Adesão terapêutica do idoso hospitalizado com doença crónica

Dissertação de Mestrado em Gerontologia Social

Auto-medicação em adolescentes do Ensino Secundário de Vila Nova de Gaia

Este trabalho de investigação encontra-se estruturado em cinco capítulos. Na Introdução geral, é apresentado o estado de arte, sendo definido o tema da investigação. No segundo capítulo são apresentados os objectivos do trabalho: geral e específicos. No capítulo da Metodologia encontram-se definidos o tipo de estudo, a população em estudo e amostra, o instrumento de recolha de dados e sua validação, as considerações éticas e finalmente, os testes estatísticos utilizados. No quarto capítulo encontram-se os Artigos redigidos, tendo sido um deles submetido à "Revista Portuguesa de Saúde Pública', cujo factor de impacto em 2009 foi de 2,655 e o outro será submetido à posteriori à revista "Pharmaceutica/ Researcli', cujo factor de impacto em 2009 foi de 3,933. O último capítulo integra as Considerações Finais. Apresenta-se como objectivo geral determinar a prevalência da automedicação numa faixa etária específica- a adolescência, procedendo para tal, a uma recolha de dados perante questionário efectuado a alunos de 12° ano das Escolas Secundárias de Vila Nova de Gaia. Foram obtidas 699 respostas, tendo sido constatada uma prevalência de auto-medicação em 83,8% dos alunos inquiridos. Esta prevalência é considerada elevada, havendo uma necessidade de desenvolver programas educacionais, promovendo aos adolescentes uma utilização adequada dos medicamentos.

O erro na aprendizagem clínica dos estudantes de enfermagem : percepções de estudantes de enfermagem em aprendizagem clínica sobre os erros cometidos e o papel que desempenham na aprendizagem e o no desenvolvimento

Tese de Doutoramento, Educação (Psicologia Educacional), 9 de Dezembro de 2013, Universidade dos Açores.

A literacia em saúde: investimento na promoção da saúde e na racionalização de custos

A Organização Mundial da Saúde define a literacia em saúde como o conjunto de competências cognitivas e sociais e a capacidade dos indivíduos para compreenderem e usarem informação para a promoção e manutenção da saúde. A transmissão de informação sobre saúde é mais eficaz quando os seus conteúdos são especificamente desenhados para uma pessoa ou para um grupo populacional e quando a mensagem é bem delimitada, realçando os benefícios (ganhos) e os custos (perdas) associados aos comportamentos e às tomadas de decisão. Analisa-se, neste estudo, o conceito de literacia em saúde e a associação da baixa literacia em saúde aos comportamentos em saúde e aos gastos em saúde. Apresenta-se uma análise da literatura científica publicada sobre a baixa literacia em saúde e a sua implicação nos custos na saúde usando, para este objectivo, uma base de dados das ciências da saúde (MEDLINE/PubMed) e quatro plataformas científicas (DOAJ, SCOPUS, SciELO e Web of Science). A literatura científica analisada evidencia que pessoas com baixa literacia em saúde apresentam uma menor capacidade de compreensão dos conteúdos de material informativo sobre alimentos, doenças crónicas ou sobre o uso de medicamentos, por exemplo, bem como maior dificuldade em pesquisar, seleccionar, ler e assimilar a informação em saúde disponível na Internet. A baixa literacia em saúde relaciona-se, então. com a dificuldade na prevenção e na gestão de problemas de saúde, bem como com comportamentos ineficazes de saúde, i.e., com o uso inadequado de medicamentos, com o recurso excessivo aos serviços de saúde (em especial, os de urgências) ou com a ineficácia em lidar com situações de emergência. A baixa literacia está também associada a taxas de hospitalização mais altas, mas também mais longas no tempo (o que implica mais custos associados a internamento prolongado, mais exames de diagnóstico e fraca adesão à terapêutica medicamentosa), a uma diminuição da utilização de medidas preventivas e a uma fraca adesão à prescrição terapêutica. A baixa literacia acaba por afectar igualmente a comunicação (e a relação) médico-doente. Apresentam-se, como complemento, sugestões de melhoria da literacia em saúde e da comunicação médico-doente para efeitos da promoção da saúde.

Household members and health care workers as supervisors of tuberculosis treatment

OBJECTIVE: To compare tuberculosis cure rates among patients supervised by household members or health care workers. METHODS: Prospective cohort study of 171 patients treated by the program in Vitoria, Southeastern Brazil, from 2004 to 2007. Each patient was followed-up for six months until the end of the treatment. Of the patients studied, a household member supervised 59 patients and healthcare workers supervised 112 patients. Patients' sociodemographic and clinic data were analyzed. Differences between groups were assessed using chi-square test or Student's t-test. Significance level was set at 5%. RESULTS: Most patients had smear positive, culture confirmed pulmonary tuberculosis. Two patients were HIV-positive. There were more illiterate patients in the healthcare-supervised group, in comparison to those supervised by their families (p=0.01). All patients supervised by a household member were cured compared to 90% of the patients supervised by health care workers (p = 0.024). CONCLUSIONS: Successful tuberculosis treatment was more frequent when supervised by household members.

Direct medical costs associated with schizophrenia relapses in health care services in the city of São Paulo

OBJECTIVE: To assess direct medical costs associated with schizophrenia relapses in mental health services. METHODS: The study was conducted in three health facilities in the city of São Paulo: a public state hospital; a Brazilian National Health System (SUS)-contracted hospital; and a community mental health center. Medical records of 90 patients with schizophrenia who received care in 2006 were reviewed. Information on inpatient expenditures was collected and used for cost estimates. RESULTS: Mean direct medical cost of schizophrenia relapses per patient was US$ 4,083.50 (R$ 8,167.58) in the public state hospital; US$ 2,302.76 (R$ 4,605.46) in the community mental health center; and US$ 1,198.50 (R$ 2,397.74) in the SUS-affiliated hospital. The main component was daily inpatient room rates (87% - 98%). Medication costs varied depending on the use of typical or atypical antipsychotic drugs. Atypical antipsychotic drugs were more often used in the community mental health center. CONCLUSIONS: Costs associated with schizophrenia relapses support investments in antipsychotic drugs and strategies to reduce disease relapse and the need for mental health inpatient services. Treating patients in a community mental health center was associated with medium costs and added the benefit of not depriving these patients from family life.

DOTS in primary care units in the city of Rio de Janeiro, Southeastern Brazil

OBJECTIVE: To describe the implantation and the effects of directly-observed treatment short course (DOTS) in primary health care units. METHODS: Interviews were held with the staff of nine municipal health care units (MHU) that provided DOTS in Rio de Janeiro City, Southeastern Brazil, in 2004-2005. A dataset with records of all tuberculosis treatments beginning in 2004 in all municipal health care units was collected. Bivariate analyses and a multinomial model were applied to identify associations between treatment outcomes and demographic and treatment process variables, including being in DOTS or self-administered therapy (SAT). RESULTS: From 4,598 tuberculosis cases treated in public health units administrated by the municipality, 1,118 (24.3%) were with DOTS and 3,480 (75.7%) with SAT. The odds of DOTS were higher among patients with age under 50 years, tuberculosis relapse and prior history of default or treatment failure. The odds of death were 52.0% higher among patients on DOTS as compared to SAT. DOTS modality including community health workers (CHWs) showed the highest treatment success rate. A reduction of 21.0% was observed in the odds of default (vs. cure) among patients on DOTS as compared to patients on SAT, and a reduction of 64.0% among patients on DOTS with CHWs as compared to those without CHWs. CONCLUSIONS: Patients with a "low compliance profile" were more likely to be included in DOTS. This strategy improves the quality of care provided to tuberculosis patients, although the proposed goals were not achieved.

Devolução de doses unitárias: análise de uma prática diária

A Distribuição Individual Diária em Dose Unitária deve assegurar o maior rigor no Processo de Distribuição de Medicamentos, o que nem sempre se verificou no Hospital Pedro Hispano, dado que as Doses Unitárias devolvidas pelos Serviços de Internamento, nem sempre seguiam os Parâmetros de Qualidade. Assim, desenvolveu-se um estudo quasi-experimental, longitudinal, prospetivo e analítico, entre 1 de Março a 30 de Junho de 2012, no qual se analisaram as Doses Unitárias, devolvidas pelos Serviços de Internamento da Unidade Local de Saúde de Matosinhos a funcionam com Distribuição Individual Diária em Dose Unitária, tendo-se recolhido as não conformes relativamente aos Parâmetros de Qualidade instituídos. Na 1.ª fase do estudo (Recolha de amostras), foram contabilizadas 337 amostras, correspondentes a uma perda de 471 €. Na 2.ª fase do estudo (Implementação de acções correctivas às amostras previamente recolhidas), foram rejeitadas definitivamente 129 amostras, correspondentes a uma perda de 198 €. Na 4.ª fase do estudo (Segunda recolha de amostras), foram contabilizadas 228 amostras, correspondentes a uma perda de 199 €. A 3.ª fase do estudo incluiu a divulgação dos resultados às enfermeiras chefes dos serviços envolvidos no estudo e a 5.ª fase a comparação dos resultados obtidos na 1.ª, 2.ª e 4.ª fase do estudo. As amostras foram recolhidas em 16 serviços de internamento, sendo os valores monetários mais relevantes associados ao Espessante para alimentos líquidos e ao Imipeno + Cilastatina. A prática observada e sujeita a estudo aumenta os riscos associados ao consumo do medicamento e os custos relativos ao Processo, sendo de eliminar. A sua monitorização deve constituir uma rotina, uma vez que houve mudança de comportamentos. A redução/eliminação desta prática não conforme conduz à integração de novas tarefas com valor acrescentado, com aumento da fiabilidade do Processo.

Low prevalence of hypertension with pharmacological treatments and associated factors

OBJECTIVE: To assess the determinants of the lack of pharmacological treatment for hypertension. METHODS: In 2005, 3,323 Mozambicans aged 25-64 years old were evaluated. Blood pressure, weight, height and smoking status were assessed following the Stepwise Approach to Chronic Disease Risk Factor Surveillance. Hypertensives (systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg and/or antihypertensive drug therapy) were evaluated for awareness of their condition, pharmacological and non-pharmacological management, as well as use of herbal or traditional remedies. Prevalence ratios (PR) were calculated, adjusted for sociodemographic characteristics, cardiovascular risk factors and non-pharmacological treatment. RESULTS: Most of the hypertensive subjects (92.3%), and nearly half of those aware of their condition were not treated pharmacologically. Among the aware, the prevalence of untreated hypertension was higher in men {PR = 1.61; 95% confidence interval (95%CI 1.10;2.36)} and was lower in subjects under non-pharmacological treatment (PR = 0.58; 95%CI 0.42;0.79); there was no significant association with traditional treatments (PR = 0.75; 95%CI 0.44;1.26). CONCLUSIONS: The lack of pharmacological treatment for hypertension was more frequent in men, and was not influenced by the presence of other cardiovascular risk factors; it could not be explained by the use of alternative treatments as herbal/traditional medicines or non-pharmacological management. It is important to understand the reasons behind the lack of management of diagnosed hypertension and to implement appropriate corrective actions to reduce the gap in the access to healthcare between developed and developing countries.

Fatores associados à baixa adesão ao tratamento medicamentoso em idosos

OBJETIVO : Analisar fatores associados à baixa adesão ao tratamento medicamentoso em idosos. MÉTODOS : Estudo transversal de base populacional, com amostra representativa de 1.593 indivíduos com 60 anos ou mais, residentes na região urbana de Bagé, RS, em 2008. A amostragem foi realizada em múltiplos estágios. Os dados foram coletados em entrevistas individuais nos domicílios. Analisou-se a associação entre a baixa adesão referida ao tratamento medicamentoso mensurado pelo Brief Medication Questionnaire (BMQ) e fatores demográficos, socioeconômicos, comportamentais e de saúde, assistência e prescrição. Foi utilizado modelo de regressão de Poisson para estimar as razões de prevalência bruta e ajustada, os respectivos intervalos de confiança de 95% e p-valor (teste de Wald). RESULTADOS : Cerca de 78,0% dos indivíduos referiram ter usado algum medicamento nos sete dias precedentes à entrevista. Desses, cerca de 1 / 3 foram considerados com baixa adesão ao tratamento. Os fatores significativamente associados à baixa adesão foram: idade (65 a 74 anos), não ter plano de saúde, ter que comprar (totalmente ou em parte) os seus medicamentos, ter três ou mais morbidades, possuir incapacidade instrumental para a vida diária e usar três ou mais medicamentos. CONCLUSÕES : A utilização elevada de medicamentos, decorrente da alta prevalência de doenças crônico-degenerativas em idosos, e o acesso ao tratamento devem ser considerados pelos profissionais de saúde para adoção de estratégias que visem diminuir a baixa adesão ao tratamento, aumentando a resolutividade terapêutica e a qualidade de vida desses pacientes.

Impact of a training course on the quality of malaria diagnosis by microscopy in Angola

Background: In Angola, malaria is an endemic disease having a major impact on the economy. The WHO recommends testing for all suspected malaria cases, to avoid the presumptive treatment of this disease. In malaria endemic regions laboratory technicians must be very comfortable with microscopy, the golden standard for malaria diagnosis, to avoid the incorrect diagnosis. The improper use of medication promotes drug resistance and undesirable side effects. The present study aims to assess the impact of a three-day refresher course on the knowledge of technicians, quality of blood smears preparation and accuracy of microscopy malaria diagnosis, using qPCR as reference method. Methods: This study was implemented in laboratories from three hospitals in different provinces of Angola: Bengo, Benguela and Luanda. In each laboratory samples were collected before and after the training course (slide with thin and thick blood smears, a dried blood spot and a form). The impact of the intervention was evaluated through a written test, the quality of slide preparation and the performance of microscopy. Results: It was found a significant increase on the written test median score, from 52.5% to 65.0%. A total of 973 slides were analysed to evaluate the quality of thick and thin blood smears. Considering all laboratories there was a significant increase in quality of thick and thin blood smears. To determine the performance of microscopy using qPCR as the reference method we used 1,028 samples. Benguela presented the highest values for specificity, 92.9% and 98.8% pre and post-course, respectively and for sensitivity the best pre-course was Benguela (75.9%) and post-course Luanda (75.0%). However, no significant increase in sensitivity and specificity after the training course was registered in any laboratory analysed. Discussion: The findings of this study support the need of continuous refresher training for microscopists and other laboratory staff. The laboratories should have a quality control programme to supervise the diagnosis and also to assess the periodicity of new training. However, other variables needed to be considered to have a correct malaria diagnosis, such as adequate equipment and reagents for staining and visualization, good working conditions, motivated and qualified personnel.

Disability in instrumental activities of daily living among older adults: gender differences

OBJECTIVE To analyze gender differences in the incidence and determinants of disability regarding instrumental activities of daily living among older adults. METHODS The data were extracted from the Saúde, Bem-Estar e Envelhecimento (SABE – Health, Wellbeing and Ageing) study. In 2000, 1,034 older adults without difficulty in regarding instrumental activities of daily living were selected. The following characteristics were evaluated at the baseline: sociodemographic and behavioral variables, health status, falls, fractures, hospitalizations, depressive symptoms, cognition, strength, mobility, balance and perception of vision and hearing. Instrumental activities of daily living such as shopping and managing own money and medication, using transportation and using the telephone were reassessed in 2006, with incident cases of disability considered as the outcome. RESULTS The incidence density of disability in instrumental activities of daily living was 44.7/1,000 person/years for women and 25.2/1,000 person/years for men. The incidence rate ratio between women and men was 1.77 (95%CI 1.75;1.80). After controlling for socioeconomic status and clinical conditions, the incidence rate ratio was 1.81 (95%CI 1.77;1.84), demonstrating that women with chronic disease and greater social vulnerability have a greater incidence density of disability in instrumental activities of daily living. The following were determinants of the incidence of disability: age ≥ 80 and worse perception of hearing in both genders; stroke in men; and being aged 70 to 79 in women. Better cognitive performance was a protective factor in both genders and better balance was a protective factor in women. CONCLUSIONS The higher incidence density of disability in older women remained even after controlling for adverse social and clinical conditions. In addition to age, poorer cognitive performance and conditions that adversely affect communication disable both genders. Acute events, such as a stroke, disables elderly men more, whereas early deficits regarding balance disable women more.

Tuberculosis Control Program and patient satisfaction, Rio de Janeiro, Brazil

OBJECTIVE To evaluate factors associated with users’ satisfaction in the Tuberculosis Control Program. METHODS A cross-sectional study of 295 patients aged ≥ 18 years, with two or more outpatient visits in the Tuberculosis Control Program, in five cities in the metropolitan region of Rio de Janeiro, RJ, Southeastern Brazil, in 2010. Considering an estimated population of 4,345 patients, the sampling plan included 15 health care units participating in the program, divided into two strata: units in Rio de Janeiro City, selected with probability proportional to the monthly average number of outpatient visits, and units in the other four cities. In the units, four temporal clusters of five patients each were selected with equal probability, totaling 300 patients. A questionnaire investigating the users’ clinical and sociodemographic variables and aspects of care and service in the program relevant to user satisfaction was applied to the patients. Descriptive statistics about users and their satisfaction with the program were obtained, and the effects of factors associated with satisfaction were estimated. RESULTS Patients were predominantly males (57.7%), with a mean age of 40.9 and with low level of schooling. The mean treatment time was 4.1 months, mostly self-administered (70.4%). Additionally, 25.8% had previously been treated for tuberculosis. There was a high level of satisfaction, especially regarding medication provision, and respect to patients by the health professionals. Patients who were younger (≤ 30), those on self-administered treatment, and with graduate level, showed less satisfaction. Suggestions to improve the services include having more doctors (70.0%), and offering exams in the same place of attendance (55.1%). CONCLUSIONS Patient satisfaction with the Tuberculosis Control Program was generally high, although lower among younger patients, those with university education and those on self-administered treatment. The study indicates the need for changes to structural and organizational aspects of care, and provides practical support for its improvement.

Biological drugs for the treatment of psoriasis in a public health system

OBJECTIVE To analyze the access and utilization profile of biological medications for psoriasis provided by the judicial system in Brazil.METHODSThis is a cross-sectional study. We interviewed a total of 203 patients with psoriasis who were on biological medications obtained by the judicial system of the State of Sao Paulo, from 2004 to 2010. Sociodemographics, medical, and political-administrative characteristics were complemented with data obtained from dispensation orders that included biological medications to treat psoriasis and the legal actions involved. The data was analyzed using an electronic data base and shown as simple variable frequencies. The prescriptions contained in the lawsuits were analyzed according to legal provisions.RESULTS A total of 190 lawsuits requesting several biological drugs (adalimumab, efalizumab, etanercept, and infliximab) were analyzed. Patients obtained these medications as a result of injunctions (59.5%) or without having ever demanded biological medication from any health institution (86.2%), i.e., public or private health services. They used the prerogative of free legal aid (72.6%), even though they were represented by private lawyers (91.1%) and treated in private facilities (69.5%). Most of the patients used a biological medication for more than 13 months (66.0%), and some patients were undergoing treatment with this medication when interviewed (44.9%). Approximately one third of the patients discontinued treatment due to worsening of their illness (26.6%), adverse drug reactions (20.5%), lack of efficacy, or because the doctor discontinued this medication (13.8%). None of the analyzed medical prescriptions matched the legal prescribing requirements. Clinical monitoring results showed that 70.3% of the patients had not undergone laboratory examinations (blood work, liver and kidney function tests) for treatment control purposes.CONCLUSIONS The plaintiffs resorted to legal action to get access to biological medications because they were either unaware or had difficulty in accessing them through institutional public health system procedures. Access by means of legal action facilitated long-term use of this type of medication through irregular prescriptions and led to a high rate of adverse drug reactions as well as inappropriate clinical monitoring.

Chronic use of benzodiazepines among older adults

OBJECTIVE To analyze the perception of and motivation for the chronic use of benzodiazepine among older adults. METHODS A qualitative study was conducted on 22 older adults living in Bambuí, MG, Southeastern Brazil, who were taking benzodiazepines and had the clinical and cognitive ability to respond to interview questions. The collected data were analyzed on the basis of the “signs, meanings, and actions” model. RESULTS The main reasons pointed out for the use of benzodiazepines were “nervousness”, “sleep problems”, and “worry” due to family and financial problems, everyday problems, and existential difficulties. None of the interviewees said that they used benzodiazepines in a dose higher than that recommended or had been warned by health professionals about any risks of their continuous use. Different strategies were used to obtain the prescription for the medication, and any physician would prescribe it, indicating that a bond was established with the drug and not with the health professional or healthcare service. Obtaining and consuming the medication turned into a crucial issue because benzodiazepine assumes the status of an essential food, which leads users to not think but sleep. It causes a feeling of relief from their problems such as awareness of human finitude and fragility, existential difficulties, and family problems. CONCLUSIONS Benzodiazepine assumes the characteristics of polyvalence among older adults, which extrapolate specific clinical indications, and of essentiality to deal with life’s problems in old age. Although it relieves the “nerves”, the chronic use of benzodiazepines buffers suffering and prevents older adults from going through the suffering. This shows important difficulties in the organization and planning of strategies that are necessary for minimizing the chronic use in this population.