Assistência em cuidados paliativos a pessoa idosa na atenção primária a saúde

This study aims to understand the significance of palliative care for the elder health care professionals working in primary health care. Descriptive study of qualitative approach. Conducted in three health units of the Family and a core of support for Health, the Felipe Camarão neighborhood, District of Natal Health West, RN. Of the 25 participants, 19 are professionals of the Family Health Strategy and six of the Center for Support to Health, the majority being women, with minimal professional work experience, a year in primary health care. The study was approved by the Ethics Committee of the Federal University of Rio Grande do Norte, under CAAE no. 43895815.4.0000.5537. There were individual interviews between July and September 2015, with the use of questionnaire containing open and closed questions on the topic of study. Our results were recorded in MP4 and transcribed into written language, and analyzed using the open coding process medium in which the categories were interpreted and identified, followed by axial coding, where categories were developed and systematically related. Three categories emerged: enhancement of elder health professionals in palliative care, behavioral health professionals across care in palliative care in primary care and disjointed Meaning between palliative care and health professionals. The categories were interpreted and analyzed by the theoretical framework of social phenomenology of Alfred Schütz. Regarding the valuation of subjective perception of professionals, it is clear the issue of the complexity of multiple relationships through various aspects of his central task: focus a philosophy of the world's reality, namely a phenomenology of natural attitude; Before the professional behavior were identified: the discovery and depth of assumptions through the structure, and meaning in a common sense, and at the meaning of the disconnection between the health professionals-including that reality imminent can be represented by individuality special interest of the experience. It follows that health professionals understand there is a difficulty facing the assistance in palliative care to the elderly in primary care, and this difficulty, characterized by the complexity of social interactions across the joint teamwork. Although, I believe that the articulation between the teams, work and family, is essential for the subsequent improvement of care in palliative care favoring the health context surrounding the Elder.

Near miss materno e iniquidades em saúde: análise de determinantes contextuais no Rio Grande do Norte, Brasil

The scope of this study was to identify socioeconomic contextual and health care factors in primary care associated with maternal near misses and their marker conditions. This is an ecological study that used aggregated data of 63 clusters formed by the municipalities of State of Rio Grande do Norte, Brazil, using the Skater method of area regionalization, as the unit of analysis. The ratio of maternal near misses and their marker conditions were obtained from the Hospital Information System of the Brazilian Unified Health System. In multiple linear regression analysis, there was a significant association between maternal near misses and variables of poverty and poor primary health care. Hypertensive disorders were also associated with poverty and poor primary care and the occurrence of hemorrhaging was associated with infant mortality. It was observed that the occurrence of maternal near misses is linked to unfavorable socioeconomic conditions and poor quality health care that are a reflection of public policies that accentuate health inequalities.

Near miss materno e iniquidades em saúde: análise de determinantes contextuais no Rio Grande do Norte, Brasil

The scope of this study was to identify socioeconomic contextual and health care factors in primary care associated with maternal near misses and their marker conditions. This is an ecological study that used aggregated data of 63 clusters formed by the municipalities of State of Rio Grande do Norte, Brazil, using the Skater method of area regionalization, as the unit of analysis. The ratio of maternal near misses and their marker conditions were obtained from the Hospital Information System of the Brazilian Unified Health System. In multiple linear regression analysis, there was a significant association between maternal near misses and variables of poverty and poor primary health care. Hypertensive disorders were also associated with poverty and poor primary care and the occurrence of hemorrhaging was associated with infant mortality. It was observed that the occurrence of maternal near misses is linked to unfavorable socioeconomic conditions and poor quality health care that are a reflection of public policies that accentuate health inequalities.

Impacto do Programa Saúde da Família sobre indicadores de saúde da criança em municípios de grande porte da região Nordeste do Brasil

The present study carried out in the context of the Baseline Studies of the PROESF was aimed at evaluating the impact of the Family Health Program (PSF) on indicators for child health in cities with more than 100,000 inhabitants in the Brazilian Northeast. Four cities were investigated. In each one, twenty censual sectors were selected randomly from areas covered by the PSF and compared with twenty sectors selected from areas not covered by the PSF on the basis of socioeconomic criteria. In most cases, no significant differences were found between the areas covered and not covered by the PSF. The only difference found was a significantly lower rate of hospital admissions due to diarrhea but this was on account of the Program of Community Health Agents. The PSF exerted no additional effect on the reduction of this indicator. It was also observed that the way by which the program is implemented in each city interferes directly in the results. Thus, there is no basis for considering the PSF per se ineffective or not differing from other programs with regard to its health care patterns. An evaluation of the PSF would necessarily have to include an analysis of the way the program is implemented and conducted in each case, besides considering its general socioeconomical and political characteristics.

Cuidado psicossocial em saúde mental: estudo em assentamentos rurais do Rio Grande do Norte

Dwellers of agrarian reform settlements have a life conditioned by poor living and work conditions, difficulties accessing health programs, social assistance and other public policies and by this exacerbating their psychosocial and environmental vulnerability, which has an impact on their mental health. This research investigates the availability of support by the health and social assistance staff, regarding the demands of common mental disorders and alcohol abuse of dwellers of nine settlements in Rio Grande do Norte. Fifty three experts from different professional categories were interviewed individually or in groups. The results indicate that the workers suffer from poor working conditions, attributes of patrimonial heritage and welfare, which still survives in Brazilian social policies and particularly at local administrations of the countryside. The staffs have little knowledge of the local conditions and of the mental health needs, which has a negative impact on the reception and offered care. The implemented health care still corresponds to the biomedical logic, characterized by ethnocentrism, technicality, biology, cure, individualism and specialization, with little participation of the dwellers and disregarding the traditional knowledge and practices of local health care and by this not achieving the expected results. The psychosocial attendance is not well coordinated, presenting problems with the follow-up and continuity of care. The psychosocial mental health care in rural context has to face the challenge of the reorganization of the health care networks, the establishment of primary health care close to the people’s everyday life, building intersectional practices considering a health multidetermination and health education connected to these specific contexts. Due to the lack of knowledge of the specifics of the life conditions of the dwellers and the fragmentation of the psychosocial health care network, these staffs do not abide and are not ready to face the mental health needs in order to interfere with these health iniquities.

Cuidado psicossocial em saúde mental: estudo em assentamentos rurais do Rio Grande do Norte

Dwellers of agrarian reform settlements have a life conditioned by poor living and work conditions, difficulties accessing health programs, social assistance and other public policies and by this exacerbating their psychosocial and environmental vulnerability, which has an impact on their mental health. This research investigates the availability of support by the health and social assistance staff, regarding the demands of common mental disorders and alcohol abuse of dwellers of nine settlements in Rio Grande do Norte. Fifty three experts from different professional categories were interviewed individually or in groups. The results indicate that the workers suffer from poor working conditions, attributes of patrimonial heritage and welfare, which still survives in Brazilian social policies and particularly at local administrations of the countryside. The staffs have little knowledge of the local conditions and of the mental health needs, which has a negative impact on the reception and offered care. The implemented health care still corresponds to the biomedical logic, characterized by ethnocentrism, technicality, biology, cure, individualism and specialization, with little participation of the dwellers and disregarding the traditional knowledge and practices of local health care and by this not achieving the expected results. The psychosocial attendance is not well coordinated, presenting problems with the follow-up and continuity of care. The psychosocial mental health care in rural context has to face the challenge of the reorganization of the health care networks, the establishment of primary health care close to the people’s everyday life, building intersectional practices considering a health multidetermination and health education connected to these specific contexts. Due to the lack of knowledge of the specifics of the life conditions of the dwellers and the fragmentation of the psychosocial health care network, these staffs do not abide and are not ready to face the mental health needs in order to interfere with these health iniquities.

Integração ensino e serviço: dizer e fazer saúde na atenção básica

The current discussion on Education and Health has shown the need for greater integration between health services and academia, and this issue has been addressed by researchers in the area as being of great importance. How do we say what we need to do? The National Policy on Education Permanent Health proposes the dissemination of pedagogical skills at SUS, so that the public health clearance to constitute an area of teaching and learning in work performance. This study aimed to know how is the process of integration between education and health services in primary health care, from the knowledge on the role of mentors in the training of undergraduate students in the healthcare field in UFRN. Qualitative Methodology possible, from the use of the techniques of Semi-Structured Interview and Direct Observation of achieving this goal. The analysis of data taken from the Hermeneutic-Dialectic Approach, taking as mediators knowledge of the areas of Education, Health Education and Public Health, showed that the performance of preceptors constitutes an important strategy to enable the integration of teaching and service, and the professionals involved in the preceptorship educate themselves while they educate. The educational process is permeated by knowledge and experiences heterogeneous, highly favorable to the training of students and professionals factor. Innovative educational practices proven capable of starting the mediation of preceptors and other professionals involved in the Work Programme Education for Health, extend learning. The curriculum components Integrated Activity of Health, Education and Citizenship, and Tutorial Program for Integrated Health Work chosen as the basis for this experiment set, for preceptors, the need to seek new knowledge, allowing each actor transcend its specific area of academic training and interact with other areas, which makes learning interesting, enjoyable and meaningful.

Intervenção mediacional e hábitos alimentares: um estudo de crianças com síndrome de Down

The inadequacy about eating habits have been established as a serious problem nowadays. It is a multifactorial and difficult to handle, given their different nuances and causes. A population particularly exposed to the bad eating habits arising harm are individuals with Down syndrome, both with regard to the aspects inherent to the individual's own condition, regarding eating misfits, making it the weight control a necessary measure for a proper development. Thus, this study aimed to develop and evaluate a proposal based nutrition education from the assumptions of mediated learning, with children three to four years with Down syndrome. The participants were five children, four girls and a boy. Also included his parents and / or guardians. The data collection procedure involved the use of eight playful workshops with children and nutritional evaluation of those five meetings with parents and three home visits with each participating family. We tried to build with these children and their families a nutritional education to contribute to their daily choices of eating. Using listening, observation and questionnaire, besides playful interventions, it was observed that the first meaning of the act of eating is built in the family and reinforced by their social life. Overall, our sample characteristics seem to agree with the literature. During the intervention, the children showed attention, but little understanding of the content. With mothers, the results were different, with reflections on the inadequate power both the type of food offered, and quantity and so this offer is performed, conducted along the interventions changes in your lifestyle, such as perception of influence they had on their children in the formation of their eating habits, as well as less frequent intake of soft drinks and sweets. Nutritional interventions and mediations conducted with the mothers is that they seem to be effective strategies to combat obesity. Face of what was discussed, we see the importance of implementing intervention measures in combating and preventing overweight or obese since childhood, particularly with children with Down syndrome. One should prevent childhood obesity with educational and informative measures from birth, with family and with each child, through the primary health care and schools.

Team reflexivity and innovation:the moderating role of team context

We developed and tested a team level contingency model of innovation, integrating theories regarding work demands, team reflexivity - the extent to which teams collectively reflect upon their working methods and functioning -, and team innovation. We argued that highly reflexive teams will be more innovative than teams low in reflexivity when facing a demanding work environment. The relationships between team reflexivity, a demanding work environment (i.e. quality of the physical work environment and work load) and team innovation was examined among 98 primary health care teams (PHCTs) in the UK, comprised of 1137 individuals. Results showed that team reflexivity is positively related to team innovation, and that there is an interaction between team reflexivity, team level workload, and team innovation, such that when team level workload is high, combined with a high level of team reflexivity, team innovation is also higher. The complementary interaction between team reflexivity, quality of physical work environment, and team innovation, showed that when the quality of the work environment is low, combined with a high level of team reflexivity, team innovation was also higher. These results are discussed in the context of the need for team reflexivity and team innovation among teams at work facing high work demands.

Natriuretic peptide-based screening and collaborative care for heart failure:the STOP-HF randomized trial

IMPORTANCE: Prevention strategies for heart failure are needed.

OBJECTIVE: To determine the efficacy of a screening program using brain-type natriuretic peptide (BNP) and collaborative care in an at-risk population in reducing newly diagnosed heart failure and prevalence of significant left ventricular (LV) systolic and/or diastolic dysfunction.

DESIGN, SETTING, AND PARTICIPANTS: The St Vincent's Screening to Prevent Heart Failure Study, a parallel-group randomized trial involving 1374 participants with cardiovascular risk factors (mean age, 64.8 [SD, 10.2] years) recruited from 39 primary care practices in Ireland between January 2005 and December 2009 and followed up until December 2011 (mean follow-up, 4.2 [SD, 1.2] years).

INTERVENTION: Patients were randomly assigned to receive usual primary care (control condition; n=677) or screening with BNP testing (n=697). Intervention-group participants with BNP levels of 50 pg/mL or higher underwent echocardiography and collaborative care between their primary care physician and specialist cardiovascular service.

MAIN OUTCOMES AND MEASURES: The primary end point was prevalence of asymptomatic LV dysfunction with or without newly diagnosed heart failure. Secondary end points included emergency hospitalization for arrhythmia, transient ischemic attack, stroke, myocardial infarction, peripheral or pulmonary thrombosis/embolus, or heart failure.

RESULTS: A total of 263 patients (41.6%) in the intervention group had at least 1 BNP reading of 50 pg/mL or higher. The intervention group underwent more cardiovascular investigations (control, 496 per 1000 patient-years vs intervention, 850 per 1000 patient-years; incidence rate ratio, 1.71; 95% CI, 1.61-1.83; P<.001) and received more renin-angiotensin-aldosterone system-based therapy at follow-up (control, 49.6%; intervention, 56.5%; P=.01). The primary end point of LV dysfunction with or without heart failure was met in 59 (8.7%) of 677 in the control group and 37 (5.3%) of 697 in the intervention group (odds ratio [OR], 0.55; 95% CI, 0.37-0.82; P = .003). Asymptomatic LV dysfunction was found in 45 (6.6%) of 677 control-group patients and 30 (4.3%) of 697 intervention-group patients (OR, 0.57; 95% CI, 0.37-0.88; P = .01). Heart failure occurred in 14 (2.1%) of 677 control-group patients and 7 (1.0%) of 697 intervention-group patients (OR, 0.48; 95% CI, 0.20-1.20; P = .12). The incidence rates of emergency hospitalization for major cardiovascular events were 40.4 per 1000 patient-years in the control group vs 22.3 per 1000 patient-years in the intervention group (incidence rate ratio, 0.60; 95% CI, 0.45-0.81; P = .002).

CONCLUSION AND RELEVANCE: Among patients at risk of heart failure, BNP-based screening and collaborative care reduced the combined rates of LV systolic dysfunction, diastolic dysfunction, and heart failure.

TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00921960.

Décentralisation et allocation des ressources : les détours de la municipalisation du système de santé brésilien.

Dans cette thèse, nous avons analysé le déroulement d’un processus de municipalisation du système de santé, effectué au Rio Grande do Norte (RN), un des états fédérés du nord-est du Brésil. En tenant compte des contextes historiques d’implantation, nous avons centré notre attention sur la contribution des acteurs impliqués dans ce processus, spécialement dans l’allocation des ressources financières du système. Les croyances, perceptions, attentes, représentations, connaissances, intérêts, l’ensemble des facteurs qui contribuent à la constitution des capacités cognitives de ces acteurs, favorise la réflexivité sur leurs actions et la définition de stratégies diverses de façon à poursuivre leurs objectifs dans le système de santé. Ils sont vus ainsi comme des agents compétents et réflexifs, capables de s’approprier des propriétés structurelles du système de santé (règles et ressources), de façon à prendre position dans l’espace social de ce système pour favoriser le changement ou la permanence du statu quo. Au cours du processus de structuration du Système unique de santé brésilien, le SUS, la municipalisation a été l’axe le plus développé d’un projet de réforme de la santé. Face aux contraintes contextuelles et de la dynamique complexe des espaces sociaux de la santé, les acteurs réformistes n’ont pas pu suivre le chemin de l’utopie idéalisée; quelques détours ont été parcourus. Au RN, la municipalisation de la santé a constitué un processus très complexe où la triade centralisation/décentralisation/recentralisation a suivi son cours au milieu de négociations, de conflits, d’alliances, de disputes, de coopérations, de compétitions. Malgré les contraintes des contextes successifs, des propriétés structurelles du système et des dynamiques sociales dans le système de santé, quelques changements sont intervenus : la construction de leaderships collectifs; l’émergence d’une culture de négociation; la création des structures et des espaces sociaux du système, favorisant les rencontres des acteurs dans chaque municipalité et au niveau de l’état fédéré; un apprentissage collectif sur le processus de structuration du SUS; une grande croissance des services de première ligne permettant d’envisager une inversion de tendance du modèle de prestation des services; les premiers pas vers la rupture avec la culture bureaucratique du système. Le SUS reste prisonnier de quelques enjeux institutionnalisés dans ce système de santé : la dépendance du secteur privé et de quelques groupes de professionnels; le financement insuffisant et instable; la situation des ressources humaines. Les changements arrivés sont convergents, incrémentiels, lents; ils résultent d’actions normatives, délibérées, formalisées. Elles aussi sont issues de l’inattendu, de l’informel, du paradoxe; quelques-unes plus localisées, d’autres plus généralisées, pour une courte ou une plus longue durée.

Atuação das equipes da atenção primária na identificação precoce do câncer infanto-juvenil

Identificar o conhecimento de profissionais da atenção primária sobre a identificação precoce do câncer infanto-juvenil e descrever o desempenho das equipes de saúde antes da realização de treinamentos para identificação precoce do câncer infanto-juvenil. Método: Os dados foram obtidos por um questionário e grupo focal com 30 profissionais de uma Unidade de Saúde da Família, e analisados por temas geradores. Resultados: Os profissionais possuem conhecimentos sobre a identificação do câncer infanto-juvenil, e, demandam conhecer mais sobre os sinais e sintomas para identificação precoce, e a prestação de uma assistência sistematizada. Conclusão: Torna-se fundamental estimular a qualificação dos profissionais da atenção primária para a identificação precoce e o fortalecimento de uma rede de assistência que proporcione atendimento integral e a redução no retardo do diagnóstico de câncer infanto-juvenil

Why is it Important to Involve New Fathers in the Care of Their Child

Research into fathers’ unique contributions to the physical, emotional, social and cognitive wellbeing of their offspring has been ongoing for several decades. Health and family care policy has focused increasingly on the imperative to include fathers in services and to see them as a vital resource for mothers and children. The author identified papers from 2000 onwards that illuminate health visitors’ level of engagement with fathers of young families. The review covers policy relating to health and family services for fathers, the nature of fathering in the 21st century, the influence of involved fathers on their partners and babies, what fathers say they want from family services, and future directions for research into fathering.

Does mode of follow-up influence contraceptive use after medical abortion in a low-resource setting? Secondary outcome analysis of a non-inferiority randomized controlled trial

BACKGROUND: Post-abortion contraceptive use in India is low and the use of modern methods of contraception is rare, especially in rural areas. This study primarily compares contraceptive use among women whose abortion outcome was assessed in-clinic with women who assessed their abortion outcome at home, in a low-resource, primary health care setting. Moreover, it investigates how background characteristics and abortion service provision influences contraceptive use post-abortion. METHODS: A randomized controlled, non-inferiority, trial (RCT) compared clinic follow-up with home-assessment of abortion outcome at 2 weeks post-abortion. Additionally, contraceptive-use at 3 months post-abortion was investigated through a cross-sectional follow-up interview with a largely urban sub-sample of women from the RCT. Women seeking abortion with a gestational age of up to 9 weeks and who agreed to a 2-week follow-up were included (n = 731). Women with known contraindications to medical abortions, Hb < 85 mg/l and aged below 18 were excluded. Data were collected between April 2013 and August 2014 in six primary health-care clinics in Rajasthan. A computerised random number generator created the randomisation sequence (1:1) in blocks of six. Contraceptive use was measured at 2 weeks among women successfully followed-up (n = 623) and 3 months in the sub-set of women who were included if they were recruited at one of the urban study sites, owned a phone and agreed to a 3-month follow-up (n = 114). RESULTS: There were no differences between contraceptive use and continuation between study groups at 3 months (76 % clinic follow-up, 77 % home-assessment), however women in the clinic follow-up group were most likely to adopt a contraceptive method at 2 weeks (62 ± 12 %), while women in the home-assessment group were most likely to adopt a method after next menstruation (60 ± 13 %). Fifty-two per cent of women who initiated a method at 2 weeks chose the 3-month injection or the copper intrauterine device. Only 4 % of women preferred sterilization. Caste, educational attainment, or type of residence did not influence contraceptive use. CONCLUSIONS: Simplified follow-up after early medical abortion will not change women's opportunities to access contraception in a low-resource setting, if contraceptive services are provided as intra-abortion services as early as on day one. Women's postabortion contraceptive use at 3 months is unlikely to be affected by mode of followup after medical abortion, also in a low-resource setting. Clinical guidelines need to encourage intra-abortion contraception, offering the full spectrum of evidence-based methods, especially long-acting reversible methods. TRIAL REGISTRATION: Clinicaltrials.gov NCT01827995.

Referenciação de crianças com problemas de comunicação e linguagem a partir dos cuidados de saúde primários

Os problemas de comunicação e linguagem (PCL) podem limitar a atividade e participação de um indivíduo ao longo da sua vida. Todavia, a intervenção precoce tem-se provado bastante eficaz nestes casos. Os médicos de família (MF) encontram-se numa posição privilegiada para deteção e referenciação destes problemas em idades precoces. Porém, há evidências de que a sua participação neste processo tem sido reduzida, nomeadamente no que respeita à referenciação para serviços de Intervenção Precoce. Assim, esta investigação pretende compreender qual o papel que os MF consideram ter relativamente a este processo e quais os fatores que podem influenciar a referenciação de crianças com suspeita de PCL. Este estudo teve como base um desenho de investigação descritivo, transversal e observacional. Recorreu-se a um método de amostragem por redes para a distribuição de um questionário On-line. O instrumento foi construído pela autora e é de caráter maioritariamente quantitativo, embora integre uma questão qualitativa de resposta semiaberta. Dos questionários enviados foram devolvidos 55. A resposta semiaberta foi preenchida por 16 dos 55 MF. Os resultados demonstram que a maioria dos MF valoriza bastante ou muito a sua participação na deteção de PCL e considera importante detetar precocemente estes problemas. Para além disso, valorizam bastante ou muito a colaboração em equipa e do terapeuta da fala. A grande parte sente-se influenciada pela preocupação dos pais, pela satisfação com os serviços e com os resultados da Escala de Avaliação de Desenvolvimento de Mary Sheridan Modificada para a referenciação de crianças com PCL. Para além disso, identificam barreiras relacionadas com recursos humanos, serviços, conhecimentos relacionados com o processo de referenciação, burocracia, lentidão do processo e com a atitude dos pais. Considera-se que este estudo pode constituir um ponto de partida para futuras investigações, para a adequação de estratégias institucionais e implementação de práticas que aproximem profissionais e serviços, de forma a melhorar o processo de referenciação de crianças com PCL a partir dos cuidados de saúde primários.