A technological framework based on automatic messaging for improving adherence of diabetic patients

En todo el mundo se ha observado un crecimiento exponencial en la incidencia de enfermedades crónicas como la hipertensión y enfermedades cardiovasculares y respiratorias, así como la diabetes mellitus, que causa un número de muertes cada vez mayor en todo el mundo (Beaglehole et al., 2008). En concreto, la prevalencia de diabetes mellitus (DM) está aumentando de manera considerable en todas las edades y representa un serio problema de salud mundial. La diabetes fue la responsable directa de 1,5 millones de muertes en 2012 y 89 millones de años de vida ajustados por discapacidad (AVAD) (OMS, 2014). Uno de los principales dilemas que suelen asociarse a la gestión de EC es la adherencia de los pacientes a los tratamientos, que representa un aspecto multifactorial que necesita asistencia en lo relativo a: educación, autogestión, interacción entre los pacientes y cuidadores y compromiso de los pacientes. Medir la adherencia del tratamiento es complicado y, aunque se ha hablado ampliamente de ello, aún no hay soluciones “de oro” (Reviews, 2002). El compromiso de los pacientes, a través de la participación, colaboración, negociación y a veces del compromiso firme, aumentan las oportunidades para una terapia óptima en la que los pacientes se responsabilizan de su parte en la ecuación de adherencia. Comprometer e involucrar a los pacientes diabéticos en las decisiones de su tratamiento, junto con expertos profesionales, puede ayudar a favorecer un enfoque centrado en el paciente hacia la atención a la diabetes (Martin et al., 2005). La motivación y atribución de poder de los pacientes son quizás los dos factores interventores más relevantes que afectan directamente a la autogestión de la atención a la diabetes. Se ha demostrado que estos dos factores desempeñan un papel fundamental en la adherencia a la prescripción, así como en el fomento exitoso de un estilo de vida sana y otros cambios de conducta (Heneghan et al., 2013). Un plan de educación personalizada es indispensable para proporcionarle al paciente las herramientas adecuadas que necesita para la autogestión efectiva de la enfermedad (El-Gayar et al. 2013). La comunicación efectiva es fundamental para proporcionar una atención centrada en el paciente puesto que influye en las conductas y actitudes hacia un problema de salud ((Frampton et al. 2008). En este sentido, la interactividad, la frecuencia, la temporalización y la adaptación de los mensajes de texto pueden promover la adherencia a un régimen de medicación. Como consecuencia, adaptar los mensajes de texto a los pacientes puede resultar ser una manera de hacer que las sugerencias y la información sean más relevantes y efectivas (Nundy et al. 2013). En este contexto, las tecnologías móviles en el ámbito de la salud (mHealth) están desempeñando un papel importante al conectar con pacientes para mejorar la adherencia a medicamentos recetados (Krishna et al., 2009). La adaptación de los mensajes de texto específicos de diabetes sigue siendo un área de oportunidad para mejorar la adherencia a la medicación y ofrecer motivación a adultos con diabetes. Sin embargo, se necesita más investigación para entender totalmente su eficacia. Los consejos de texto personalizados han demostrado causar un impacto positivo en la atribución de poder a los pacientes, su autogestión y su adherencia a la prescripción (Gatwood et al., 2014). mHealth se puede utilizar para ofrecer programas de asistencia de autogestión a los pacientes con diabetes y, al mismo tiempo, superar las dificultades técnicas y financieras que supone el tratamiento de la diabetes (Free at al., 2013). El objetivo principal de este trabajo de investigación es demostrar que un marco tecnológico basado en las teorías de cambios de conducta, aplicado al campo de la mHealth, permite una mejora de la adherencia al tratamiento en pacientes diabéticos. Como método de definición de una solución tecnológica, se han adoptado un conjunto de diferentes técnicas de conducta validadas denominado marco de compromiso de retroacción conductual (EBF, por sus siglas en inglés) para formular los mensajes, guiar el contenido y evaluar los resultados. Los estudios incorporan elementos del modelo transteórico (TTM, por sus siglas en inglés), la teoría de la fijación de objetivos (GST, por sus siglas en inglés) y los principios de comunicación sanitaria persuasiva y eficaz. Como concepto general, el modelo TTM ayuda a los pacientes a progresar a su próxima fase de conducta a través de mensajes de texto motivados específicos y permite que el médico identifique la fase actual y adapte sus estrategias individualmente. Además, se adoptan las directrices del TTM para fijar objetivos personalizados a un nivel apropiado a la fase de cambio del paciente. La GST encierra normas que van a ponerse en práctica para promover la intervención educativa y objetivos de pérdida de peso. Finalmente, los principios de comunicación sanitaria persuasiva y eficaz aplicados a la aparición de los mensajes se han puesto en marcha para aumentar la efectividad. El EBF tiene como objetivo ayudar a los pacientes a mejorar su adherencia a la prescripción y encaminarlos a una mejora general en la autogestión de la diabetes mediante mensajes de texto personalizados denominados mensajes de retroacción automáticos (AFM, por sus siglas en inglés). Después de una primera revisión del perfil, consistente en identificar características significativas del paciente basadas en las necesidades de tratamiento, actitudes y conductas de atención sanitaria, el sistema elige los AFM personalizados, los aprueba el médico y al final se transfieren a la interfaz del paciente. Durante el tratamiento, el usuario recopila los datos en dispositivos de monitorización de pacientes (PMD, por sus siglas en inglés) de una serie de dispositivos médicos y registros manuales. Los registros consisten en la toma de medicación, dieta y actividad física y tareas de aprendizaje y control de la medida del metabolismo. El compromiso general del paciente se comprueba al estimar el uso del sistema y la adherencia del tratamiento y el estado de los objetivos del paciente a corto y largo plazo. El módulo de análisis conductual, que consiste en una serie de reglas y ecuaciones, calcula la conducta del paciente. Tras lograr el análisis conductual, el módulo de gestión de AFM actualiza la lista de AFM y la configuración de los envíos. Las actualizaciones incluyen el número, el tipo y la frecuencia de mensajes. Los AFM los revisa periódicamente el médico que también participa en el perfeccionamiento del tratamiento, adaptado a la fase transteórica actual. Los AFM se segmentan en distintas categorías y niveles y los pacientes pueden ajustar la entrega del mensaje de acuerdo con sus necesidades personales. El EBF se ha puesto en marcha integrado dentro del sistema METABO, diseñado para facilitar al paciente diabético que controle sus condiciones relevantes de una manera menos intrusiva. El dispositivo del paciente se vincula en una plataforma móvil, mientras que una interfaz de panel médico permite que los profesionales controlen la evolución del tratamiento. Herramientas específicas posibilitan que los profesionales comprueben la adherencia del paciente y actualicen la gestión de envíos de AFM. El EBF fue probado en un proyecto piloto controlado de manera aleatoria. El principal objetivo era examinar la viabilidad y aceptación del sistema. Los objetivos secundarios eran también la evaluación de la eficacia del sistema en lo referente a la mejora de la adherencia, el control glucémico y la calidad de vida. Se reclutaron participantes de cuatro centros clínicos distintos en Europa. La evaluación del punto de referencia incluía datos demográficos, estado de la diabetes, información del perfil, conocimiento de la diabetes en general, uso de las plataformas TIC, opinión y experiencia con dispositivos electrónicos y adopción de buenas prácticas con la diabetes. La aceptación y eficacia de los criterios de evaluación se aplicaron para valorar el funcionamiento del marco tecnológico. El principal objetivo era la valoración de la eficacia del sistema en lo referente a la mejora de la adherencia. En las pruebas participaron 54 pacientes. 26 fueron asignados al grupo de intervención y equipados con tecnología móvil donde estaba instalado el EBF: 14 pacientes tenían T1DM y 12 tenían T2DM. El grupo de control estaba compuesto por 25 pa cientes que fueron tratados con atención estándar, sin el empleo del EBF. La intervención profesional tanto de los grupos de control como de intervención corrió a cargo de 24 cuidadores, entre los que incluían diabetólogos, nutricionistas y enfermeras. Para evaluar la aceptabilidad del sistema y analizar la satisfacción de los usuarios, a través de LimeSurvey, se creó una encuesta multilingüe tanto para los pacientes como para los profesionales. Los resultados también se recopilaron de los archivos de registro generados en los PMD, el panel médico profesional y las entradas de la base de datos. Los mensajes enviados hacia y desde el EBF y los archivos de registro del sistema y los servicios de comunicación se grabaron durante las cinco semanas del estudio. Se entregaron un total de 2795 mensajes, lo que supuso una media de 107,50 mensajes por paciente. Como se muestra, los mensajes disminuyen con el tiempo, indicando una mejora global de la adherencia al plan de tratamiento. Como se esperaba, los pacientes con T1DM recibieron más consejos a corto plazo, en relación a su estado. Del mismo modo, al ser el centro de T2DM en cambios de estilo de vida sostenible a largo plazo, los pacientes con T2DM recibieron más consejos de recomendación, en cuanto a dietas y actividad física. También se ha llevado a cabo una comparación de la adherencia e índices de uso para pacientes con T1DM y T2DM, entre la primera y la segunda mitad de la prueba. Se han observado resultados favorables para el uso. En lo relativo a la adherencia, los resultados denotaron una mejora general en cada dimensión del plan de tratamiento, como la nutrición y las mediciones de inserción de glucosa en la sangre. Se han llevado a cabo más estudios acerca del cambio a nivel educativo antes y después de la prueba, medidos tanto para grupos de control como de intervención. Los resultados indicaron que el grupo de intervención había mejorado su nivel de conocimientos mientras que el grupo de control mostró una leve disminución. El análisis de correlación entre el nivel de adherencia y las AFM ha mostrado una mejora en la adherencia de uso para los pacientes que recibieron los mensajes de tipo alertas, y unos resultados no significativos aunque positivos relacionados con la adherencia tanto al tratamiento que al uso correlacionado con los recordatorios. Por otra parte, los AFM parecían ayudar a los pacientes que no tomaban suficientemente en serio su tratamiento en el principio y que sí estaban dispuestos a responder a los mensajes recibidos. Aun así, los pacientes que recibieron demasiadas advertencias, comenzaron a considerar el envío de mensajes un poco estresante. El trabajo de investigación llevado a cabo al desarrollar este proyecto ofrece respuestas a las cuatro hipótesis de investigación que fueron la motivación para el trabajo. • Hipótesis 1 : es posible definir una serie de criterios para medir la adherencia en pacientes diabéticos. • Hipótesis 2: es posible diseñar un marco tecnológico basado en los criterios y teorías de cambio de conducta mencionados con anterioridad para hacer que los pacientes diabéticos se comprometan a controlar su enfermedad y adherirse a planes de atención. • Hipótesis 3: es posible poner en marcha el marco tecnológico en el sector de la salud móvil. • Hipótesis 4: es posible utilizar el marco tecnológico como solución de salud móvil en un contexto real y tener efectos positivos en lo referente a indicadores de control de diabetes. La verificación de cada hipótesis permite ofrecer respuesta a la hipótesis principal: La hipótesis principal es: es posible mejorar la adherencia diabética a través de un marco tecnológico mHealth basado en teorías de cambio de conducta. El trabajo llevado a cabo para responder estas preguntas se explica en este trabajo de investigación. El marco fue desarrollado y puesto en práctica en el Proyecto METABO. METABO es un Proyecto I+D, cofinanciado por la Comisión Europea (METABO 2008) que integra infraestructura móvil para ayudar al control, gestión y tratamiento de los pacientes con diabetes mellitus de tipo 1 (T1DM) y los que padecen diabetes mellitus de tipo 2 (T2DM). ABSTRACT Worldwide there is an exponential growth in the incidence of Chronic Diseases (CDs), such as: hypertension, cardiovascular and respiratory diseases, as well as diabetes mellitus, leading to rising numbers of deaths worldwide (Beaglehole et al. 2008). In particular, the prevalence of diabetes mellitus (DM) is largely increasing among all ages and constitutes a major worldwide health problem. Diabetes was directly responsible for 1,5 million deaths in 2012 and 89 million Disability-adjusted life year (DALYs) (WHO 2014). One of the key dilemmas often associated to CD management is the patients’ adherence to treatments, representing a multi-factorial aspect that requires support in terms of: education, self-management, interaction between patients and caregivers, and patients’ engagement. Measuring adherence is complex and, even if widely discussed, there are still no “gold” standards ((Giardini et al. 2015), (Costa et al. 2015). Patient’s engagement, through participation, collaboration, negotiation, and sometimes compromise, enhance opportunities for optimal therapy in which patients take responsibility for their part of the adherence equation. Engaging and involving diabetic patients in treatment decisions, along with professional expertise, can help foster a patient-centered approach to diabetes care (Martin et al. 2005). Patients’ motivation and empowerment are perhaps the two most relevant intervening factors that directly affect self-management of diabetes care. It has been demonstrated that these two factors play an essential role in prescription adherence, as well as for the successful encouragement of a healthy life-style and other behavioural changes (Heneghan et al. 2013). A personalised education plan is indispensable in order to provide the patient with the appropriate tools needed for the effective self-management of the disease (El-Gayar et al. 2013). Effective communication is at the core of providing patient-centred care since it influences behaviours and attitudes towards a health problem (Frampton et al. 2008). In this regard, interactivity, frequency, timing, and tailoring of text messages may promote adherence to a medication regimen. As a consequence, tailoring text messages to patients can constitute a way of making suggestions and information more relevant and effective (Nundy et al. 2013). In this context, mobile health technologies (mHealth) are playing significant roles in improving adherence to prescribed medications (Krishna et al. 2009). The tailoring of diabetes-specific text messages remains an area of opportunity to improve medication adherence and provide motivation to adults with diabetes but further research is needed to fully understand their effectiveness. Personalized text advices have proven to produce a positive impact on patients’ empowerment, self-management, and adherence to prescriptions (Gatwood et al. 2014). mHealth can be used for offering self-management support programs to diabetes patients and at the same time surmounting the technical and financial difficulties involved in diabetes treatment (Free et al. 2013). The main objective of this research work is to demonstrate that a technological framework, based on behavioural change theories, applied to mHealth domain, allows improving adherence treatment in diabetic patients. The framework, named Engagement Behavioural Feedback Framework (EBF), is built on top of validated behavioural techniques to frame messages, guide the definition of contents and assess outcomes: elements from the Transtheoretical Model (TTM), the Goal-Setting Theory (GST), Effective Health Communication (EHC) guidelines and Principles of Persuasive Technology (PPT) were incorporated. The TTM helps patients to progress to a next behavioural stage, through specific motivated text messages, and allow clinician’s identifying the current stage and tailor its strategies individually. Moreover, TTM guidelines are adopted to set customised goals at a level appropriate to the patient’s stage of change. The GST was used to build rules to be applied for enhancing educational intervention and weight loss objectives. Finally, the EHC guidelines and the PPT were applied to increase the effectiveness of messages. The EBF aims to support patients on improving their prescription adherence and persuade them towards a general improvement in diabetes self-management, by means of personalised text messages, named Automatic Feedback Messages (AFM). After a first profile screening, consisting in identifying meaningful patient characteristics based on treatment needs, attitudes and health care behaviours, customised AFMs are selected by the system, approved by the professional, and finally transferred into the patient interface. During the treatment, the user collects the data into a Patient Monitoring Device (PMD) from a set of medical devices and from manual inputs. Inputs consist in medication intake, diet and physical activity, metabolic measurement monitoring and learning tasks. Patient general engagement is checked by estimating the usage of the system and the adherence of treatment and patient goals status in the short and the long term period. The Behavioural Analysis Module, consisting in a set of rules and equations, calculates the patient’s behaviour. After behavioural analysis is accomplished, the AFM library and the dispatch setting are updated by the AFM Manager module. Updates include the number, the type and the frequency of messages. The AFMs are periodically supervised by the professional who also participates to the refinement of the treatment, adapted to the current transtheoretical stage. The AFMs are segmented in different categories and levels and patients can adjust message delivery in accordance with their personal needs. The EBF was integrated to the METABO system, designed to facilitate diabetic patients in managing their disease in a less intrusive approach. Patient device corresponds in a mobile platform, while a medical panel interface allows professionals to monitoring the treatment evolution. Specific tools allow professional to check patient adherence and to update the AFMs dispatch management. The EBF was tested in a randomised controlled pilot. The main objective was to examine the feasibility and acceptance of the system. Secondary objectives were also the assessment of the effectiveness of system in terms of adherence improvement, glycaemic control, and quality of life. Participants were recruited from four different clinical centres in Europe. The baseline assessment included demographics, diabetes status, profile information, knowledge about diabetes in general, usage of ICT platforms, opinion and experience about electronic devices and adoption of good practices with diabetes. Acceptance and the effectiveness evaluation criteria were applied to evaluate the performance of the technological framework. The main objective was the assessment of the effectiveness of system in terms of adherence improvement. Fifty-four patients participated on the trials. Twenty-six patients were assigned in the intervention group and equipped with mobile where the EBF was installed: 14 patients were T1DM and 12 were T2DM. The control group was composed of 25 patients that were treated through a standard care, without the usage of the EBF. Professional’s intervention for both intervention and control groups was carried out by 24 care providers, including endocrinologists, nutritionists, and nurses. In order to evaluate the system acceptability and analyse the users’ satisfaction, an online multi-language survey, using LimeSurvey, was produced for both patients and professionals. Results were also collected from the log-files generated in the PMDs, the professional medical panel and the entries of the data base. The messages sent to and from the EBF and the log-files of the system and communication services were recorded over 5 weeks of the study. A total of 2795 messages were submitted, representing an average of 107,50 messages per patient. As demonstrated, messages decrease over time indicating an overall improvement of the care plan’s adherence. As expected, T1DM patients were more loaded with short-term advices, in accordance with their condition. Similarly, being the focus of T2DM on long-term sustainable lifestyle changes, T2DM received more reminders advices, as for diet and physical activity. Favourable outcomes were observed for treatment and usage adherences of the intervention group: for both the adherence indices, results denoted a general improvement on each care plan’s dimension, such as on nutrition and blood glucose input measurements. Further studies were conducted on the change on educational level before and after the trial, measured for both control and intervention groups. The outcomes indicated the intervention group has improved its level of knowledge, while the control group denoted a low decrease. The correlation analysis between the level of adherences and the AFMs showed an improvement in usage adherence for patients who received warnings message, while non-significantly yet even positive indicators related to both treatment and usage adherence correlated with the Reminders. Moreover, the AFMs seemed to help those patients who did not take their treatment seriously enough in the beginning and who were willing to respond to the messages they received. Even though, patients who received too many Warnings, started to consider the message dispatch to be a bit stressful. The research work carried out in developing this research work provides responses to the four research hypothesis that were the motivation for the work: •Hypothesis 1: It is possible to define a set of criteria to measure adherence in diabetic patients. •Hypothesis 2: It is possible to design a technological framework, based on the aforementioned criteria and behavioural change theories, to engage diabetic patients in managing their disease and adhere to care plans. •Hypothesis 3: It is possible to implement the technological framework in the mobile health domain. •Hypothesis 4: It is possible to use the technological framework as a mobile health solution in a real context and have positive effects in terms of diabetes management indicators. The verification of each hypothesis allowed us to provide a response to the main hypothesis: The Main Hypothesis is: It is possible to improve diabetic adherence through a mHealth technological framework based on behavioural change theories. The work carried out to answer these questions is explained in this research work. The framework was developed and applied in the METABO project. METABO is an R&D project, co-funded by the European Commission (METABO 2008) that integrates mobile infrastructure for supporting the monitoring, management, and treatment of type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) patients.

Aprendiendo a interpretar el aprendizaje de las matemáticas en educación primaria. Características en un contexto B-Learning

El objetivo de esta investigación es identificar características del proceso de instrumentalización del conocimiento de didáctica de la matemática de profesores de educación primaria en un curso de especialización desarrollado en un contexto b-learning. Participaron 65 maestros en un entorno de aprendizaje b-learning integrando debates virtuales y centrados en el análisis del pensamiento matemático de alumnos de educación primaria. El análisis de las participaciones en los debates virtuales y la resolución de las tareas nos han permitido caracterizar el aprendizaje del conocimiento sobre el aprendizaje de las matemáticas como un cambio en el discurso de los estudiantes. Este cambio se puso de manifiesto por la integración paulatina del conocimiento de didáctica de la matemática en la interpretación del pensamiento matemático de los alumnos. Los resultados indican que las aportaciones a los debates en forma de refutaciones favorecieron el proceso de instrumentalización de las ideas teóricas.

Inclusion of immersive virtual learning environments and visual control systems to support the learning of students with Asperger syndrome

This paper presents the use of immersive virtual reality systems in the educational intervention with Asperger students. The starting points of this study are features of these students' cognitive style that requires an explicit teaching style supported by visual aids and highly structured environments. The proposed immersive virtual reality system, not only to assess the student's behavior and progress, but also is able to adapt itself to the student's specific needs. Additionally, the immersive reality system is equipped with sensors that can determine certain behaviors of the students. This paper determines the possible inclusion of immersive virtual reality as a support tool and learning strategy in these particular students' intervention. With this objective two task protocols have been defined with which the behavior and interaction situations performed by participant students are recorded. The conclusions from this study talks in favor of the inclusion of these virtual immersive environments as a support tool in the educational intervention of Asperger syndrome students as their social competences and executive functions have improved.

Evaluación del practicum en la formación de posgrado en los estudios de comunicación desde una orientación profesional y discente

La investigación evaluativa se erige como una herramienta necesaria para reorientar las propuestas docentes desarrolladas con los estudiantes. A través de este estudio se evalúa la consecución de los objetivos relacionados con las prácticas profesionales de los alumnos del Master Comunicación en Industrias Creativas, durante el curso académico 2011-2012, en la Universidad de Alicante. Los resultados obtenidos permiten establecer una reflexión en torno a la orientación futura que debemos otorgar a este proceso de intervención didáctica, reforzando los objetivos de aprendizaje menos consolidados.

A importância da metodologia das oficinas formativas na educação sexual na escola

Enquadramento: O interesse pelo tema Educação Sexual germinou da conscientiza-ção de que a sexualidade está na essência do homem, com o ideal de ser experimentada e vivida; procura-se cada vez mais expandir esses conhecimentos com responsabilidade e naturalidade, principalmente frente à responsabilidade de educadores por participar de uma capacitação oferecida pelo grupo do Instituto Kaplan Programa / PROJETO VALE SONHAR. Objetivo: Proposemo-nos analisar a importancia da metodologia das oficinas formati-vas na Educação Sexual na Escola;Determinar a eficácia das oficinas nos conhecimentos sobre sexualidade nos adolescentes;Construir conhecimento sobre sexualidade, desmitifi- cando conceitos. Método: Foi desenvolvida uma intervenção formativa com aplicação de 03 (três) ofi-cinas, em que foram avaliados os conhecimentos antes e após a intervenção formativa. Du-rante estas oficinas foram aplicados questionários e coleta de depoimentos dos participantes. A amostra foi constituída por adolescentes de ambos os sexos, que frequentavam o 1º ano do ensino médio na Escola Estadual de Educação Básica Costa Rêgo, no ano letivo de 2013 e 2014. Resultados: Os conhecimentos sobre planejamento familiar, infecções sexualmente transmissíveis e reprodução dos adolescentes na maioria aumentaram após a intervenção formativa no âmbito da afetividade/sexualidade na adolescência. Os conhecimentos estão relacionados com a idade no sentido em que são os mais novos que demonstram mais co-nhecimentos. Na separação dos conhecimentos por sexo são as meninas que manifestam mais conhecimentos, assim como os residentes em meio urbano. A existência de irmãos, a idade e escolaridade dos pais não influenciam os conhecimentos dos adolescentes. Obser-vou-se também que os adolescentes que já tinham iniciado relações sexuais são aqueles que detêm menos conhecimentos. Conclusão: Os dados mostram que as oficinas realizadas e os questionários servi-ram para conscientização dos alunos e contribuiu para a redução dos índices de evasão escolar por motivos de gravidez, mostrando assim a importância de se tratar de educação sexual no ambiente escolar. Palavras-chave: Adolescência, Sexualidade, Educação Sexual, Planejamento Famili-ar, Infecções Sexualmente Transmissíveis.

Sexualidade nos adolescentes : intervenção formativa

Enquadramento – Os adolescentes com acesso a conhecimentos, informação e motivação, para adotarem comportamentos sexuais seguros, serão capazes de alterar as suas atitudes e os seus comportamentos. Objetivos – Caraterizar os adolescentes relativamente às variáveis de contexto sexual; identificar os conhecimentos dos adolescentes sobre IST e planeamento familiar; identificar as atitudes dos adolescentes face à sexualidade, pílula e preservativos; identificar a motivação dos adolescentes para terem ou não relações sexuais; determinar a eficácia de uma intervenção formativa no âmbito da sexualidade nos conhecimentos sobre IST, Planeamento Familiar, bem como nas suas atitudes face à sexualidade. Métodos - Investigação experimental de campo. O instrumento de recolha de dados é um questionário, elaborado pela equipa de investigadores do Projeto Monitorização de Indicadores de Saúde Infanto-Juvenil (MISIJ) no domínio temático da “Sexualidade Adolescente”. Este permite caracterizar sociodemograficamente e sexualmente os adolescentes, inclui ainda a Escala de atitudes face à sexualidade em adolescentes (AFSA) (Nelas et al., 2010), Escala de conhecimentos sobre infeções de transmissão sexual (Nelas et al., 2010), Escala de atitudes face ao preservativo (Ramos et al., 2009), Escala de atitudes face à pílula (Ramos et al., 2009), Escala de conhecimentos sobre planeamento familiar (Nelas et al., 2010), Escala de motivação para fazer e para não fazer sexo (Alferes, 1997). Resultados - A amostra é constituída por 56 estudantes do 9º ano de escolaridade (28 do grupo de controlo e 28 do grupo experimental). A maioria dos adolescentes do grupo de controlo é do sexo feminino (71,4%), contrariamente ao grupo de controlo onde 64,3% é do sexo masculino. As raparigas do grupo de controlo revelaram mais conhecimentos sobre infeções transmissíveis sexualmente, em ambos os momentos da avaliação, os adolescentes do sexo masculino, em ambos os momentos, revelam mais conhecimentos sobre o planeamento familiar, comparativamente às adolescentes do género feminino. Aos índices positivos antes da intervenção formativa corresponderam melhores índices após a intervenção formativa. Conclusão - Os profissionais de saúde devem, através da educação para a saúde, promover atitudes que promovam a saúde sexual e reprodutiva e promover o desenvolvimento de competências indispensáveis para adoção de comportamentos saudáveis. Palavras-chave - Adolescentes; Sexualidade; Educação sexual; Intervenção formativa.

Beliefs and attitudes of nurses regarding visitation in the pediatric intensive care unit

The purpose of this study was to investigate the beliefs and attitudes of nurses regarding the effects of visitation in pediatric intensive care units (PICU).^ Questionnaires were used to gather data from nurses (n = 48) in four study sites. Data were analyzed according to the Theory of Reasoned Action.^ A predominant theme among the beliefs was that visitation should be individualized. It was found that PICU nurses have more positive attitudes regarding traditional visitation as opposed to open visitation (p $<$.01). Significant relationships were found between nurses' years of education and attitudes toward traditional (p $<$.01) and open (p $<$.05) visitation.^ In light of the literature suggesting the positive effects of open visitation, it appears that PICU nurses' attitudes may present a barrier when implementing open policies. Since years of education shows a positive correlation with nurses' attitudes, educational intervention may be helpful in overcoming this obstacle. ^

A competência leitora de alunos do ensino fundamental: uma proposta de intervenção

Reading is a activity of paramount importance in the life of every human being, since this practice is essential condition for the exercise of citizenship. Therefore, it is through reading that the student has access to the knowledge that part of the world around him. However, given the complexity involved in the process of learning to read, teach students to read is not an easy task because often they do not acquire the skills necessary to understand the texts. According to this view, the present study focuses on an educational intervention who aim at contribut to the development of reading competence of students in 6th grade "U" of the State School Senador José Bernardo, in São João do Sabugi - RN. The activities which were of that intervention process were conducted in Portuguese Language classroom and developed through didactic sequences drawn from reading strategies, based on the genres tale and news, since students had serious problems with regard to reading comprehension. Given the importance of meeting the aforementioned difficulty, we seek to develop a proposal for interactive reading activities through genres as a language of social practices, whose goal aimed read to understand and make sense of texts. This intervention proposal falls under the Applied Linguistics and to perform it, were taken as a basis some theories focused on the notion of language as sociointerativa practice, such as studies of Bakhtin (2006, 2011), Bronckart (2012) and targeted contributions to the teaching of reading activity, including, Solé (1998), Oliveira (2010), Kleiman (2013), Leffa (1996, 1999), Silveira (2005). Discussions about genres followed the studies of Bakhtin (2011), Marcuschi (2008), as well as other theoretical; the didactic sequences were constructed from Bronckart (2012), Dolz; Noverraz; Schneuwly (2013) and, with regard to the teaching of Portuguese Language, the guidelines were adopted contained in PCN / LP (1998), as well as in Antunes (2003, 2009) and other authors. The results showed that students in the 6th grade increased their understanding capacity of the read texts, by implementing the didactic and pedagogical actions, thereby acquiring the reading competence they needed to keep learning.

A produção textual no ensino fundamental: processo de retextualização com o gênero memórias

Teaching Portuguese language in Brazilian public schools is still limited mostly to studying decontextualized text fragments, memorizing classifications and cult of grammar rules. Considering the language as a social, cultural practice which emerges from the intersubjective interaction, we sought to propose an educational intervention that prioritizes the retextualization processes from speech to the writing of memoirs as a textual genre, so as to contribute for improving learner’s discursive performances. Therefore, paying attention to these concerns and in attempt to contribute for improving the teaching of Portuguese language in elementary school, we chose as privileged locus a 9th grade class from a state school in Bento Fernandes, RN. The corpus is formed by texts produced and retextualized by students from the elders’ oral reports within local community. We sought thus to understand what memory is, its importance for registering local spoken language and culture, as much as to carry out didactic actions that favor students’ learning in the activities of textual production. In light of the theoretical overviews about linguistic-discursive relations, based on Marcuschi’s (1993, 1997, 2001, 2002, 2006, 2008, 2010) conception of oralitiy-writing continuum and the debates proposed by Antunes (2003, 2014), Alves Filho (2011), Koch (2012) and Bakhtin (1992, 2011), we aimed to understand, by analyzing the retextualized memoirs, how these practices complement each other within the process of orality and writing. As for the proposal of didactic sequences, the study has been oriented by Dolz and Scheneuely (2004); as for the memoirs, by the guidelines of Coracine and Ghiraldelo (2011) and Le Goff (2010, 2013). In this way, this work followed the action-research methodology in a qualitative approach, considering the teacher (researcher) as an active agent involved in the process of knowledge production in his own educational practice, so as to interfere in the mediation, knowledge production and its dissemination in classroom context, which is the privileged locus for constructing and transforming process. There is much to be research within the area of retextualization. Yet we verified that this educational intervention, based on discursive operators of retextualization, has been proven viable as an efficient path so that we teachers can work the peculiarities of usages and functions of textual genres in oral and written modalities of a language, without grasping both as a dichotomy. This accredited us to strengthen a discourse that undoes many myths still present in that order, especially the one that causes more damage for the learners of Portuguese language – that writing is a representation of speech.

The effect of complex workplace dietary interventions on employees dietary behaviours, nutrition knowledge and health status

Background The growing prevalence and associated burden of diet-related non-communicable diseases is a global public health concern. The environments in which people live and work influences their dietary behaviours. Aim The focus of this thesis was on the effectiveness of complex workplace dietary interventions. The comparative effectiveness of a complex workplace environmental dietary modification intervention and an educational intervention were assessed both alone and in combination relative to a control workplace setting. Methods The systematic review was guided by the PRISMA statement. In a cluster controlled trial, four workplaces were purposively allocated to control, nutrition education alone (Education), environmental dietary modification alone (Environment) and nutrition education and environmental dietary modification (Combined intervention). The interventions were guided by the MRC framework. In the control workplace, data were collected at baseline and follow-up. In the intervention related sub-study, the relationships between nutrition knowledge, diet quality and hypertension were examined. Results The systematic review provided limited evidence. In the FCW study, 850 employees aged 18-64 years were recruited at baseline with N(response rate %) in each workplace as follows: Control: 111(72%), Education: 226(71%), Environment: 113(91%), Combined intervention: 400(61%). Complete follow-up data was obtained for 517 employees (61%). There were significant positive changes in dietary intakes of saturated fat(p=0.013), salt(p=0.010) and nutrition knowledge(p=0.034) between baseline and follow-up at 7-9 months in the combined intervention versus the control workplace in the fully adjusted multivariate analysis. Small but significant changes in BMI(-1.2kg/m2 (p=0.047) were also observed in the combined intervention. In the sub-study, nutrition knowledge was positively significantly associated with diet quality and blood pressure but no evidence of a mediation effect of the DASH score was detected between nutrition knowledge and blood pressure. Conclusion This thesis provides critical evidence on the effectiveness of complex workplace dietary interventions in a manufacturing working population.

Aconselhamento de produtos de apoio para alunos com NEE: levantamento das estratégias e modelos utilizados pelos CRTIC

Na senda do contexto legislativo de outros países, também Portugal criou uma conjuntura legislativa, no âmbito da Educação Especial, que consagrou a possibilidade de utilização de produtos de apoio, como um recurso ao serviço dos alunos com Necessidades Educativas Especiais (NEE). Entre outras iniciativas, o Ministério da Educação lançou, em 2007, uma rede constituída por 25 centros, designados por Centro de Recursos TIC para Educação Especial (CRTIC) que, entre outras missões, são responsáveis pela avaliação de alunos com NEE tendo em vista a implementação dos produtos de apoio na intervenção educativa junto deste tipo de discentes. É neste contexto que surge a proposta de, com o estudo aqui apresentado, investigar e compreender as práticas atualmente em curso nos CRTIC, nomeadamente no que respeita às estratégias e os modelos aplicados nas avaliações de alunos com NEE, para efeitos de atribuição de produtos de apoio. O referencial teórico que sustentou este estudo foi analisado considerando o contexto legislativo nacional e internacional, que enquadra a utilização deste tipo de recursos junto destes alunos. Considerámos ainda as classificações existentes que caracterizam a diversidade dos produtos de apoio disponíveis no mercado, tendo a presente investigação sido focada no âmbito do aconselhamento tipicamente realizado pelos CRTIC. Por último, fez-se uma reflexão acerca dos processos implicados na prestação de serviços, analisando alguns indicadores de qualidade de serviço aconselhados pela literatura da especialidade. Do ponto de vista metodológico, e atendendo à finalidade desta investigação, delineou-se uma estratégia que permitiu recolher dados provenientes de diferentes fontes, tendo-se desenvolvido um estudo do tipo survey, sustentado por um paradigma pluri-metodológico, cujo corpus de análise proveio da análise documental de relatórios oficiais e de inquéritos por entrevista e por questionário. Estes últimos foram aplicados a todo o universo dos CRTIC (25 centros), tendo-se obtido uma taxa de resposta de 100%. A análise dos dados obtidos revelou que o processo de avaliação desenvolvido por estes centros já tem em conta alguns dos aspetos destacados na literatura, tais como: equipas multidisciplinares; tomada de decisão colaborativa e observação dos fatores ambientais do aluno. Porém, verifica-se que são escassos os CRTIC que disponibilizam um apoio sistemático e continuo aos intervenientes educativos na fase de implementação/utilização dos produtos atribuídos. Sustentados na constatação deste facto, conceptualizámos e prototipámos uma proposta de uma plataforma de apoio à avaliação e monitorização dos produtos de apoio, designada por “Rede NEE”, que visa facilitar a comunicação entre os intervenientes. Esta proposta revela-se inovadora no modo como os pedidos podem ser realizados, contemplando ainda estratégias que poderão facilitar a monitorização dos produtos de apoio atribuídos.

Refletir sobre a língua através do jogo – um estudo com alunos do 2.º ano do ensino básico

Relatório de estágio apresentado à Escola Superior de Educação para obtenção de grau de mestre em Ensino do 1.º e do 2.º Ciclo do Ensino Básico

A consolidação da relação entre a teoria e a prática na construção da profissionalidade docente

Relatório de Estágio apresentado à Escola Superior de Educação de Paula Frassinetti para obtenção do grau de Mestre em Educação Pré-Escolar e Ensino do 1º Ciclo do Ensino Básico, Sob orientação Professora Doutora Brigite Carvalho da Silva | Mestre Maria Ivone Couto Monforte das Neves.

(Re)configurar a prática educativa a partir da reflexão sobre o(s) contexto(s)

Relatório de Estágio apresentado à Escola Superior de Educação de Paula Frassinetti para obtenção do grau de Mestre em Educação Pré-Escolar e Ensino do 1º Ciclo do Ensino Básico, sob orientação de Doutora Daniela Alexandra Ramos Gonçalves | Mestre Maria Ivone Couto Monforte das Neves

O ato de educar na construção da profissionalização

Relatório de Estágio apresentado à Escola Superior de Educação de Paula Frassinetti para obtenção de grau Mestre em Educação Pré-Escolar e Ensino 1º ciclo do Ensino Básico.