ABSTRACT
BACKGROUND: Evidence-based interventions are more likely to be adopted if practitioners collaborate with researchers to develop an implementation strategy. This paper describes the steps to plan and execute a strategy, including the development of structure and supports needed for implementing proven health promotion interventions in primary and community care. RESULTS: Between 10 and 13 discussion and consensus sessions were performed in four highly-motivated primary health care centers involving 80% of the primary care staff and 21 community-based organizations. All four centers chose to address physical activity, diet, and smoking. They selected the 5 A's evidence-based clinical intervention to be adapted to the context of the health centers. The planned implementation strategy worked at multiple levels: bottom-up primary care organizational change, top-down support from managers, community involvement, and the development of innovative e-health information and communication tools. Shared decision making and practice facilitation were perceived as the most positive aspects of the collaborative modeling process, which took more time than expected, especially the development of the new e-health tools integrated into electronic health records. CONCLUSIONS: Collaborative modeling of an implementation strategy for the integration of health promotion in primary and community care was feasible in motivated centers. However, it was difficult, being hindered by the heavy workload in primary care and generating uncertainty inherent to a bottom-up decision making processes. Lessons from this experience could be useful in diverse settings and for other clinical interventions. Two companion papers report the evaluation of its feasibility and assess quantitatively and qualitatively the implementation process.
Subject(s)
Community Health Services/organization & administration , Health Promotion/organization & administration , Models, Organizational , Primary Health Care/organization & administration , Evidence-Based PracticeABSTRACT
OBJETIVO: Implementar y evaluar una experiencia colaborativa entre Atención Primaria (AP) y Salud Mental (SM) para mejorar la asistencia a los pacientes con depresión. DISEÑO: Proyecto colaborativo piloto con enfoque de investigación acción participativa (IAP) durante 2013. EMPLAZAMIENTO: País Vasco. Osakidetza (Servicio Vasco de Salud). Bizkaia y Gipuzkoa. PARTICIPANTES: Doscientos siete profesionales de medicina de familia, enfermería, psiquiatría, enfermería psiquiátrica, psicología y trabajo social de 9 centros de salud y 6 centros de salud mental de Osakidetza. INTERVENCIONES: Diseño y desarrollo compartido de 4 ejes de intervención: 1) comunicación y conocimiento entre profesionales de AP y SM; 2) mejora en la codificación diagnóstica y derivación de pacientes; 3) formación compartida mediante sesiones y guías de práctica clínica comunes, y 4) evaluación. MEDICIONES PRINCIPALES: Encuestas a profesionales de centros de intervención y control sobre conocimiento y satisfacción en la relación AP-SM, actividades formativas conjuntas y valoración de la experiencia. Registros de Osakidetza sobre prevalencias, derivaciones y tratamientos. Reuniones de seguimiento. RESULTADOS: Mejoría en los centros de intervención respecto a los de control en los 4 ejes de intervención. Identificación de factores a considerar en el desarrollo y la sostenibilidad de la colaboración AP-SM. CONCLUSIONES: La experiencia piloto confirma que los proyectos colaborativos promovidos por AP y SM pueden mejorar la asistencia y satisfacción de los profesionales. Son proyectos complejos que requieren intervenciones simultáneas adecuadas a las singularidades de los servicios de salud. La participación pluridisciplinaria y continuada, y el apoyo de la gestión y los sistemas de información, son condiciones necesarias para su implementación
OBJECTIVE: To implement and assess a collaborative experience between Primary Care (PC) and Mental Health (MH) in order to improve the care of patients with depression. DESIGN: Pilot collaborative project from a participatory action research approach during 2013. LOCATION: Basque Country. Osakidetza (Basque Health Service). Bizkaia and Gipuzkoa. PARTICIPANTS: The study included 207 professionals from general practice, nursing, psychiatry, psychiatric nursing, psychology and social work of 9 health centres and 6 mental health centres of Osakidetza. INTERVENTIONS: Shared design and development of four axes of intervention: 1) Communication and knowledge between PC and MH professionals, 2) Improvement of diagnostic coding and referral of patients, 3) Training programmes with meetings and common Clinical Practice Guidelines, and 4) Evaluation. MAIN MEASUREMENTS: Intervention and control questionnaires to professionals of the centres on the knowledge and satisfaction in the PC-MH relationship, joint training activities, and assessment of the experience. Osakidetza registers of prevalences, referrals and treatments. Follow-up meetings. RESULTS: Improvement in the 4 axes of intervention in the participant centres compared with the controls. Identification of factors to be considered in the development and sustainability of PC-MH collaborative care. CONCLUSIONS: The pilot experience confirms that collaborative projects promoted by PC and MH can improve depression care and the satisfaction of professionals. They are complex projects that need simultaneous interventions adjusted to the particularities of the health services. Multidisciplinary and continuous participation and management and information system support are necessary for their implementation
Subject(s)
Humans , Male , Female , Depression/diagnosis , Depression/epidemiology , Depression/prevention & control , Mental Health/standards , Mental Health/trends , Mental Health Services/organization & administration , Mental Health Services/standards , Pilot Projects , Primary Health Care/methods , Primary Health Care , Health Centers , Surveys and QuestionnairesABSTRACT
OBJECTIVE: To implement and assess a collaborative experience between Primary Care (PC) and Mental Health (MH) in order to improve the care of patients with depression. DESIGN: Pilot collaborative project from a participatory action research approach during 2013. LOCATION: Basque Country. Osakidetza (Basque Health Service). Bizkaia and Gipuzkoa. PARTICIPANTS: The study included 207 professionals from general practice, nursing, psychiatry, psychiatric nursing, psychology and social work of 9 health centres and 6 mental health centres of Osakidetza. INTERVENTIONS: Shared design and development of four axes of intervention: 1) Communication and knowledge between PC and MH professionals, 2) Improvement of diagnostic coding and referral of patients, 3) Training programmes with meetings and common Clinical Practice Guidelines, and 4) Evaluation. MAIN MEASUREMENTS: Intervention and control questionnaires to professionals of the centres on the knowledge and satisfaction in the PC-MH relationship, joint training activities, and assessment of the experience. Osakidetza registers of prevalences, referrals and treatments. Follow-up meetings. RESULTS: Improvement in the 4 axes of intervention in the participant centres compared with the controls. Identification of factors to be considered in the development and sustainability of PC-MH collaborative care. CONCLUSIONS: The pilot experience confirms that collaborative projects promoted by PC and MH can improve depression care and the satisfaction of professionals. They are complex projects that need simultaneous interventions adjusted to the particularities of the health services. Multidisciplinary and continuous participation and management and information system support are necessary for their implementation.
Subject(s)
Depression/therapy , Mental Health Services , Patient Care Team , Primary Health Care , Humans , Pilot Projects , SpainABSTRACT
BACKGROUND: The effects of tobacco, physical exercise, diet, and alcohol consumption on morbidity and mortality underline the importance of health promotion and prevention (HPP) at the primary health care (PHC) level. Likewise, the deficiencies when putting such policies into practice and assessing their effectiveness are also widely recognised. The objectives of this research were: a) to gain an in-depth understanding of general practitioners' (GPs) and patients' perceptions about HPP in PHC, and b) to define the areas that could be improved in future interventions. METHODS: Qualitative methodology focussed on the field of health services research. Information was generated on the basis of two GP-based and two patient-based discussion groups, all of which had previously participated in two interventions concerning healthy lifestyle promotion (tobacco and physical exercise). Transcripts and field notes were analysed on the basis of a sociological discourse-analysis model. The results were validated by triangulation between researchers. RESULTS: GPs and patients' discourses about HPP in PHC were different in priorities and contents. An overall explanatory framework was designed to gain a better understanding of the meaning of GP-patient interactions related to HPP, and to show the main trends that emerged from their discourses. GPs linked their perceptions of HPP to their working conditions and experience in health services. The dimensions in this case involved the orientation of interventions, the goal of actions, and the evaluation of results. For patients, habits were mainly related to ways of life particularly influenced by close contexts. Health conceptions, their role as individuals, and the orientation of their demands were the most important dimensions in patients' sphere. CONCLUSIONS: HPP activities in PHC need to be understood and assessed in the context of their interaction with the conditioning trends in health services and patients' social micro-contexts. On the basis of the explanatory framework, three development lines are proposed: the incorporation of new methodological approaches according to the complexity of HPP in PHC; the openness of habit change policies beyond the medical services; and the effective commitments in the medium to long term by the health services themselves at the policy management level.
Subject(s)
Health Promotion , Physician-Patient Relations , Primary Health Care , Qualitative Research , Female , Focus Groups , General Practitioners , Humans , Male , Middle Aged , SpainABSTRACT
BACKGROUND: The adoption of a healthy lifestyle, including physical activity, a balanced diet, a moderate alcohol consumption and abstinence from smoking, are associated with large decreases in the incidence and mortality rates for the most common chronic diseases. That is why primary health care (PHC) services are trying, so far with less success than desirable, to promote healthy lifestyles among patients. The objective of this study is to design and model, under a participative collaboration framework between clinicians and researchers, interventions that are feasible and sustainable for the promotion of healthy lifestyles in PHC. METHODS AND DESIGN: Phase I formative research and a quasi-experimental evaluation of the modelling and planning process will be undertaken in eight primary care centres (PCCs) of the Basque Health Service--OSAKIDETZA, of which four centres will be assigned for convenience to the Intervention Group (the others being Controls). Twelve structured study, discussion and consensus sessions supported by reviews of the literature and relevant documents, will be undertaken throughout 12 months. The first four sessions, including a descriptive strategic needs assessment, will lead to the prioritisation of a health promotion aim in each centre. In the remaining eight sessions, collaborative design of intervention strategies, on the basis of a planning process and pilot trials, will be carried out. The impact of the formative process on the practice of healthy lifestyle promotion, attitude towards health promotion and other factors associated with the optimisation of preventive clinical practice will be assessed, through pre- and post-programme evaluations and comparisons of the indicators measured in professionals from the centres assigned to the Intervention or Control Groups. DISCUSSION: There are four necessary factors for the outcome to be successful and result in important changes: (1) the commitment of professional and community partners who are involved; (2) their competence for change; (3) the active cooperation and participation of the interdisciplinary partners involved throughout the process of change; and (4) the availability of resources necessary to facilitate the change.
Subject(s)
Health Promotion/methods , Health Services Research , Primary Health Care/methods , Community Health Centers/organization & administration , Cooperative Behavior , Health Planning/methods , Humans , Organizational Innovation , Outcome Assessment, Health Care , Patient Selection , Primary Health Care/organization & administration , Research Design , Risk Reduction Behavior , SpainABSTRACT
Objetivos: profundizar en las percepciones de los médicos de familia y de los pacientes acerca las actividades de promoción ante el tabaco, ejercicio, alcohol y dieta. Metodología: metodología cualitativa. Obtención de la información mediante dos grupos de discusión de médicos y dos de pacientes que habían participado en intervenciones previas. Como modelo de análisis se utilizo el análisis sociológico del discurso. Resultados: las actividades de promoción de la salud AP son percibidas de modo diferente por los médicos y los pacientes en función de sus correspondientes contextos sanitarios y sociales. Dichas perspectivas y contextos pueden representarse en torno a dos ejes: uno, de interrelación profesionales sanitarios-pacientes, y otro entre el polo de orientación más biomédica, parcelar y orientado a la enfermedad y el polo que representa las visiones más integrales y orientadas a la salud. Conclusiones: los resultados de la investigación permiten identificar los principales factores sanitarios y extra-sanitarios percibidos por los médicos y pacientes como condicionantes de sus comportamientos y configurar un marco interpretativo de su significado para ambos agentes en el contexto de la APS.
Objective: to deepen our knowledge of family physician's and patients perceptions of the promotion activities for health behaviors in smoking, exercise, diet and alcohol consumption. Methodology: qualitative methodology. Information was obtained by conducting two discussion groups with physicians and two with patients who had previously participated and two with patients who had previously participated in some interventions. Data were analyzed using the sociological discourse model. Validation was carried out by triangulation among researchers. Results: health promotion activities are differently perceived by doctors and patients depending on their health services and social contexts. These perspectives and contexts can be graphically represented around two axes: the first one interrelates doctors and patients, and the second one between a biomedical and disease oriented pole, and another pole representing a more integral and health oriented vision of promotion. Conclusions: the obtained results allow us to identify the main health and non-health related factors perceived by doctors and patients as influencing their behaviors. The data will also allow for the construction of a framework in which to interpret the meaning of the promotion activities within the relationship of both agents in the context of the Primary Health Care.
Subject(s)
Health Promotion , Primary Health Care , Qualitative ResearchABSTRACT
BACKGROUND: The adoption of a healthy lifestyle, including physical activity, a healthy diet, moderate alcohol consumption and abstinence from smoking, is associated with a major decrease in the incidence of chronic diseases and mortality. Primary health-care (PHC) services therefore attempt, with rather limited success, to promote such lifestyles in their patients. The objective of the present study is to ascertain the perceptions of clinicians and researchers within the Basque Health System of the factors that hinder or facilitate the integration of healthy lifestyle promotion in routine PHC setting. METHODS: Formative research based on five consensus meetings held by an expert panel of 12 PHC professionals with clinical and research experience in health promotion, supplied with selected bibliographic material. These meetings were recorded, summarized and the provisional findings were returned to participants in order to improve their validity. RESULTS: The Health Belief Model, the Theory of Planned Action, the Social Learning Theory, "stages of change" models and integrative models were considered the most useful by the expert panel. Effective intervention strategies, such as the "5 A's" strategy (assess, advise, agree, assist and arrange) are also available. However, none of these can be directly implemented or continuously maintained under current PHC conditions. These strategies should therefore be redesigned by adjusting the intervention objectives and contents to the operation of primary care centres and, in turn, altering the organisation of the centres where they are to be implemented. CONCLUSION: It is recommended to address optimisation of health promotion in PHC from a research perspective in which PHC professionals, researchers and managers of these services cooperate in designing and evaluating innovative programs. Future strategies should adopt a socio-ecological approach in which the health system plays an essential role but which nevertheless complements other individual, cultural and social factors that condition health. These initiatives require an adequate theoretical and methodological framework for designing and evaluating complex interventions.
Subject(s)
Delivery of Health Care, Integrated , Health Behavior , Health Promotion/organization & administration , Life Style , Primary Health Care/organization & administration , Health Services Research , Humans , SpainABSTRACT
We describe in this work the identification and the conjugal properties of two cryptic plasmids present in the strain Sinorhizobium meliloti LPU88 isolated from an Argentine soil. One of the plasmids, pSmeLPU88b (22 kb), could be mobilised from different S. meliloti strains to other bacteria by conjugation only if the other plasmid, pSmeLPU88a (139 kb), was present. This latter plasmid, however, could not be transferred via conjugation (frequency <10(-9) transconjugants per recipient) contrasting with the conjugal system from the previously described strain GR4, where one plasmid is mobilisable and a second one (helper) is self-transmissible. Despite the differences between the two systems, the conjugative helper functions present in the cryptic plasmids of strain GR4 were active in the mobilisation of plasmid pSmeLPU88b from strain LPU88. Contrasting with this, plasmid pSmeLPU88b was not mobilised by the helper functions of the broad-host-range plasmid RP4. Eckhardt gel analysis showed that none of the plasmids from strain GR4 were excluded in the presence of plasmid pSmeLPU88b suggesting that they all belong to different incompatibility groups for replication. The small plasmid from strain LPU88, pSmeLPU88b, was only able to replicate in members of the Rhizobiaceae family such as Rhizobium leguminosarum, Rhizobium tropici and Agrobacterium tumefaciens, but not in Escherichia coli or Pseudomonas fluorescens. The observation suggests that most likely plasmid pSmeLPU88b was not received from a phylogenetically distant bacterium.
Subject(s)
Plasmids/genetics , Sinorhizobium meliloti/genetics , Agrobacterium tumefaciens/genetics , Argentina , Base Sequence , Conjugation, Genetic , DNA Replication/genetics , DNA, Bacterial/genetics , Europe , Genetic Complementation Test , Plasmids/isolation & purification , Rhizobium/genetics , Sinorhizobium meliloti/isolation & purification , Soil Microbiology , Species SpecificityABSTRACT
El objetivo del trabajo fue identificar y analizar la percepcion ambiental del cuerpo docente del nivel primario (hoy nivel de enseñnza general basica) de la ciudad de Arrecifes,provincia de Buenos Aires,apuntando a determinar el concepto que se tiene de "medio ambiente" aplicado tanto al ambito rural como al urbano
Subject(s)
Argentina , Environmental StatisticsABSTRACT
El objetivo del trabajo fue identificar y analizar la percepcion ambiental del cuerpo docente del nivel primario (hoy nivel de enseñnza general basica) de la ciudad de Arrecifes,provincia de Buenos Aires,apuntando a determinar el concepto que se tiene de "medio ambiente" aplicado tanto al ambito rural como al urbano
Subject(s)
Argentina , Environmental StatisticsABSTRACT
A doença de Lyme é uma desordem inflamatória, intermediada pelo sistema imunogênico, transmitida por carrapatos (especialmente do Gênero Ixodes) e causada por uma espiroqueta recentemente descoberta, a Borrelia burgdorferi. A técnica de Imunofluorescência Indireta (IF) é, com freqüência, usada para confirmar o diagnóstico da infecçäo por este microrganismo. Embora os métodos práticos tenham limitaçöes, é, no entanto, o único método prático para seu diagnóstico. Devido a näo existência de registros prévios dessa doença na Argentina, foi realizada pesquisa seroepidemiológica para determinar a presença de imunoglobinas nos trabalhadores rurais da Argentina, com sintomas de artrite. Sobre um total de 28 soros analisados, 3 resultaram positivos (o soro número 1 com um título de 1:320 para IgG, embora os soros números 5 e 9 ambos foram reativos a diluiçäo 1:160). Esses mesmos soros foram analisados para a IgM sendo todos eles levemente reativos (1:40), usando IF. Os resultados mostram que anticorpos anti Borrelia burgdorferi se encontram presentes na populaçäo da Argentina. Deve-se ter, portanto, precauçäo na interpretaçäo clínica das artrites até que a presença de Borrelia burgdorferi seja confirmada pelo cultivo nos meios específicos
