Opinión de las mujeres desplazadas sobre la repercussion en su salud del desplazamiento forzado

ResumenObjetivoAnalizar la adaptación de la mujer desplazada a la ciudad y su relación con los problemas de salud percibidos.MétodosEstudio cualitativo descriptivo, de tipo exploratorio, desarrollado mediante entrevistas individuales semiestructuradas a una muestra de variación máxima de 25 mujeres desplazadas. Se efectuó un análisis narrativo de contenido, con generación mixta de categorías y segmentación de datos por grupos de edad y tema. El área de estudio fueron 5 localidades de Bogotá (Colombia).ResultadosEn su discurso, las mujeres entrevistadas expresan que su adaptación a la ciudad está mediada por las nuevas condiciones económicas y del entorno y por las consecuencias psicosociales del desplazamiento. Las condiciones económicas precarias les obligan a vivir en entornos insalubres y, en ocasiones, a asumir la jefatura del hogar. En este papel presentan importantes dificultades para satisfacer las necesidades familiares, particularmente la adulta joven; junto con las adolescentes, refiere cambios comportamentales, como la reproducción de acciones violentas hacia la familia. Las mujeres desplazadas perciben alteraciones de la salud mental, nutricionales, infecciones y afecciones ginecológicas, como los principales problemas de salud, e identifican la situación económica y las responsabilidades del hogar como restrictores del acceso a los servicios de salud.ConclusionesEl desplazamiento forzado coloca a la mujer en una situación con exigencias nuevas del entorno y de roles familiares que inciden negativamente sobre su salud y acceso a la atención. La promoción de la salud de este colectivo requiere acciones que posibiliten su acceso al trabajo y su estabilización socioeconómica a largo plazo.AbstractObjectiveTo analyze the adaptation process of women internally displaced to the city and the relationship between displacement and their self-perceived main health problems.MethodsA qualitative, exploratory, descriptive study was carried out by means of semi-structured individual interviews with a maximum variation sample of 25 internally displaced women. A narrative content analysis was conducted with mixed generation of categories and data segmentation by age and themes. The area under study consisted of five localities in the city of Bogotá (Colombia).ResultsAccording to the interviewed women's discourses, their adaptation to city life depended on the new socioeconomic and environmental conditions and the psychosocial impact of displacement on the family. Precarious economic conditions forced them to live in an unhealthy environment and, occasionally, to adopt the role of head of household. In this role, many of these women, particularly young women, faced great difficulties in ensuring that the family's needs were met. Young women and teenagers reported behavioral changes due to displacement, including reproduction of violence in the home. The main self-perceived health problems among displaced women were mental health, access to food, infections and gynecological alterations. Displaced women identified the main factors hindering their access to health services as their economic situation and home responsibilities.ConclusionsDisplaced women face new environmental and family challenges that negatively affect their health and access to healthcare. Specific interventions aimed at displaced women are required to foster better health through access to work and long –term socioeconomic stability

Access to health care in Colombia

Objetivo Contribuir al conocimiento sobre el acceso a los servicios en Colombia tras la reforma del sistema de salud, exponiendo los principales resultados y vacíos en las investigaciones. Métodos Se realizó una revisión sistemática de la bibliografía, a través de la búsqueda exhaustiva y análisis de artículos originales publicados entre 1994 y 2009. Se incluyeron 27 investigaciones cuantitativas y cualitativas que cumplían los criterios de selección. El análisis se enmarcó en los modelos teóricos de Aday y Andersen y Gold, que diferencian entre acceso potencial y realizado y consideran las características de la población, proveedores y aseguradoras que influyen en la utilización. Resultados Los análisis explicativos de la utilización de los servicios de salud a partir de modelos de determinantes resultan escasos y parciales (limitados a áreas geográficas, patologías o colectivos específicos). Pocos estudios profundizan en factores de contexto –políticas y características de proveedores y asegura-doras- o en la perspectiva de los actores sobre los factores que influyen en el acceso. Los estudios no parecen indicar un aumento del acceso realizado –salvo en el régimen subsidiado- y, en cambio, señalan la existencia de importantes barreras relacionadas con factores poblacionales (aseguramiento, renta y educación) y características de los servicios (accesibilidad geográfica, organizativas y calidad). Conclusiones La revisión muestra limitaciones importantes en el análisis del acceso en Colombia que indican la necesidad de reorientar la evaluación hacia el acceso realizado, e incorporar variables de contexto y la perspectiva de los actores para comprender mejor el impacto de la reforma en el uso de servicios.OBJECTIVES: Contributing towards improving knowledge about access to health services in Colombia following health-sector reform, highlighting the main results and gaps in research.METHODS: Original papers were systematically reviewed through a comprehensive search and analysis of original papers published between 1994 and 2009. After selection criteria had been applied, 27 papers were included in the review. Analysis was based on Aday Aday & Andersen and Gold's theoretical frameworks, distinguishing between potential and actual healthcare access and considering the characteristics of the population, health services and insurers influencing service use.RESULTS: There was little explanatory analysis of service use applying determinant models; this was also partial (limited to geographical areas, diseases or specific groups). Likewise, only a few studies analysed contextual factors influencing service use (health policies and health providers and insures) or social actors' perspectives. The available studies did not seem to indicate increased actual access (except for subsidised system users) but, on the contrary the existence of barriers relating to population (insurance coverage, income and education) and health service factors (geographic and organizational accessibility and quality of care).CONCLUSIONS: This review led to identifying important limitations in the analysis of healthcare access in Colombia and highlighted the need for further research on actual access and the better incorporation of context variables and actors perspectives in understanding the impact of reform on health service use

Care coordination in two of Bogota’s public healthcare networks: A cross-sectional study among doctors

Introduction: Care coordination is a priority concern for healthcare systems. In Colombia, there is a lack of information on the topic. This study analysed how doctors of two Bogotá’s public healthcare networks perceived coordination between healthcare levels and what factors are associated with their perception. Methods: A cross-sectional study using the COORDENA-CO questionnaire to a sample of 363 doctors (network-1 = 181; network-2 = 182) in 2015. The questionnaire asks about types and dimensions of care coordination: information and clinical management, with items in a Likert scale, as well as conditions regarding health system, organisational and doctors’ conditions. Descriptive statistics and logistic regression analysis were performed. Results: The doctors’ perception of a high level of coordination did not exceed 25.4%. On coordination of information, limited transfer of clinical information was found. Concerning clinical management, there were limited care coherence, deficits in patient follow-up and lengthy waiting times for specialised care. A high perception of coordination were associated with being female, being over 50 years old, being a specialist, having less than one year’s working experience, working less than 20 h per week at the centre, forming part of network-1, having time available for performing coordination tasks, having job satisfaction and not identifying limitations imposed by healthcare insurers. Discussion: There was limited perception of coordination, in its different dimensions and types with some differences between networks. The results support the importance of guaranteeing job satisfaction, ensuring sufficient time to coordination-related activities and intervening in the restrictions imposed by healthcare insurers to improve care coordination. © The Author(s) 2019

Dominant logics at the policy making and services organization that affect the access to comprehensive rehabilitation

Introduction: The health sector reform in Colombia, generated inequities in access to services, including rehabilitation; poor identification of population needs and low sectorial response to their problems. Metodology: An exploratory, descriptive-interpretative qualitative study was carried out. Individual semi-structured interviews and focus group were conducted to policy makers, providers, rehabilitation professionals, professors, social organizations, persons with disabilities and caregivers. Results: The absence of a rights approach, targeting and the model of health insurance, as dominant logics policy stands. There is a reductionist view of rehabilitation and services organization models with low response to the needs of people with disabilities. Conclusion: The need to reconceptualize access to services arises; rehabilitation is claimed as a right that demands redesign of services and organization models

Regional-based Integrated Healthcare Network policy in Brazil: from formulation to practice

Background Regional-based Integrated Healthcare Networks (IHNs) have been promoted in Brazil to overcome the fragmentation due to the health system decentralization to the municipal level; however, evaluations are scarce. The aim of this article is to analyse the content of IHN policies in force in Brazil, and the factors that influence policy implementation from the policymakers’ perspective. Methods A two-fold, exploratory and descriptive qualitative study was carried out based on (1) content analysis of policy documents selected to meet the following criteria: legislative documents dealing with regional-based IHNs; enacted by federal government; and in force, (2) semi-structured individual interviews were conducted to a theoretical sample of policymakers at federal (eight), state (five) and municipal levels (four). Final sample size was reached by saturation of information. An inductive thematic analysis was conducted. Results The results show difficulties in the implementation of IHN policies due to weaknesses that arise from the policy design and the performance of the three levels of government. There is a lack of specificity as to the criteria and tools for configuring and financing IHNs that need to be agreed upon between involved governments. For their part, policymakers emphasize the difficulty of establishing agreements in a health system with disincentives for collaboration between municipalities. The allocation of responsibilities that are too complex for the capacity and size of the municipalities, the abandonment of essential functions such as network planning by states and the strategic role by the Ministry, the ‘invasion’ of competences among levels of government and high political turnover are also highlighted. Conclusions The implementation of regional-based IHN policy in Brazil is hampered by the decentralized organization of the health system to the municipal level, suggesting the need to centralize certain functions to regional structures or states and to define better the role of the government levels involved

Evaluación de la efectividad de las intervenciones de coordinación de la atención diseñadas e implementadas a través de un proceso de investigación acción participativa: lecciones aprendidas de un estudio cuasi-experimental en redes públicas de salud en América Latina

Antecedentes: a pesar de las crecientes recomendaciones para que los profesionales de la salud participen en el diseño y la implementación de intervenciones para efectuar cambios en la práctica clínica, se sabe poco sobre la efectividad de esta estrategia. Este estudio analiza la efectividad de las intervenciones diseñadas e implementadas a través de procesos de investigación acción participativa (PAR) en redes de salud de Brasil, Chile, Colombia, México y Uruguay para mejorar la coordinación clínica entre los niveles de atención y ofrece recomendaciones para futuras investigaciones. Métodos: El estudio fue cuasi-experimental. En cada país se seleccionaron dos redes comparables, una de intervención (IN) y otra de control (CN). Se realizaron encuestas de línea de base (2015) y de evaluación (2017) a una muestra de médicos de atención primaria y secundaria (174 médicos/red/año) mediante el cuestionario COORDENA®. La mayoría de las intervenciones elegidas se basaron en reuniones conjuntas, promoviendo el acuerdo clínico entre niveles y la comunicación para el seguimiento de los pacientes. Las variables de resultado fueron: a) intermedias: factores interaccionales y organizacionales; b) distal: experiencia de coordinación de información clínica transversal, de coordinación de gestión clínica y percepción general de coordinación entre niveles. Se estimaron modelos de regresión de Poisson. Resultados: Se observó un aumento estadísticamente significativo en algunos de los factores interaccionales (resultados intermedios) -conocimiento personal y confianza mutua- en los IN de Brasil y Chile; y en algunos factores organizacionales -apoyo institucional- en Colombia y México. En comparación con los CN en 2017, los IN de Brasil, Chile, Colombia y México mostraron diferencias significativas en algunos factores. En los resultados distales, los ítems de consistencia asistencial mejoraron en los IN de Brasil, Colombia y Uruguay; y mejoró el seguimiento de los pacientes en Chile y México. Se incrementó la percepción general de coordinación clínica en los IN de Brasil, Colombia y México. En comparación con los CN en 2017, solo Brasil mostró diferencias significativas. Conclusiones: aunque se necesita más investigación, los resultados muestran que las intervenciones basadas en PAR mejoraron algunos resultados con respecto a la coordinación clínica a nivel de red, con diferencias entre países. Sin embargo, un proceso PAR es, por definición, lento y gradual, y se necesitan períodos de implementación más prolongados para lograr una mayor penetración y cambios cuantificables. La naturaleza participativa y flexible de las intervenciones desarrolladas a través de los procesos PAR plantea desafíos metodológicos (como definir los resultados o asignar a las personas a diferentes grupos por adelantado) y requiere un enfoque integral de métodos mixtos que evalúe simultáneamente la efectividad y el proceso de implementación para comprender mejor sus resultados.Background: Despite increasing recommendations for health professionals to participate in intervention design and implementation to effect changes in clinical practice, little is known about this strategy’s effectiveness. This study analyses the effectiveness of interventions designed and implemented through participatory action research (PAR) processes in healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay to improve clinical coordination across care levels, and offers recommendations for future research. Methods: The study was quasi-experimental. Two comparable networks, one intervention (IN) and one control (CN), were selected in each country. Baseline (2015) and evaluation (2017) surveys of a sample of primary and secondary care doctors (174 doctors/network/year) were conducted using the COORDENA® questionnaire. Most of the interventions chosen were based on joint meetings, promoting cross-level clinical agreement and communication for patient follow-up. Outcome variables were: a) intermediate: interactional and organizational factors; b) distal: experience of cross-level clinical information coordination, of clinical management coordination and general perception of coordination between levels. Poisson regression models were estimated. Results: A statistically significant increase in some of the interactional factors (intermediate outcomes) -knowing each other personally and mutual trust- was observed in Brazil and Chile INs; and in some organizational factors -institutional support- in Colombia and Mexico. Compared to CNs in 2017, INs of Brazil, Chile, Colombia and Mexico showed significant differences in some factors. In distal outcomes, care consistency items improved in Brazil, Colombia and Uruguay INs; and patient follow-up improved in Chile and Mexico. General perception of clinical coordination increased in Brazil, Colombia and Mexico INs. Compared to CNs in 2017, only Brazil showed significant differences. Conclusions: Although more research is needed, results show that PAR-based interventions improved some outcomes regarding clinical coordination at network level, with differences between countries. However, a PAR process is, by definition, slow and gradual, and longer implementation periods are needed to achieve greater penetration and quantifiable changes. The participatory and flexible nature of interventions developed through PAR processes poses methodological challenges (such as defining outcomes or allocating individuals to different groups in advance), and requires a comprehensive mixed-methods approach that simultaneously evaluates effectiveness and the implementation process to better understand its outcomes

Inequities in access to health care in different health systems: A study in municipalities of central Colombia and north-eastern Brazil

Introduction. Health system reforms are undertaken with the aim of improving equity of access to health care. Their impact is generally analyzed based on health care utilization, without distinguishing between levels of care. This study aims to analyze inequities in access to the continuum of care in municipalities of Brazil and Colombia. Methods. A cross-sectional study was conducted based on a survey of a multistage probability sample of people who had had at least one health problem in the prior three months (2,163 in Colombia and 2,167 in Brazil). The outcome variables were dichotomous variables on the utilization of curative and preventive services. The main independent variables were income, being the holder of a private health plan and, in Colombia, type of insurance scheme of the General System of Social Security in Health (SGSSS). For each country, the prevalence of the outcome variables was calculated overall and stratified by levels of per capita income, SGSSS insurance schemes and private health plan. Prevalence ratios were computed by means of Poisson regression models with robust variance, controlling for health care need. Results: There are inequities in favor of individuals of a higher socioeconomic status: in Colombia, in the three different care levels (primary, outpatient secondary and emergency care) and preventive activities; and in Brazil, in the use of outpatient secondary care services and preventive activities, whilst lower-income individuals make greater use of the primary care services. In both countries, inequity in the use of outpatient secondary care is more pronounced than in the other care levels. Income in both countries, insurance scheme enrollment in Colombia and holding a private health plan in Brazil all contribute to the presence of inequities in utilization. Conclusions: Twenty years after the introduction of reforms implemented to improve equity in access to health care, inequities, defined in terms of unequal use for equal need, are still present in both countries. The design of the health systems appears to determine access to the health services: two insurance schemes in Colombia with different benefits packages and a segmented system in Brazil, with a significant private component. © 2014 Garcia-Subirats et al.; licensee BioMed Central Ltd

Análisis cualitativo del concepto y praxis de rehabilitación integral percibido por distintos actores involucrados

Introducción. La rehabilitación integral es un concepto de difícil consenso, dado que es resultado de una evolución histórica. Objetivo. Presentar los hallazgos del estudio “Acceso a los servicios de rehabilitación integral en Colombia: una aproximación desde los conceptos y las prácticas de distintos actores sociales” y describir las comprensiones de la rehabilitación integral de parte de diversos actores desde una perspectiva comprensiva de la discapacidad. Materiales y métodos. Se realizó un estudio descriptivo-exploratorio, cualitativo y de múltiples fuentes de evidencia para identificar las percepciones de actores responsables de formular e implementar políticas públicas (FP), académicos (A), profesionales (P), representantes de organizaciones sociales (OS), gestores de servicios (GS), gestores y profesionales de servicios de educación inclusiva (EI), personas con discapacidad (PCD) y cuidadores (C), involucrados en la rehabilitación integral en una ciudad colombiana. Se realizaron entrevistas a 18 actores y se desarrollaron seis grupos focales. Para el análisis de datos, se usó el Atlas ti®, el acuerdo entre jueces y el análisis de las narrativas. Resultados. La rehabilitación integral es percibida de distintas maneras por los actores, entre las que priman tres concepciones de ella: como resultado de un proceso de rehabilitación funcional, como derecho y como garante de inclusión social. Conclusiones. Mientras exista diversidad y dispersión acerca de la rehabilitación integral, será difícil concebir, implementar, evaluar y participar activamente en dicho proceso. En consecuencia, las barreras de acceso a ella se incrementarán y estará lejos de entenderse como un derecho que se ejerce desde una visión integral de ser humano. Dicho esto, se enuncian implicaciones para la academia, los prestadores de servicios y las políticas públicas.Introduction: Comprehensive rehabilitation is a difficult concept since it is the result of historical evolution.Objective: To present the findings of the study “Access to comprehensive rehabilitation services in Colombia: an approach from the concepts and practices of different social actors”, and to describe the perception of comprehensive rehabilitation based on the opinions of different actors from a comprehensive perspective of disability.Material and methods: A descriptive and exploratory, qualitative study was conducted, taking into account multiple sources of evidence to identify the perceptions of actors responsible for formulating and implementing public policies (PP), academicians (A), professionals (P), representatives of social organizations (SO), service managers (SM), service managers and professionals in inclusive education (IE), persons with disabilities (PWD) and caregivers (C), involved in comprehensive rehabilitation in a Colombian city. 18 interviews with actors were conducted; six focus groups were developed. For data analysis, the Atlas ti® software, the agreement between judges and the analysis of narratives were considered.Results: Comprehensive rehabilitation is perceived differently by the actors, and three conceptions are relevant: it is a result of a functional rehabilitation process; it is a right, and it is also a guarantor of social inclusion.Conclusions: While there is diversity and dispersion in opinions on comprehensive rehabilitation, it will be difficult to conceive, implement, evaluate and actively participate in this process. Consequently, access barriers will increase and it will be far from understood as a right exercised from an integral vision of the human being. With this in mind, implications for academia, service providers and public policies are set

Evaluating the effectiveness of care integration strategies in different healthcare systems in Latin America : The EQUITY-LA II quasi-experimental study protocol

Introduction: Although fragmentation in the provision of healthcare is considered an important obstacle to effective care, there is scant evidence on best practices in care coordination in Latin America. The aim is to evaluate the effectiveness of a participatory shared care strategy in improving coordination across care levels and related care quality, in health services networks in six different healthcare systems of Latin America. Methods and analysis: A controlled before and after quasi-experimental study taking a participatory action research approach. In each country, two comparable healthcare networks were selected-intervention and control. The study contains four phases: (1) A baseline study to establish network performance in care coordination and continuity across care levels, using (A) qualitative methods: semi-structured interviews and focus groups with a criterion sample of health managers, professionals and users; and (B) quantitative methods: two questionnaire surveys with samples of 174 primary and secondary care physicians and 392 users with chronic conditions per network. Sample size was calculated to detect a proportion difference of 15% and 10%, before and after intervention (α=0.05; β=0.2 in a two-sided test); (2) a bottom-up participatory design and implementation of shared care strategies involving micro-level care coordination interventions to improve the adequacy of patient referral and information transfer. Strategies are selected through a participatory process by the local steering committee (local policymakers, health care network professionals, managers, users and researchers), supported by appropriate training; (3) Evaluation of the effectiveness of interventions by measuring changes in levels of care coordination and continuity 18 months after implementation, applying the same design as in the baseline study; (4) Crosscountry comparative analysis. Ethics and dissemination: This study complies with international and national legal stipulations on ethics. Conditions of the study procedure were approved by each country's ethical committee. A variety of dissemination activities are implemented addressing the main stakeholders. Registration No.257 Clinical Research Register of the Santa Fe Health Department, Argentina

Introducción a las técnicas cualitativas de investigación aplicadas en salud.

Éste no es un texto teórico sobre métodos cualitativos aplicados en salud, sino un manual autoinstructivo, cuyo propósito es proporcionar a los profesionales de la salud una introducción práctica y sencilla a la investigación cualitativa aplicada en salud. A través de un ejemplo real, se conduce al lector desde los fundamentos teóricos al diseño y desarrollo de un estudio cualitativo en el ámbito de la salud, y se presta especial atención al rigor y al análisis de los datos. Los contenidos teóricos se trabajan mediante el análisis del caso y numerosos ejercicios, y se complementan con una lista de bibliografía comentada. El libro puede ser utilizado de forma individual o bien como base para un curso de investigación cualitativa aplicada en salud.Prólogo a la edición Colombiana -- Introducción al manual -- Introducción al caso -- Introducción a los fundamentos teóricos de la investigación cualitativa -- Diseño de estudios y diseños muestrales en investigación cualitativa -- Técnicas cualitativas aplicadas en salud -- El rigor en la investigación cualitativa -- Análisis de los datos cualitativos -- Divulgación de los resultados de investigaciones cualitativa