colegas, salário, promoções e trabalho realizado, além de um questionário sócio-ocupacional. Resultados: participaram 70 trabalhadoras, sendo a grande maioria auxiliares de Enfermagem e agentes comunitárias de saúde, com idade média de 45±10,6 anos. Constatou-se indiferença nos campos colegas, chefia e natureza do trabalho. Por outro lado, verificou-se insatisfação com os campos salário e promoções. Conclusão: foi constatada insatisfação no trabalho na APS, e os achados demonstram a necessidade de revisão do plano de carreira e ajustes salariais.

RESUMEN Objetivo: identificar los factores relacionados con la (in)satisfacción laboral de los trabajadores de la Atención Primaria de Salud (APS) Métodos: estudio exploratorio con enfoque cuantitativo, realizado en 23 unidades de APS del estado de São Paulo. Se utilizó la Escala de Satisfacción Laboral, que abarca el grado de satisfacción con la dirección, los compañeros, el salario, las promociones y el trabajo realizado, además de un cuestionario sociolaboral. Resultados: participaron 70 trabajadoras, la gran mayoría auxiliares de enfermería y agentes de salud comunitarios, con una edad media de 45±10,6 años. Hubo indiferencia en los compañeros de campo, el liderazgo y la naturaleza del trabajo. Por otro lado, se comprobó la insatisfacción con los campos salariales y las promociones. Conclusión: se ha constatado la insatisfacción laboral en APS, los resultados demuestran la necesidad de revisar el plano de carrera y los ajustes salariales.

ABSTRACT Objective: to identify factors related to (dis)satisfaction at work among Primary Health Care (PHC) workers. Methods: exploratory study with a quantitative approach, conducted in 23 PHC units in the state of São Paulo, Brazil. The Job Satisfaction Scale was used, which covers the degree of satisfaction with management, colleagues, salary, promotions, and work performed, in addition to a socio-occupational questionnaire. Results: 70 workers participated, most of them Nursing assistants and community healthcare agents, with a mean age of 45±10.6 years. Indifference was found in the fields of colleagues, management, and nature of work. On the other hand, there was dissatisfaction with the salary and promotions fields. Conclusion: job dissatisfaction was found in PHC, and the findings demonstrate the need to review the career plan and salary adjustments.

Satisfacción de los servicios de medicina alópata vs la medicina tradicional en Oaxaca, México / Satisfaction with Allopathic Medicine Services versus Traditional Medicine in Oaxaca, Mexico

Introducción: Se ha reportado baja satisfacción con la atención recibida en el primer y el segundo nivel de atención de instituciones públicas. Existe incremento del uso de la medicina tradicional. Objetivo: Comparar el nivel de satisfacción percibida por los pacientes que acuden a los servicios de medicina alópata y medicina tradicional. Métodos: Estudio descriptivo, transversal y comparativo. La población estuvo constituida por pacientes que acudieron al Centro de Salud Urbano y curandero de medicina tradicional de la misma comunidad. El tamaño de la muestra fue de 344 personas, seleccionados por muestreo sistemático. Resultados: La media de edad fue de 40,6 años (DE=16,1), predominó el sexo femenino, los casados, con educación primaria y de religión católica. El padecimiento por el cual acudieron a los servicios de medicina alópata fue por consulta familiar y en la medicina tradicional por espanto. Se encontraron diferencias significativas entra la satisfacción medicina tradicional y alópata. Los pacientes reportan mayor satisfacción en los servicios de medicina tradicional. Conclusiones: Los pacientes perciben mayor satisfacción en la explicación, trato y tratamiento médico en la medicina tradicional(AU)

Introduction: Low satisfaction with the care received at the first and second levels in public institutions has been reported. There is an increase in the use of traditional medicine. Objective: To compare the level of satisfaction perceived by patients attending allopathic and traditional medicine services. Methods: Descriptive, cross-sectional and comparative study. The population consisted of patients attending the Urban Health Center and traditional medicine healer in the community of Oaxaca. The sample size was 344 people, selected by systematic sampling. Results: The mean age was 40.6 years (SD=16.1). There was a predominance of the female sex, married persons, with primary education and Catholic religion. The condition for which they sought allopathic medicine services was that they received family advice and, in traditional medicine, for fear. Significant differences were found between satisfaction with traditional and allopathic medicine. Patients report greater satisfaction in traditional medicine services. Conclusions: Patients perceive greater satisfaction in the explanation, treatment and medical treatment in traditional medicine(AU)

Management and prevention of diabetes in primary health care in Amazonas / Ações de prevenção e controle de diabetes na atenção primária no Amazonas

Actions for the prevention and management of type 2 diabetes (T2DM PM) are priorities within primary health care, from the dispensing of specific medications to non-pharmacological actions, such as physical activity and nutrition. The aim of the study was to describe prevention and man-agement of type 2 diabetes actions and their components in primary health settings in the State of Amazonas, Brazil. An observational study based on RE-AIM framework. Preventions and manage-ments actions approach were described by 5 dimensions: (R) reach, (E) effectiveness, (A) adoption, (I) implementation, and (M) maintenance. Data was collected in Primary Health Care Units from 6 cities from Amazonas, Brazil. The questionnaires were addressed to managers regarding current T2DM PM programs and their development. This study identified 17 different types of diabetes prevention and/or management actions currently implemented. Eleven actions included both pre-vention and management actions with 53.8% focusing on physical activity and nutrition orientation. However, zero actions reported any form of evaluation measuring changes in physical activity and nutrition behavior, and actions reported collecting feedback from participants, providers, and health professionals' workers. A total of 310 health professionals participated in diabetes actions, including 4 physical educational professionals and 3 nutritionists, with 100% of the efforts coordinated by nurses. Actions were based on traditional health education practices such as lectures and did not have practical activities that help to change and maintain healthy habits. Despite this, primary care plays a fundamental role in caring for users with chronic illnesses in cities in the interior of Amazonas

Ações de prevenção e controle da diabetes do tipo 2 (T2DM) são prioridades dentro da atenção primária de saúde, desde a dispensação de medicações específicas, às ações não medicamentosas como atividade física e nutrição. O objetivo foi caracterizar ações de prevenção e manejo (PM) e seus componentes na atenção primária no Estado do Amazonas, Brasil. Estudo observacional baseado no modelo RE-AIM. Estratégias adotadas em ações de PM foram descritas pelas 5 dimensões: (R) Alcance, (E) Efetividade, (A) Adoção, (I) Implementação e (M) Manutenção. Dados foram coletados em Unidades Básicas de Saúde em 6 cidades do Amazonas, Brasil. Os questionários endereçados aos gestores visavam ações de PM e seu desenvolvimento. Este estudo identificou 17 diferentes tipos de ações. Onze ações contemplaram ambas as estratégias de PM com 53,8% focadas em atividade física e orientações nutricionais. No entanto, nenhuma ação relatou mensuração para avaliação de mudanças no nível de atividade física e no comportamento nutricional. As ações baseiam suas avaliações em coleta de feedback dos participantes, equipe executora e profissionais de saúde. Ao todo, 310 profissionais de saúde participaram de ações, incluindo 4 profissionais de educação física e 3 nutricionistas, sendo 100% dos esforços coordenados por enfermeiros. As ações de PM da T2DM são baseadas em práticas tradicionais de educação em saúde como palestras e não possuem atividades práticas que auxiliem na mudança e manutenção de comportamentos saudáveis. Apesar disso, a atenção primária exerce um papel fundamental no cuidado ao usuário portador de doença crônica em municípios do interior do Amazonas

Community-based mental health project in Davao Region: Policy notes

@#In accordance with the Republic Act (RA) 11036, also known as the Mental Health Act of 2017, the Department of Health (DOH) was tasked to "establish a balanced system of community-based and hospital-based mental health services at all levels of the public health care system from the barangay, municipal, city, provincial, regional to the national level." It is also expected that the Local Government Units (LGUs) "promote deinstitutionalization and other recovery-based approaches to the delivery of mental health care services."1 Even before RA 11036 was enacted, the Davao Center for Health Development (DCHD) had already facilitated the establishment of several Community-Based Mental Health Programs (CBMHPs) in rural health units (RHUs) within the region since 2015. These programs are guided by six principles–coordinated level of referral system for better patient care, optimizing the expertise of the regional mental hub to guarantee rational use of drugs, community-based patient care for a more cost-effective treatment, capitalizing family and patient's support groups for better patient outcomes, optimizing innovative long-acting injections for better compliance and decreased relapse, and neutralizing the stigma against schizophrenia to improve mental health.2 The aim of this article is to recommend health care policies based on the report on observations and lessons learned from the implementation of the CBMHPs by the DCHD in four municipalities in Davao Region.

Fatores relacionados com a prevalência de lesões por pressão em contexto comunitário / Factores relacionados con la prevalencia de lesiones por presión en el contexto comunitario / Factors related to the prevalence of pressure injuries in community context

Objetivo: identificar fatores relacionados com a prevalência de lesões por pressão. Método: estudo descritivo-correlacional, transversal, com usuários adultos dependentes em contexto comunitário. Os dados foram coletados em um formulário, mediante consulta de documentação no Sistema de Informação SClínico. No tratamento de dados foi utilizado o Statistical Package for the Social Sciences. Resultados: do total da amostra (n=771), a maioria era do sexo feminino (68,2%) e pertencia à faixa etária de 85 anos ou mais (45,1%). A maioria apresentava Alto Risco de desenvolver lesão por pressão (52,1%). A prevalência foi de 11,2%, diferindo significativamente entre as categorias do Grau de Risco e a dimensão Mobilidade da escala de Braden (c2: p<0,000). Conclusão: identificados fatores relacionados com a prevalência da lesão por pressão, entre os quais o Grau de Risco e a dimensão mobilidade.

Objetivo: identificar factores relacionados con la prevalencia de lesiones por presión. Método: estudio descriptivo-correlacional, transversal con usuarios adultos dependientes en un contexto comunitario. Los datos fueron recolectados en una forma, a través de la consulta de la documentación en el Sistema de Información Clínica. En el procesamiento de datos se utilizó el Statistical Package for the Social Sciences. Resultados: del total de la muestra (n=771), la mayoría eran mujeres (68,2%) y pertenecían al grupo de edad de 85 años o más (45,1%). La mayoría tenía un alto riesgo de desarrollar lesiones por presión (52,1%). La prevalencia fue del 11,2%, difiriendo significativamente entre las categorías del Grado de Riesgo y la dimensión movilidad de la escala de Braden (c2: p<0.000). Conclusión: se identificaron factores relacionados con la prevalencia de lesión por presión, incluyendo el Grado de Riesgo y la dimensión de movilidad.

Objective: to identify factors related to the prevalence of pressure injuries. Method: descriptive-correlational, cross-sectional study with dependent adult users in a community context. Data were collected in a form, through consultation of documentation in the Clinical Information System. The Statistical Package for the Social Sciences was used in the data processing. Results: of the total sample (n=771), the majority were female (68.2%) and belonged to the age group of 85 years or more (45.1%). The majority had a high risk of developing pressure injury (52.1%). Prevalence was 11.2%, differing significantly between the categories of the Degree of Risk and the Mobility dimension of the Braden scale (c2: p<0,000). Conclusion: factors related to the prevalence of pressure injury were identified, including the Degree of Risk and the mobility dimension.

Clinical practice guideline and pathways for the evaluation and management of patients with dizziness in family and community practice

Background@#Dizziness is a commonly encountered symptom in the primary care which can be caused, most of the time by benign condition and rarely due to serious conditions needing higher level of care.@*Objective@#To develop a clinical guideline and pathway that will serve as guide in the diagnosis and management of adult patients with dizziness in primary care and outpatient setting@*Methods@#A guideline development team was formed which is composed of family and community medicine specialists from different institutions. Searching, selection and assessment of the latest evidence on dizziness diagnosis and management was done using the search terms: “dizziness”, “diagnosis”, “management”, and “primary care”. Formulation of the recommendation was done using Grade approach and graded with modified GRADEPro and expert panel consensus. External review was also done by an expert in otorhinolaryngology.@*Recommendations@#Clinical Assessment •Recommendation1.Askforthepatient’sdescriptionofdizzinessandclassifythepatientintooneofthefourtypes: vertigo, presyncope, disequilibrium, and lightheadedness and classify as acute/episodic or chronic/sustained. (Strong Recommendation, Low Quality Evidence) •Recommendation2.Obtainamedicalhistoryfocusingonthetiming,triggers,associatedsymptoms,riskfactorsfor atherosclerotic vascular disease, and functional status or quality of life. (Strong Recommendation, High Quality Evidence) •Recommendation3.Performaphysicalexaminationfocusingonvitalsigns,HEENT(includingotoscopy),cardiovascular and neurologic examination. (Strong Recommendation, High Quality Evidence) •Recommendation4.PerformspecialphysicalexaminationslikeDix-Hallpikemaneuverforacuteepisodictriggeredvertigo to check for BPPV (most common cause of peripheral vertigo), HINTS plus test for spontaneous episodic vertigo to check for stroke and hyperventilation provocation test for patients suspected of anxiety (Strong Recommendation, High Quality Evidence) •Recommendation5.Elicitredflagsthatshouldwarrantreferrallikeseveredizzinessandassociated,alteredmentalstatus, loss of consciousness and abnormal vital signs. Other symptoms like chest pain, palpitations, dyspnea, neurologic deficit may warrant referral for evaluation and management. (Strong Recommendation, High Quality Evidence) •Recommendation6.Forpatientsconsultingviatelemedicine,obtainamedicalhistoryfocusingonthetiming,triggers, associated symptoms, risk factors for atherosclerotic vascular disease, and functional status or quality of life, and observe and conduct self-physical examination (vital signs, mental status, ocular and facial nerve) (Strong Recommendation, Low Quality Evidence) Diagnostic •Recommendation7.Laboratorytestingisnotroutinelyrecommendedamongpatientswithdizziness.However,testingmay be requested if there is a need to identify a definite etiology to guide treatment and should be guided by the classification of dizziness, possible etiology, and the medical history and physical examination. (Strong Recommendation, High Quality Evidence).Recommendation8.Forpatientswithvertigoandwithauditorysymptoms(i.e.,hearingloss,tinnitusandauralfullness, etc.), pure tone audiometry speech test may be requested if available. (Strong Recommendation, High Quality Evidence) •Recommendation9.Forpatientswithpresyncope/syncopeandachronicmedicalconditionisbeingconsidered,complete blood count may be requested for those with probable blood dyscrasia, serum blood glucose may be requested for those with diabetes, electrocardiogram and lipid profile may be requested for those with cardiovascular disease. (Strong Recommendation, High Quality Evidence) •Recommendation10.Forpatientswithdisequilibriumandwithanabnormalneurologicphysicalexaminationfinding,CT scan may be requested. (Strong Recommendation, High Quality Evidence) Pharmacologic •Recommendation11.Empirictrialofshortcourse(7days)pharmacologictreatmentforsymptomreliefshouldbeoffered. Referral should be considered if the dizziness become more severe or it did not improve in 7 days. (Strong Recommendation, High Quality Evidence) •Recommendation12.Forpatientswithmildtomoderatevertigo,offerhistamineanalogue(betahistine)orantihistamine (meclizine, diphenhydramine, dimenhydrinate or cinnarizine) for symptom relief. (Strong Recommendation, High Quality Evidence) •Recommendation13.Forpatientswithmildtomoderatevertigoassociatedwithmigraine(vestibularmigraine),aside from symptom relief, offer any of the triptans as preventive medication. (Strong Recommendation, High Quality Evidence) •Recommendation14.Forpatientswhosedizzinessisdescribedasdisequilibrium(gaitimbalance)orpresyncope(near faintness) or dizziness with anxiety attack, offer symptomatic treatment and intervention based on the underlying cause or consider referral to appropriate specialist. (Strong Recommendation, High Quality Evidence) Non-pharmacologic •Recommendation15.Allpatientsshouldbeprovidedwithhealtheducationoncauses,triggersandfollowup.(Strong Recommendation, Low Quality Evidence) •Recommendation16.Allpatientsshouldbeadvisedonappropriatedietandlifestylemodification.(StrongRecommendation, Low Quality Evidence) •Recommendation17.Dependingonthenatureofvertigo,educateandtrainthepatientoncanalrepositioningmaneuver and vestibular rehabilitation. Referral to rehabilitation medicine may be considered. (Strong Recommendation, High Quality Evidence) •Recommendation18.Thepatient’sfamilymustalsobeprovidedwithhealtheducationandidentifyacaregivertoassist and promote compliance to management. (Strong Recommendation, Low Quality Evidence) •Recommendation19.Encouragecommunity-basedvestibularrehabilitationactivitiessuchasgroupbalancetraining exercise. (Strong Recommendation, Low Quality Evidence) Patient Outcomes •Recommendation20.Thepatientshouldknowthenatureofdizziness,causesandpotentialcomplicationsanddevelop skills in postural exercises. (Strong Recommendation, Moderate Quality Evidence) •Recommendation21.Decreaseinfrequencyandseverityshouldexpectedwithin48hoursandresolutionisexpectedwithin a month. (Strong Recommendation, Moderate Quality Evidence) •Recommendation22.Improvedqualityoflifeshouldalsobeelicited.(StrongRecommendation,ModerateQualityEvidence) •Recommendation23.Referraltoappropriatespecialtyshouldbedoneifnoresolutionorprogressionofsymptomsor impaired quality of life for more than a month. (Strong Recommendation, Expert Opinion)@*Implementation@#The committee shall disseminate the guidelines through presentations and via journal publications. The QA committee shall be in charge of implementation of the guideline and pathway.

Patients’ preferences for primary care clinic and provider characteristics and services during the COVID-19 pandemic: A cross-sectional study

Introduction@#The Universal Health Care Law in the Philippines brought cost and quality at the forefront of the healthcare industry, ensuring all Filipinos have the right to health. With family medicine physicians as implementers, it is important to know what the patients/ consumer wants for their clinic. But during the pandemic, challenges were laid bare, highlighting how the health care sector should respond to the country’s health care needs.@*Objectives@#The study aimed to determine patient preferences for primary care clinics and provider characteristics among patients and caregivers from a community-based clinic chain in Cavite and Taguig City@*Methods@#A descriptive, cross-sectional study was conducted among 168 patients who consulted two private primary clinics in Cavite and Taguig in December 2021. After a comprehensive literature review and pilot study, a self-administered survey questionnaire was utilized. Data as frequencies and percentages were analyzed@*Results@#Preferences for primary care clinics were well-equipped clinic, safety protocols, PPE for the healthcare team, pleasing/ accommodating receptionist, separate area for patients with covid like symptoms, located within their community (< 1km away), 15-30 mins waiting time, and morning visit. Top preferences for provider characteristics were physicians who do careful examination and history, spoke in layman’s terms, rational prescription of drugs/tests, trustworthy, with <5 years of experience, 4- 8 clinic hours and to be seen by only one doctor. A pharmacy and x-ray/ultrasound, face to face consultation, affordable services, and consultation fees less than PhP500 (10 USD) were also preferred.@*Conclusion@#This study revealed that the patients’ preference was affected by the pandemic. Results showed that even as there are existing studies, it can change depending on the circumstances, and must change with the times in order to move forward. Taking into consideration these preferences is vital for the survival of the primary care clinic.

Critical appraisal

@#Critical appraisal is the process of reading published research to make a judgement on its scientific value (validity), and to consider how its results can be applied in family and community practice (applicability). There are four main elements of critical appraisal in EBFP i.e., relevance, validity, results, and applicability. Some family practitioners are not so comfortable with appraisal because of their poor background in research. But we developed the guide questions for critical appraisal simple and provide advice on what and where to look for it in the published evidence.

La integración de cuidados de enfermería en el anciano en estado de necesidad desde la perspectiva comunitaria / Integration of Nursing Care in the Elderly in Need from the Community Perspective

Introducción: El cuidado en enfermería se aborda desde una perspectiva holística que permita cubrir las necesidades reales de los pacientes en su entorno, que tienen entre sus funciones la de ayudar al anciano enfermo o sano a realizar las actividades que contribuyen a su salud, recuperación o una muerte tranquila en la comunidad. Objetivo: Exponer algunas consideraciones sobre la integración de los cuidados de enfermería en el anciano en estado de necesidad desde la perspectiva comunitaria. Métodos: Se realizó una revisión bibliográfica sistemática para desarrollar un análisis crítico reflexivo sobre la integración cuidados de enfermería en el anciano en estado de necesidad desde la perspectiva comunitaria, en documentos, artículos originales y de revisión disponible en Google Académico y Medline en el período de marzo a junio de 2018, las palabras clave utilizadas fueron Cuidado de enfermería; cuidados comunitarios; Enfermería; integración de cuidados de enfermería, identificadas a través del DECs o de MeSH. Se utilizaron los métodos de análisis, síntesis y sistematización, que posibilitaron la interpretación y la organización de los conocimientos. Tras la identificación de los estudios preseleccionados se llevó a cabo la lectura de los títulos, resumen y palabras clave, y se comprobó la pertinencia con el estudio. Conclusiones: La integración de los cuidados de enfermería permitió contextualizar este fenómeno desde la perspectiva de la comunidad, mediante el aporte de elementos puntuales en el manejo, seguimiento y control de los ancianos en estado de necesidad(AU)

Introduction: Nursing care is approached from a holistic perspective that allows meeting the real needs of patients in their settings, whose functions include helping the sick or healthy elderlies carry out activities that contribute to their health, recovery or having a quiet death in the community. Objective: To present some considerations about the integration of nursing care in the elderly in need from the community perspective. Methods: A systematic bibliographic review was carried out to develop a critical-reflective analysis about the integration of nursing care in the elderly in need from the community perspective, using documents, original articles and review available in Google Scholar and Medline, in the period from March to June 2018. The keywords used were Cuidado de enfermería [Nursing care], cuidados comunitarios [community care], Enfermería [Nursing] and integración de cuidados de enfermería [integration of nursing care], identified through DECs or MeSH. Analysis, synthesis and systematization methods were used, which made the interpretation and organization of knowledge possible. After the identification of the preselected studies, the titles, abstract and keywords were read, and the relevance to the study was checked. Conclusions: The integration of nursing care allowed contextualizing this phenomenon from the community perspective, through the contribution of specific elements to the management, follow-up and control of the elderly in need(AU)

La actualización sobre el uso racional de medicamentos en el proceso de superación del médico general integral en Cuba: aspectos históricos / Upgrading on the rational use of medications in the training process of the comprehensive general doctor in Cuba: historical aspects

La relevancia y el alcance del uso racional de medicamentos y su contribución al mejoramiento de la salud poblacional constituyen suficientes argumentos para que el médico general integral en Cuba lo adopte como modalidad de superación que cualifica su desempeño profesional. Al respecto, se han desarrollado varios estudios históricos sobre la superación de este especialista; sin embargo, se requiere profundizar en determinados temas que pueden aportarle un sentido renovador como prescriptor de medicamentos. A tal efecto, en este artículo se exponen los antecedentes del proceso de educación de posgrado de este galeno, con énfasis en la actualización sobre el uso racional de medicamentos. Pudo concluirse que existen vacíos importantes en el diseño de superación profesional en cuanto al uso racional de medicamentos en la atención primaria de salud; no obstante, se reconoce la trascendencia social de esa problemática por parte de los niveles directivos correspondientes.

The relevance and reach of the rational use of medications and their contribution to the improvement of the populational health constitute enough arguments so that the comprehensive general doctor in Cuba adopts it as training modality that qualifies his professional performance. In this respect, several historical studies have been developed on the training of these specialists; however, it is required to deepen in certain topics that can contribute a renovating sense to them as drugs prescribers. To such an effect, the history of the postdegree educational process of this doctor is exposed in this work, with emphasis in upgrading on the rational use of medications. It could be concluded that there are important gaps in the training design as for the rational use of medications in the primary health care; nevertheless, the social transcendency of that problem is recognized on the part of the corresponding directive levels.

El sistema de salud con su necesaria pieza en la Atención Primaria de Salud / The Health System with Primary Healthcare as its Necessary Piece

Con el devenir de la pandemia por COVID-19, ha quedado en evidencia la necesidad de contar con sistemas de salud públicos y fortalecidos, bien estructurados y capaces de dar respuesta inmediata y sostenida a los problemas de salud pública. El Sistema de Salud tiene como eslabón la Atención Primaria en Salud (APS), constituye una función central en el desarrollo económico, social, cultural y global de la sociedad.1) La APS se encamina hacia los principales problemas sanitarios de la comunidad, brinda prevención, curación, rehabilitación y fomenta la salud. Por tanto, se puede definir la APS como la asistencia sanitaria al alcance de los individuos y familias de la comunidad, en su plena participación y a un costo que la sociedad y el país puedan soportar.2 La APS descansa en el equipo de atención, compuesto principalmente por un médico, preferiblemente especialista en medicina familiar, y una enfermera con formación y orientación en la atención comunitaria. Este equipo de atención es un elemento clave para fomentar las actividades de prevención y promoción de la salud en su comunidad, como por ejemplo, con mejoras en los modos y estilos de vida y cumplir con el esquema de vacunación; también favorecer la adherencia terapéutica o facilitar la rehabilitación.3 Es necesario tener en cuenta una herramienta importante para lograr los cambios, y es el análisis de la situación de salud. Esta herramienta, que tiene componentes netamente de la atención sanitaria y la dispensarización de la población en grupos que permitan realizar labores conscientes y organizadas de prevención y promoción, de atención médica directa y de rehabilitación en los casos que los ameriten, también cuenta con elementos sociales como las necesidades sentidas de la comunidad, los factores o elementos que ponen en riesgo la salud de las personas y el entorno social, así como sugerencias y mejoras a las autoridades de gobierno. Además, de un último componente de investigación...(AU)

La familia y la medicina familiar en la educación de posgrado en Cuba / Family and family medicine in postgraduate education in Cuba

Introducción: La familia funciona como una unidad de atención en la medicina familiar. Junto con las personas y la comunidad se conforman los escenarios principales de las acciones de salud en la formación posgraduada de Medicina General Integral, que asume así una atención integral a la persona desde el punto de vista biopsicosocial. Objetivo: Describir la evolución del sistema de objetivos y contenidos en los programas de formación de la especialidad Medicina General Integral, propuestos para el abordaje de la familia y la medicina familiar en la educación de posgrado en Cuba. Métodos: Se realizó una investigación descriptiva, de corte educacional. Se emplearon métodos teóricos y empíricos en función de la revisión bibliográfica y documental, relacionada con los objetivos y contenidos sobre familia y medicina familiar en el posgrado. Se hizo análisis, síntesis y contrastación de criterios, a partir de los materiales revisados. Resultados: La especialidad Medicina General Integral ha transitado hasta 2018 por cinco programas de estudios. Los contenidos familia y medicina familiar se ubican a partir del tercero, en función de profundizar y consolidar las habilidades necesarias para la intervención, tanto educativa como terapéutica de la familia. El primero carecía de integralidad, y la quinta y actual versión está organizada mediante cursos. Conclusiones: El abordaje del sistema de objetivos y contenidos sobre la familia y la medicina familiar en el programa de la especialidad Medicina General Integral ha evolucionado hacia su inclusión progresiva, que contribuye a perfeccionar las competencias de los egresados en el cumplimiento del ejercicio de la medicina familiar(AU)

Introduction: Family functions as a unit during the process of care provision in family medicine. People and the community together make up the main scenarios of health actions in postgraduate training in Family Medicine, which allows comprehensive care for the person from the biopsychosocial point of view. Objective: To describe the evolution of the system of objectives and contents in the training programs of the Family Medicine specialty, proposed for the managment of family and family medicine in postgraduate education in Cuba. Methods: A descriptive and educational research was carried out. Theoretical and empirical methods were used, focused on bibliographic and document review, related to the objectives and contents about family and family medicine in postgraduate studies. Analysis, synthesis and contrast of criteria were used, based on the reviewed materials. Results: Until 2018, the Family Medicine specialty has gone through five study programs. The contents about family and family medicine are included to be studied from the third program, in order to deepen and consolidate the necessary skills for intervention, both educational and therapeutic, of the family. The first one lacked comprehensiveness, and the fifth and current version is organized through courses. Conclusions: The way the system of objectives and contents about family and family medicine are dealt with in the program of the Family Medicine specialty has evolved towards its progressive inclusion, which contributes to perfecting the competences of graduates, in order to fulfill the practice of medicine family(AU)