Salud comunitaria. Innovando en la formación de residentes de medicina familiar y comunitaria / Community health. Innovating in the training of family and community medicine residents

Objetivo: Conocer las opiniones de los agentes implicados en la formación de residentes de medicina familiar y comunitaria para mejorar el proceso formativo del «Proyecto de Apoyo a la Revitalización de la Atención Primaria; Activos para la Salud Comunitaria» (PARAC) teniendo en cuenta su adecuación, contextualización y las metodologías utilizadas.Método: Estudio cualitativo interpretativo-explicativo de orientación fenomenológica, multinivel y multicéntrico, en el que se analiza la opinión de las personas participantes. Entre 2018 y 2020 se realizaron 12 grupos focales y 24 entrevistas semiestructuradas, participando 67 profesionales pertenecientes a seis distritos sanitarios de Andalucía, que estuvieron implicados/as en el proceso formativo PARAC.Resultados: Las personas participantes consideran necesario ampliar la formación en salud comunitaria de los/las residentes. Para ello, creen necesario realizar cambios en el plan formativo de la especialidad, otorgando mayor protagonismo a la atención primaria de salud que a las rotaciones hospitalarias. Valoran positivamente las metodologías utilizadas en el proceso formativo PARAC, que consideran «novedosas», y la elección de docentes jóvenes que sirvan como referentes. Para que sus intervenciones en el territorio se realicen con calidad y seguridad para la población, piden que se garanticen unos tiempos y unos espacios específicos para la salud comunitaria, así como una adecuada supervisión que ayude a asegurar la coherencia y la continuidad de sus intervenciones.Conclusiones: La formación en salud comunitaria de los/las residentes de medicina familiar y comunitaria requiere un esfuerzo pedagógico, didáctico y curricular que los/las prepare para el trabajo con la comunidad, así como la garantía de unas condiciones organizativas que permitan este trabajo.(AU)

Objective: To know the opinions of the agents involved in the training of family and community medicine residents in order to improve the training process of the «Project to Support the Revitalization of Primary Care; Assets for Community Health» (PARAC) taking into account its adequacy, contextualization and the methodologies used.Method: Qualitative interpretative-explanatory study of phenomenological orientation, multilevel and multicenter, in which the opinion of the participants is analyzed. Between 2018 and 2020, 12 focus groups and 24 semi-structured interviews were carried out, with the participation of sixty-seven professionals from six health districts of Andalusia (Spain), who were involved in the PARAC training process.Results: The participants consider it necessary to broaden training in community health for residents. To this end, they consider it necessary to make changes in the training plan of the specialty, giving more importance to primary health care than to hospital rotations. They value positively the methodologies used in the PARAC training process, which they consider «novel», and the choice of young teachers to serve as references. In order for their interventions in the territory to be carried out with quality and safety for the population, they ask that specific times and spaces be guaranteed for community health, as well as adequate supervision to help ensure the coherence and continuity of their interventions.Conclusions: Training in community health for family and community medicine residents requires a pedagogical, didactic and curricular effort that prepares them for work with the community, as well as the guarantee of organizational conditions that allow this work.(AU)

Eight years of the East African Community Medicines Regulatory Harmonization initiative: Implementation, progress, and lessons learned.

Jane H. Mashingia and colleagues reveal the progress made to date for the East African Community Medicines Regulatory Harmonization initiative.

Optimizing the East African Community's Medicines Regulatory Harmonization initiative in 2020-2022: A Roadmap for the Future.

Margareth Ndomondo-Sigonda outlines future challenges for the East African Medicines Regulatory Harmonization initiative.

Coming together to improve access to medicines: The genesis of the East African Community's Medicines Regulatory Harmonization initiative.

Hiiti Sillo and colleagues reveal how the East African Community's Medicines Regulatory Harmonization initiative improves access to important medicines in Africa.

Family and Community Medicine in Uruguay from 1997 to 2019: how many kilometers will it take to reach that town? / La Medicina Familiar y Comunitaria en Uruguay de 1997 a 2019: ¿cuántos kilómetros faltarán para llegar al pueblo aquel?

The Family and Community Medicine Residency started in Uruguay in 1997. Through a self-managed process, the first generations were molded into training that integrated hospital knowledge and experience with territorial praxis in a community-based health service with a population of reference. The academic recognition of the specialty and the installation of the institutional areas for its management were achievements parallel to that process in the first decade. The second decade was marked by the territorial teaching-assistance expansion in the country, university decentralization and the active participation of Family and Community Medicine in the Health Reform, and the country's rights agenda. The third decade of the specialty begins with a crisis triggered by the sustained decline in the aspiration for residency. An initial approach to explanations reflects on the possibility of facing a more profound crisis and the need to find the keys to a 21st century Medicine that allows us to achieve the principles of Alma-Ata that are still current.

La residencia de medicina familiar y comunitaria comenzó en Uruguay en el año 1997. A través de un proceso autogestionado, las primeras generaciones se moldearon en una formación que integraba en ellos el conocimiento y la experiencia hospitalarios junto con la praxis territorial en un servicio de salud de base comunitaria con población de referencia. El reconocimiento académico de la especialidad y la instalación de los ámbitos institucionales para su gestión fueron conquistas paralelas a ese proceso en la primera década. La segunda década estuvo marcada por la expansión territorial de la estructura docente-asistencial, la descentralización de la universidad y la participación activa de la medicina familiar y comunitaria en la reforma de la salud y la agenda de derechos. La tercera década de la especialidad se presenta en su inicio como crisis dada por la caída sostenida en la aspiración a la residencia. Desde una aproximación inicial a las explicaciones, se reflexiona sobre la posibilidad de estar frente a una crisis más profunda y la necesidad de encontrar las claves de una medicina del siglo XXI que permita alcanzar los principios de Alma Ata, siempre vigentes.

La Medicina Familiar y Comunitaria en Uruguay de 1997 a 2019: ¿cuántos kilómetros faltarán para llegar al pueblo aquel? / Family and Community Medicine in Uruguay from 1997 to 2019: how many kilometers will it take to reach that town?

Resumen La residencia de medicina familiar y comunitaria comenzó en Uruguay en el año 1997. A través de un proceso autogestionado, las primeras generaciones se moldearon en una formación que integraba en ellos el conocimiento y la experiencia hospitalarios junto con la praxis territorial en un servicio de salud de base comunitaria con población de referencia. El reconocimiento académico de la especialidad y la instalación de los ámbitos institucionales para su gestión fueron conquistas paralelas a ese proceso en la primera década. La segunda década estuvo marcada por la expansión territorial de la estructura docente-asistencial, la descentralización de la universidad y la participación activa de la medicina familiar y comunitaria en la reforma de la salud y la agenda de derechos. La tercera década de la especialidad se presenta en su inicio como crisis dada por la caída sostenida en la aspiración a la residencia. Desde una aproximación inicial a las explicaciones, se reflexiona sobre la posibilidad de estar frente a una crisis más profunda y la necesidad de encontrar las claves de una medicina del siglo XXI que permita alcanzar los principios de Alma Ata, siempre vigentes.

Abstract The Family and Community Medicine Residency started in Uruguay in 1997. Through a self-managed process, the first generations were molded into training that integrated hospital knowledge and experience with territorial praxis in a community-based health service with a population of reference. The academic recognition of the specialty and the installation of the institutional areas for its management were achievements parallel to that process in the first decade. The second decade was marked by the territorial teaching-assistance expansion in the country, university decentralization and the active participation of Family and Community Medicine in the Health Reform, and the country's rights agenda. The third decade of the specialty begins with a crisis triggered by the sustained decline in the aspiration for residency. An initial approach to explanations reflects on the possibility of facing a more profound crisis and the need to find the keys to a 21st century Medicine that allows us to achieve the principles of Alma-Ata that are still current.

Advancements and achievements in the Brazilian Federal District public health: an essential contribution by family and community medicine. / Avanços e conquistas na saúde pública do DF, Brasil: uma contribuição essencial da medicina de família e comunidade.

The history of Primary Health Care (PHC) in the Federal District (DF) is as old as the history of the Federative Unit. The history of Family and Community Medicine (MFC), however, is relatively recent, both locally and nationally. This paper proposes to focus on the fundamental contribution of MFC to advances in Public Health in the Federal District, especially in the last 10 years, after the founding of the Family and Community Medicine Association of Brasília (ABMFC). In order to do so, the most relevant historical events and contexts related to Health Care, Management, Social Control and Medical Education - including Undergraduate course and Residency - were documented, which support this position, in parallel with the evolution of the specialty in the Federal District. Therefore, its organization was divided into four historical stages: until 2008, from 2008 to 2011, from 2011 to 2016, and from 2016 to 2018.

A história da Atenção Primária à Saúde (APS) no Distrito Federal (DF) é tão antiga quanto a história da unidade federativa. A história da especialidade Medicina de Família e Comunidade (MFC), porém, é relativamente recente, tanto em âmbito local como nacional. O presente artigo se propõe a focar na fundamental contribuição da MFC para os avanços na Saúde Pública do DF, sobretudo nos últimos 10 anos, após a fundação da Associação Brasiliense de Medicina de Família e Comunidade (ABMFC). Para tanto, foram rememorados os eventos e os contextos históricos mais relevantes, relacionados às áreas de Assistência à Saúde, Gestão, Controle Social e Ensino Médico ­ incluindo Graduação e Residência ­, que embasam essa posição, paralelamente à evolução da própria especialidade no DF. Sua organização foi, portanto, dividida em quatro etapas históricas: até 2008, de 2008 a 2011, de 2011 a 2016, e de 2016 até 2018.

Avanços e conquistas na saúde pública do DF, Brasil: uma contribuição essencial da medicina de família e comunidade / Advancements and achievements in the Brazilian Federal District public health: an essential contribution by family and community medicine

Resumo A história da Atenção Primária à Saúde (APS) no Distrito Federal (DF) é tão antiga quanto a história da unidade federativa. A história da especialidade Medicina de Família e Comunidade (MFC), porém, é relativamente recente, tanto em âmbito local como nacional. O presente artigo se propõe a focar na fundamental contribuição da MFC para os avanços na Saúde Pública do DF, sobretudo nos últimos 10 anos, após a fundação da Associação Brasiliense de Medicina de Família e Comunidade (ABMFC). Para tanto, foram rememorados os eventos e os contextos históricos mais relevantes, relacionados às áreas de Assistência à Saúde, Gestão, Controle Social e Ensino Médico - incluindo Graduação e Residência -, que embasam essa posição, paralelamente à evolução da própria especialidade no DF. Sua organização foi, portanto, dividida em quatro etapas históricas: até 2008, de 2008 a 2011, de 2011 a 2016, e de 2016 até 2018.

Abstract The history of Primary Health Care (PHC) in the Federal District (DF) is as old as the history of the Federative Unit. The history of Family and Community Medicine (MFC), however, is relatively recent, both locally and nationally. This paper proposes to focus on the fundamental contribution of MFC to advances in Public Health in the Federal District, especially in the last 10 years, after the founding of the Family and Community Medicine Association of Brasília (ABMFC). In order to do so, the most relevant historical events and contexts related to Health Care, Management, Social Control and Medical Education - including Undergraduate course and Residency - were documented, which support this position, in parallel with the evolution of the specialty in the Federal District. Therefore, its organization was divided into four historical stages: until 2008, from 2008 to 2011, from 2011 to 2016, and from 2016 to 2018.

Qué, cómo y cuánto debe hacer un residente de Medicina Familiar y Comunitaria para ser un buen especialista / What, how, and how much should a Family and Community Medicine resident do to become a good specialist?

Objetivo: Determinar cuál es el volumen idóneo de actividad que deben llevar a cabo los residentes de Medicina Familiar y Comunitaria para adquirir las competencias propias de su desempeño profesional. Material y método: Se recogió la opinión consensuada de un grupo de expertos en formación de residentes en Medicina Familiar y Comunitaria mediante una encuesta realizada con el método Delphi vía online en la que participaron 152 tutores. Resultados: La mediana total obtenida en las diferentes actividades a desarrollar por los residentes de Medicina Familiar y Comunitaria son: intervenciones individuales diagnósticas/terapéuticas: retinografías 60, espirometrías 40, anticoagulación 45, crio/electrocoagulación 35, infiltraciones 45, teledermatología 60, otras 45; salud mujer: embarazo 45, ecografía ginecológica/DIU 41, citologías 32,5, planificación 19,5, educación maternal 17; intervenciones estilo vida y cuidados: geriatría 30, enfermería 45, tabaco individual 30, grupal 15, problemas salud 15, consejo dietético 15; intervención comunitaria: sesiones con jóvenes 15, riesgo social 15; formación: sesiones 40, continuada 40

Objective: To determine the ideal volume of activity to be carried out by residents in Family and Community Medicine in order to acquire the competencies of their professional activity. Material and method: The consensus opinion of a group of experts in the training of residents in Family and Community Medicine was collected from 152 tutors using an online Delphi-type questionnaire. Results: The overall medians obtained in the different activities that should be developed by residents of Family and Community Medicine were: individual diagnostic/therapeutic interventions: retinography 60, spirometry 40, anticoagulation 45, cryo/electrocoagulation 35, infiltrations 45, tele-dermatology 60, and others 45; women's health: pregnancy 45, gynaecological ultrasound/IUD 41, cytology 32.5, family planning 19.5, and maternal education 17; lifestyle and care interventions: geriatrics 30, nursing 45, individual tobacco advice 30, group advice 15, health problems 15, and dietary advice 15; community intervention: sessions with youth 15, and social risk 15; training: sessions 40, continuing education 40. Conclusions: This information has defined the activity volumes that should be developed by the residents in order to acquire an adequate level of competence in the areas of individual diagnostic and therapeutic interventions, women's health, interventions to change lifestyles, community intervention, and clinical and training sessions. The consensus obtained could serve as a basis for the creation of a road map in the training of residents as a complementary tool to the Resident's Book, which is obligatory in all specialties

Pluripatología, polifarmacia, complejidad terapéutica y uso adecuado de la medicación / Polypathology, polypharmacy, medication regimen complexity and drug therapy appropriateness

Los pacientes pluripatológicos suelen ser ancianos y consumen muchos fármacos. La polifarmacia afecta a un 85% de los mismos y no se asocia con mayor supervivencia. Al contrario, los expone a más efectos adversos, como pérdida de peso, caídas, deterioro funcional y cognitivo, y hospitalizaciones. La complejidad del régimen medicamentoso incluye más aspectos que el simple número de medicamentos consumidos. La forma galénica, la frecuencia de las dosis, o la forma de preparar la medicación pueden complicar la comprensión y el seguimiento de las prescripciones. Tanto la polifarmacia como la complejidad terapéutica se asocian con una peor adherencia de los pacientes. Para evitar la polifarmacia, la complejidad y mejorar la adherencia es necesario un uso adecuado de la medicación. Prescribir bien consiste en seleccionar aquellos medicamentos de los que hay claras evidencias para su empleo en la indicación, que son adecuados a las circunstancias del paciente, bien tolerados, coste-efectivos y en los que los beneficios de su uso superan a los riesgos. Para mejorar la prescripción de medicamentos es necesario llevar a cabo de forma periódica revisiones de la medicación, especialmente cuando el paciente cambia de médico y en las transiciones asistenciales. Los criterios de Beers y los STOPP/START (Screening Tool of Older Person's potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment) son herramientas eficaces para ello. La desprescripción en los pacientes pluripatológicos polimedicados atendiendo a sus circunstancias clínicas, pronóstico y preferencias puede contribuir a un uso más adecuado de la medicación (AU)

Polypathological patients are usually elderly and take numerous drugs. Polypharmacy affects 85% of these individuals and is not associated with greater survival. On the contrary, polypharmacy exposes these individuals to more adverse effects, such as weight loss, falls, functional and cognitive impairment and hospitalisations. The complexity of a drug regimen covers more aspects than the simple number of drugs consumed. The galenic form, the dosage and the method for preparing the drug can impede the understanding of and compliance with prescriptions. Both polypharmacy and therapeutic complexity are associated with poorer adherence by patients. To prevent polypharmacy, reduce complexity and improve adherence, the appropriate use of drugs is needed. Proper prescribing consists of selecting drugs that have clear evidence for their use in the indication, which are appropriate for the patient's circumstances, are well tolerated and cost-effective and whose benefits outweigh the risks. To improve the drug prescription, periodic reviews of the drugs need to be conducted, especially when the patient changes doctor and during healthcare transitions. The Beers and STOPP/START (Screening Tool of Older Person's potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment) criteria are effective tools for this improvement. Deprescription for polymedicated polypathological patients that considers their clinical circumstances, prognosis and preferences can contribute to a more appropriate use of drugs (AU)

Anaphylaxis challenges on the front line: perspectives from community medicine.

This report reflects a discussion from the multidisciplinary Partnership for Anaphylaxis Round Table meeting, held in November 2012, in Dallas, Texas. Community medicine participants included John R. Bennett, MD, an internist who practiced in Cumming, Georgia, and whose patients were adults; Leonard Fromer, MD, a family practitioner in Los Angeles, California, who was the medical director of a network of 600 medical groups, including pediatricians, internists, and family physicians, and who in his previous practice treated children and adults, many of them with severe allergies; and Mary Lou Hayden, MS, RN, FNP-BC, AE-C, a nurse practitioner who treated adults in a university employee health clinic and in an allergy clinic in Charlottesville, Virginia, and whose prior practice focused on allergy and immunology in children and adults. This discussion was moderated by Dr Bennett. Participants provided their perspectives as primary care providers (PCPs) concerning anaphylaxis, which has become a major public health concern. The rising prevalence of severe allergies and incidence of anaphylaxis and other severe allergic reactions among children and adults is shifting more care to PCPs. This discussion provides insights into challenges faced by PCPs in treating patients at risk for anaphylaxis in the community setting and provides potential solutions to those challenges.

The emergence of primary care in Latin America: reflections from the field.

A U.S. family physician educator working in El Salvador, recently returned from the WONCA Fourth Regional Congress of the Ibero American Confederation of Family Medicine, reflects on the state of primary care in Latin America. Progress in primary health care and family medicine is occurring in several countries in the region as many countries are coming to accept that primary care is a systematic solution to their structural problems. The author discusses reasons for this progress in the context of political, economic, medical, and cultural dynamics. He notes several key points of comparing this development with the health care system in the United States and suggests that there is much to learn from those systems that are making their way on the path toward primary care.

[Community health: where do we stand after forty years?]. / Quarante ans après, où en est la santé communautaire ?

At the end of the 1970s, the term "community health" was hugely popular in the field of health and welfare in many countries throughout the world. Mainly inspired by American and Latin American sources, the concept was based on a participatory and multidisciplinary approach to preventive and curative health services. What is the current state of community health? The objective of this study was to examine the socio-historical development of community health over the last 40 years. The paper begins by presenting a conceptual framework defining community health and public health as two distinct domains in the field of health and welfare. The study found that depending on the setting, the historical period and the ability of actors to promote their views, the space occupied by the two domains and the relationships between them tend to vary, as shown by a comparative analysis between France and Québec from the 1970s to the 2010s. Based on the results of this study, the expression ?doing community health' appears to refer to a precise set of?practices based on certain approaches and methods implemented by actors in specific areas of intervention. Depending on the time and place, the actions and practices of the?concerned actors will determine the extent to which they are incorporated into the institutional context of public interventions.

[How should population health be approached? SESPAS Report 2012]. / ¿Cómo abordar la dimensión colectiva de la salud de las personas? Informe SESPAS 2012.

The health of the population largely depends on environmental factors, raising the issue of what the role of health professionals, particularly those in public health and primary care, should be in the planning of objectives and actions for improvement. The present article proposes a trajectory, starting with knowledge of the community's strong points in health and its needs, and ending with taking action. This trajectory requires discussion on how information can be transformed into action. We analyze the current situation and its strengths and weaknesses, and make proposals for the entire process: from information to action. Information is more than just the available data gathered from different sources; it is also knowledge of those who belong to the community or are very close to it. This perspective should include both health deficits and health assets. This information should be used not only by health professionals, but by all those in a position to influence the determinants of health. Finally, when considering the actions required to improve the health of a community, we emphasize the benefits of health promotion, in the genuine sense of the term, by reflecting on effectiveness and efficiency. The question of whether the failure of an intervention to improve health is due to the futility of the action, or to be action being undertaken in an inefficient way, is discussed.

Brote de gripe pandémica (H1N1) 2009 en una academia militar: inicio de la circulación comunitaria en España / Pandemic influenza (H1N1) 2009 outbreak in a military academy: start of community circulation in Spain

Fundamento: El 19 de mayo de 2009 se declararon 21 casos de soldados con síntomas de infección respiratoria aguda en la Academia Militar de Ingenieros (ACING) en Hoyo de Manzanares, España. En el contexto de una alerta mundial por gripe A(H1N1) 2009, se decide investigar la posible aparición de un brote por este virus. El objetivo es describir un posible brote de gripe (H1N1) 2009 en un Centro de Formación Militar y describir las medidas adoptadas, en la fase de contención, para evitar su transmisión. Métodos: Se administró un cuestionario específico y se recogieron muestras biológicas a todos los casos en investigación. Se recomendaron aislamiento y cuarentena, respectivamente de los casos y contactos. Resultados: Se confirmaron 81 casos de infección por virus de la gripe A (H1N1)2009. De las 52 muestras procesadas 31 fueron positivas para virus influenza A/California/7/2009. La edad media de los casos fue 22,0 años (rango, 18-31). El 84% eran varones. Los síntomas más comunes fueron tos y fiebre. Todos los casos permanecieron aislados y fueron tratados con oseltamivir, con buena evolución. La tasa de ataque global fue 12,42%. Ningún caso tenía antecedentes de viaje a zonas de riesgo o vinculo epidemiológico con un caso diagnosticado previamente fuera de la ACING. Se identificaron 31 casos relacionados con este brote fuera de la ACING, 24 casos eran contactos familiares y amigos. Conclusiones: Este brote alertó del inicio de la circulación comunitaria del virus pandémico en España. La detección precoz del mismo favoreció la puesta en marcha de medidas para la contención de su trasmisión(AU)

Background: On May 19, 2009, 21 cases of influenza-like illness were reported among soldiers from an Engineering Military Academy (ACING) in Hoyo de Manzanares, Spain. In the context of an influenza A (H1N1)2009 global alert, it was decided to investigate a possible pandemic influenza outbreak. To describe a possible outbreak of influenza A (H1N1)2009 in a Military Training Centre and to describe the measures adopted for transmission control of this new infection. Methods: A specific questionnaire was administered and biological samples were collected from all cases under investigation. Isolation and quarantine were recommended for cases and contacts, respectively. Results: Eighty-one cases were confirmed. Among 52 samples tested, 31 were positive for influenza virus A/California/7/2009. The average age of the cases was 22.0 years (range 18-31 years) and 84% were men. Most common reported symptoms were cough and fever. All cases were isolated and treated with oseltamivir, with full recovery. The total attack rate was 12.42%. None of the cases had history of travel to risk areas or contact with previously diagnosed cases outside the academy. Thirty-one confirmed cases related to this outbreak were identified outside the academy, 24 cases were family contacts and friends. Conclusions: This outbreak was the first evidence of community transmission of pandemic influenza H1N1 in Spain. The rapid detection of this outbreak enhanced an early implementation of measures aiming at the containment of its transmission(AU)