Projeto de Investigação-Ação : Vozes tocadas ... bandas cantadas

O presente documento reflete o trabalho desenvolvido no âmbito da Prática de Ensino Supervisionada (PES), realizada no Agrupamento de Escolas D. Filipa de Lencastre, em Lisboa, durante o ano letivo de 2014-2015 sob a orientação da Professora Micaela Patrício. Os relatos, e respetivas reflexões críticas são referentes à observação das aulas lecionadas pela professora Micaela Patrício ao longo do ano letivo, e à prática em onze aulas (90 minutos cada) lecionadas - 5 aulas na turma 5ºF e 6 aulas na turma 6ºD. A organização do documento consiste em quatro Capítulos: no Capítulo 1 é feito o enquadramento do ensino da música em Portugal no contexto vocacional e genérico; no Capítulo 2 é caracterizada a escola onde decorreu a PES; no Capítulo 3 são referidas as aulas observadas, lecionadas, atividades desenvolvidas fora da sala de aula e as reuniões assistidas ao longo do ano letivo; no Capítulo 4 é descrito o projeto de Investigação-ação: “Vozes Tocadas…Bandas Cantadas”. Esta temática justifica-se pela necessidade de proporcionar aos alunos aprendizagens ativas, significativas, diversificadas, integradas e socializadoras no âmbito da música. Por fim e em jeito de conclusão, apresenta-se uma reflexão englobante da aprendizagem direta e indireta no decurso da PES.

Introdução de medidas centradas no doente para avaliação de resultados em saúde

A introdução na rotina da prática clínica de medidas de avaliação de resultados centradas no paciente permite a identificação de problemas físicos e psicológicos, a monitorização da evolução e impacto provocado no estado de saúde e possibilita a adequação dos cuidados e verificação da sua efetividade. Objetivos: Avaliar estado de saúde e mudanças ocorridas após processo de cuidados de fisioterapia. Material e métodos: Efetuou‐se um estudo de desenho longitudinal e preditivo em 511 indivíduos utilizadores do Serviço de Fisioterapia do Hospital da Misericórdia da Mealhada, avaliados no início e no fim do tratamento. Do protocolo constava a medida de estado de saúde MOS SF‐36 e o índice de saúde SF-6D. Resultados: Observaram-se melhorias significativas do estado de saúde dos indivíduos entre o início e o fim do tratamento. Houve grande variabilidade de tratamentos realizados com predominância dos agentes físicos, terapia manual e terapia pelo movimento. Não se encontraram fatores preditivos para as mudanças de estado de saúde ocorridas. Conclusões: A criação de um sistema de recolha de dados reportados pelo paciente é necessário para a melhoria dos cuidados, bem como a sustentação dos mesmos na prática baseada na evidência.

Accidental SUSY: Enhanced bulk supersymmetry from brane back-reaction

We compute how bulk loops renormalize both bulk and brane effective interactions for codimension-two branes in 6D gauged chiral supergravity, as functions of the brane tension and brane-localized flux. We do so by explicitly integrating out hyper- and gauge-multiplets in 6D gauged chiral supergravity compactified to 4D on a flux-stabilized 2D rugby-ball geometry, specializing the results of a companion paper, arXiv:1210.3753 , to the supersymmetric case. While the brane back-reaction generically breaks supersymmetry, we show that the bulk supersymmetry can be preserved if the amount of brane- localized flux is related in a specific BPS-like way to the brane tension, and verify that the loop corrections to the brane curvature vanish in this special case. In these systems it is the brane-bulk couplings that fix the size of the extra dimensions, and we show that in some circumstances the bulk geometry dynamically adjusts to ensure the supersymmetric BPS-like condition is automatically satisfied. We investigate the robustness of this residual supersymmetry to loops of non-supersymmetric matter on the branes, and show that supersymmetry- breaking effects can enter only through effective brane-bulk interactions involving at least two derivatives. We comment on the relevance of this calculation to proposed applications of codimension-two 6D models to solutions of the hierarchy and cosmological constant problems. © 2013 SISSA.

The Preferential Liberalization of Services Trade

This paper takes stock of the most recent wave of PTAs with a view to informing some of the policy choices developing countries face in negotiating preferential agreements in services. The paper documents a number of lessons in rule-making and market opening arising from the practice of preferential liberalization in services trade as seen from a sample of fifty five agreements (out of the 76 PTAs featuring services provisions that have been notified to the WTO to date). The paper asks whether and how PTAs differ from the GATS and whether such differences matter in policy terms.

Relationship between health-related quality of life, comorbidities and acute health care utilisation, in adults with chronic conditions

Background: There is increased interest in developing multidisciplinary ambulatory care models of service delivery to manage patients with complex chronic diseases. These programs are expensive and given limited resources it is important that care is targeted effectively. One potential screening strategy is to identify individuals who report the greatest decrement in health related quality of life (HRQoL) and thus greater need. The aim of this study was to explore the relationship between HRQoL, comorbid conditions and acute health care utilisation. Methods: A prospective, longitudinal cohort design was used to evaluate the impact of HRQoL on acute care utilisation rates over three-years of follow-up. Participants were enrolled in chronic disease management programs run by a metropolitan health service in Australia. Baseline data was collected from 2007-2009 and follow-up data until 2012. Administrative data was used to classify patients' primary reasons for enrolment, number of comorbidities (Charlson Score) and presentations to acute care. At enrolment, HRQoL was measured using the Assessment of Quality of Life (AQoL) instrument, for analysis AQoL scores were dichotomised at two standard deviations below the population norm. Results: There were 1999 participants (54% male) with a mean age of 63years (range 18-101), enrolled in the study. Participants' primary health conditions at enrolment were: diabetes 915 (46%), chronic respiratory disease 463 (23%), cardiac disease 260 (13%), peripheral vascular disease, and 181 (9%) and aged care 180 (9%). At 1-year multivariate logistic regression models demonstrated that AQOL utility score was not predictive of acute care presentations after adjusting for comorbidities. Over 3-years an AQoL utility score in the lowest quartile was predictive of both ED presentation (OR 1.58, 95% CI, 1.16-2.13, p=0.003) and admissions (OR 1.67, 95% CI.1.21 to 2.30, p=0.002) after adjusting for differences in age and comorbidities. Conclusion: This study found that both HRQoL and comorbidities were predictive of subsequent acute care attendance over 3-years of follow-up. At 1-year, comorbidities was a better predictor of acute care representation than HRQoL. To maximise benefits, programs should initially focus on medical disease management, but subsequently switch to strategies that enhance health independence and raise HRQoL.

Improving access for community health and sub-acute outpatient services: protocol for a stepped wedge cluster randomised controlled trial

BACKGROUND: Waiting lists for treatment are common in outpatient and community services, Existing methods for managing access and triage to these services can lead to inequities in service delivery, inefficiencies and divert resources from frontline care. Evidence from two controlled studies indicates that an alternative to the traditional "waitlist and triage" model known as STAT (Specific Timely Appointments for Triage) may be successful in reducing waiting times without adversely affecting other aspects of patient care. This trial aims to test whether the model is cost effective in reducing waiting time across multiple services, and to measure the impact on service provision, health-related quality of life and patient satisfaction.

METHODS/DESIGN: A stepped wedge cluster randomised controlled trial has been designed to evaluate the impact of the STAT model in 8 community health and outpatient services. The primary outcome will be waiting time from referral to first appointment. Secondary outcomes will be nature and quantity of service received (collected from all patients attending the service during the study period and health-related quality of life (AQOL-8D), patient satisfaction, health care utilisation and cost data (collected from a subgroup of patients at initial assessment and after 12 weeks). Data will be analysed with a multiple multi-level random-effects regression model that allows for cluster effects. An economic evaluation will be undertaken alongside the clinical trial.

DISCUSSION: This paper outlines the study protocol for a fully powered prospective stepped wedge cluster randomised controlled trial (SWCRCT) to establish whether the STAT model of access and triage can reduce waiting times applied across multiple settings, without increasing health service costs or adversely impacting on other aspects of patient care. If successful, it will provide evidence for the effectiveness of a practical model of access that can substantially reduce waiting time for outpatient and community services with subsequent benefits for both efficiency of health systems and patient care.

Perceptions of individuals living with spinal cord injury toward preference-based quality of life instruments : a qualitative exploration

BACKGROUND: Generic preference-based health-related quality of life instruments are widely used to measure health benefit within economic evaluation. The availability of multiple instruments raises questions about their relative merits and recent studies have highlighted the paucity of evidence regarding measurement properties in the context of spinal cord injury (SCI). This qualitative study explores the views of individuals living with SCI towards six established instruments with the objective of identifying 'preferred' outcome measures (from the perspective of the study participants). METHODS: Individuals living with SCI were invited to participate in one of three focus groups. Eligible participants were identified from Vancouver General Hospital's Spine Program database; purposive sampling was used to ensure representation of different demographics and injury characteristics. Perceptions and opinions were solicited on the following questionnaires: 15D, Assessment of Quality of Life 8-dimension (AQoL-8D), EQ-5D-5L, Health Utilities Index (HUI), Quality of Well-Being Scale Self-Administered (QWB-SA), and the SF-36v2. Framework analysis was used to analyse the qualitative information gathered during discussion. Strengths and limitations of each questionnaire were thematically identified and managed using NVivo 9 software. RESULTS: Major emergent themes were (i) general perceptions, (ii) comprehensiveness, (iii) content, (iv) wording and (v) features. Two sub-themes pertinent to content were also identified; 'questions' and 'options'. All focus group participants (n = 15) perceived the AQoL-8D to be the most relevant instrument to administer within the SCI population. This measure was considered to be comprehensive, with relevant content (i.e. wheelchair inclusive) and applicable items. Participants had mixed perceptions about the other questionnaires, albeit to varying degrees. CONCLUSIONS: Despite a strong theoretical underpinning, the AQoL-8D (and other AQoL instruments) is infrequently used outside its country of origin (Australia). Empirical comparative analyses of the favoured instruments identified in this qualitative study are necessary within the context of spinal cord injury.

"When I saw walking I just kind of took it as wheeling": interpretations of mobility-related items in generic, preference-based health state instruments in the context of spinal cord injury

Background : In health economic analyses, health states are typically valued using instruments with few items per dimension. Due to the generic (and often reductionist) nature of such instruments, certain groups of respondents may experience challenges in describing their health state. This study is concerned with generic, preference-based health state instruments that provide information for decisions about the allocation of resources in health care. Unlike physical measurement instruments, preference-based health state instruments provide health state values that are dependent on how respondents interpret the items. This study investigates how individuals with spinal cord injury (SCI) interpret mobility-related items contained within six preference-based health state instruments.

Methods : Secondary analysis of focus group transcripts originally collected in Vancouver, Canada, explored individuals’ perceptions and interpretations of mobility-related items contained within the 15D, Assessment of Quality of Life 8-dimension (AQoL-8D), EQ-5D-5L, Health Utilities Index (HUI), Quality of Well-Being Scale Self-Administered (QWB-SA), and the 36-item Short Form health survey version 2 (SF-36v2). Ritchie and Spencer’s ‘Framework Approach’ was used to perform thematic analysis that focused on participants’ comments concerning the mobility-related items only.

Results : Fifteen individuals participated in three focus groups (five per focus group). Four themes emerged: wording of mobility (e.g., ‘getting around’ vs ‘walking’), reference to aids and appliances, lack of suitable response options, and reframing of items (e.g., replacing ‘walking’ with ‘wheeling’). These themes reflected item features that respondents perceived as relevant in enabling them to describe their mobility, and response strategies that respondents could use when faced with inaccessible items.

Conclusion : Investigating perceptions to mobility-related items within the context of SCI highlights substantial variation in item interpretation across six preference-based health state instruments. Studying respondents’ interpretations of items can help to understand discrepancies in the health state descriptions and values obtained from different instruments. This line of research warrants closer attention in the health economics and quality of life literature.