Le cadre de raisonnement clinique Bobath: un modèle de science des systèmes pour aborder la complexité des troubles neurodéveloppementaux, y compris la paralysie cérébrale

La pratique Bobath actuelle telle qu'elle est recommandée dans le cadre du Bobath Clinical Reasoning Framework (BCRF) se base sur une application clinique de la science des systèmes. Elle offre une perspective holistique des relations entre les variables qui sont associées à l'apparition d'un handicap chez l'enfant. Le BCRF est un cadre de raisonnement clinique qui peut aider à comprendre les relations entre les domaines de la Classification Internationale du Fonctionnement, du Handicap et de la Santé. C'est un système d'observation transdisciplinaire de raisonnement pratique qui vise à proposer un plan d'intervention. Plus généralement, le BCRF permet une compréhension holistique de la complexité des situations associées à des troubles tels que la paralysie cérébrale et indique des choix d'adaptation et de prise en charge tout au long de la vie des personnes vivant avec des troubles neurologiques. Ce raisonnement clinique se base sur les facteurs contextuels importants de l'individu et de son environnement social, principalement la cellule familiale, et sur une compréhension des relations entre le développement typique et atypique, la physiopathologie (sensorimotrice, cognitive, comportementale) et les neurosciences, ainsi que sur l'impact des fonctions et des structures corporelles sur les activités et la participation. Le modèle de la science des systèmes du BCRF permet d'aborder la complexité de la paralysie cérébrale, avec l'objectif global d'optimiser l'expérience vécue par chaque individu dans chaque contexte

Bobath Klinik Gerekçelendirme Çerçevesi: Serebral palsi dahil nörogelişimsel durumların karmaşıklığında sistemler bilimi yaklaşımı

Bobath Klinik Gerekçelendirme Çerçevesi (BKGÇ) içerisindeki önerilen güncel gelişimsel Bobath uygulaması sistemler bilimi merceği kullanılarak kavramsallaştırılabilir ve bunu çocukluk çağı engelliliği ile ilişkilendirilen değişkenlerin birbirine bağlılığı ve etkileşimine bütüncül bir bakış açısıyla sağlar. BKGÇ, İşlevsellik, Yetiyitimi ve Sağlığın Uluslararası Sınıflandırması (ICF)’nın alt boyutları arasındaki ilişkiyi ve bu alt boyutların birbirini nasıl etkilediğini anlamak için uygulanabilen derinlemesine bir klinik gerekçelendirme çerçevesi olarak tanımlanmaktadır. BKGÇ, bir tedavi planı ile sonuçlanan klinik gerekçelendirme ve transdisipliner gözlemsel bir sistemdir. Bu sistem ise, serebral palsi (SP) gibi bozuklukların karmaşıklığını anlamak için bütüncül bir anlayış sunar ve nörolojik bozukluğu olan bireylerin yaşam boyu tedavisi ve rehabilitasyonu için temel oluşturur. BKGÇ tarafından kullanılan klinik gerekçelendirme, başta aile birimi olmak üzere bireyin ve sosyal çevresinin önemli bağlamsal faktörlerine dayanmaktadır. Tipik ve atipik gelişim, patofizyoloji (sensorimotor, bilişsel, davranışsal) ve sinirbilim arasındaki karşılıklı ilişkilerin ve bu vücut yapı ve fonksiyonlarının aktivite ve katılım üzerindeki etkisinin anlaşılmasına dayanır. BKGÇ'nin ayrılmaz bir parçası olan sistemler bilimi modeli, SP'nin karmaşıklığını anlamak ve buna yanıt vermek için yararlı bir yoldur; kapsayıcı hedef, herhangi bir bağlamda herhangi bir bireyin yaşadığı deneyimi optimize etmektir

El marco de razonamiento clínico de Bobath: Un modelo de ciencia de sistemas para abordar la complejidad de los trastornos del neurodesarrollo incluida la parálisis cerebral

La actual práctica de desarrollo Bobath recomendada dentro del Marco de Razonamiento Clínico Bobath (BCRF) puede conceptualizarse utilizando la visión de la ciencia de los sistemas. Proporciona, así, una perspectiva holística de la interrelación e interconexión de las variables asociadas con la discapacidad aparecida durante la infancia. El BCRF se define como un marco exhaustivo de razonamiento clínico que puede aplicarse para ayudar a comprender las relaciones entre los dominios de la Clasificación Internacional del Funcionamiento, de la Discapacidad y de la Salud, cómo se puede influir en esos dominios y cómo influyen entre sí. El BCRF es un sistema de observación transdisciplinario y de razonamiento práctico que da lugar a un plan de intervención. Esto proporciona una comprensión holística de la complexidad de las situaciones asociadas a trastornos como la parálisis cerebral (PC) y la base para la gestión y habilitación a lo largo de la vida de personas que viven con trastornos neurológicos. El razonamiento clínico utilizado por el BCRF se basa en los importantes factores contextuales del individuo y su entorno social, principalmente la unidad familiar. Se basa en la comprensión de las interrelaciones entre el desarrollo típico y atípico, la fisiopatología (sensoriomotora, cognitiva, conductual) y la neurociencia, así como el impacto de funciones y estructuras corporales sobre la actividad y la participación. El modelo de ciencia de sistemas del BCRF es una forma útil de comprender y responder a la complejidad de la parálisis cerebral, con el objetivo global de optimizar la experiencia vivida de todo individuo en cualquier contexto

O Quadro de Raciocínio Clínico Bobath: Uma abordagem de ciência de sistemas para a complexidade das condições do neurodesenvolvimento, incluindo a paralisia cerebral

A prática de desenvolvimento Bobath recomendada atualmente dentro do Quadro de Raciocínio Clínico Bobath (BCRF) pode ser conceptualizada usando a abordagem de ciência de sistemas, proporcionando assim uma perspetiva holística sobre a inter-relação e interconexão das variáveis associadas às deficiências iniciadas na infância. O BCRF é definido como um quadro de raciocínio clínico aprofundado que pode ser aplicado para ajudar a compreender as relações entre os domínios da Classificação Internacional de Funcionalidade, Incapacidade e Saúde, como esses domínios podem ser influenciados e como podem ter impacto uns nos outros. O BCRF é um sistema de observação transdisciplinar e uma abordagem de raciocínio prático que resulta num plano de intervenção. Isso proporciona uma compreensão holística da complexidade das situações associadas a distúrbios como a paralisia cerebral (PC) e a base para a gestão e habilitação de pessoas que vivem com distúrbios neurológicos ao longo da vida. O raciocínio clínico usado pelo BCRF baseia-se nos importantes fatores contextuais do indivíduo e no seu ambiente social, principalmente o meio familiar. Está enraizado na compreensão das inter-relações entre o desenvolvimento típico e atípico, a fisiopatologia (sensoriomotora, cognitiva, comportamental) e a neurociência, e o impacto destas conceções de estrutura e função corporal na atividade e participação. O modelo de ciência de sistemas integrado no BCRF é uma maneira útil de avançar na compreensão e resposta à complexidade da PC, sendo o objetivo principal otimizar a experiência de vida de qualquer indivíduo em qualquer contexto

Implementation science protocol for a participatory, theory-informed implementation research programme in the context of health system strengthening in sub-Saharan Africa (ASSET-ImplementER).

Objectives ASSET (Health System Strengthening in sub-Saharan Africa) is a health system strengthening (HSS) programme involving eight work-packages (ie, a research study that addresses a specific need for HSS) that aims to develop solutions that support high-quality care. Here we present the protocol for the implementation science (IS) theme within ASSET (ASSET-ImplmentER) that aims to understand what HSS interventions work, for whom and how, and how IS methodologies can be adapted to improve the HSS interventions within resource-poor contexts. Settings Publicly funded health facilities in rural and urban areas in in Ethiopia, South Africa, Sierra Leone, and Zimbabwe. Participants Research staff including principal investigators, coinvestigators, field staff, PhD students, and research assistants. Interventions Work-packages use a mixed-methods effectiveness–effectiveness hybrid designs. At the end of the pre-implementation phase, a workshop is held whereby the IS theme, jointly with ASSET work-packages apply IS determinant frameworks to research findings to identify factors that influence the effectiveness of delivering evidence-informed care. Determinants are used to select a set of HSS interventions for further evaluation, where work-packages also theorise selective mechanisms. In the piloting and rolling implementation phase, work-packages pilot the HSS interventions. An iterative process then begins involving evaluation, reflection and adaptation. Throughout this phase, IS determinant frameworks are applied to monitor and identify barriers/enablers to implementation. Selective mechanisms of action are also investigated. Implementation outcomes are evaluated using qualitative and quantitative methods. The psychometric properties of outcome measures including acceptability, appropriateness and feasibility are also evaluated. In a final workshop, work-packages come together, to reflect and explore the utility of the selected IS methods and provide suggestions for future use. Structured templates are used to organise and analyse common and heterogeneous patterns across work-packages. Qualitative data are analysed using thematic analysis and quantitative data are analysed using means and proportions. Conclusions We use a novel combination of IS methods at a programmatic level to facilitate comparisons of determinants and mechanisms that influence the effectiveness of HSS interventions in achieving implementation outcomes across different contexts. The study also contributes conceptual development and clarification at the underdeveloped interface of IS, HSS and global health

A cohort study of the effects of older adult care dependence upon household economic functioning, in Peru, Mexico and China

BACKGROUND: While links between disability and poverty are well established, there have been few longitudinal studies to clarify direction of causality, particularly among older adults in low and middle income countries. We aimed to study the effect of care dependence among older adult residents on the economic functioning of their households, in catchment area survey sites in Peru, Mexico and China. METHODS: Households were classified from the evolution of the needs for care of older residents, over two previous community surveys, as 'incident care', 'chronic care' or 'no care', and followed up three years later to ascertain economic outcomes (household income, consumption, economic strain, satisfaction with economic circumstances, healthcare expenditure and residents giving up work or education to care). RESULTS: Household income did not differ between household groups. However, income from paid work (Pooled Count Ratio pCR 0.88, 95% CI 0.78-1.00) and government transfers (pCR 0.80, 95% CI 0.69-0.93) were lower in care households. Consumption was 12% lower in chronic care households (pCR 0.88, 95% CI 0.77-0.99). Household healthcare expenditure was higher (pCR 1.55, 95% CI 1.26-1.90), and catastrophic healthcare spending more common (pRR 1.64, 95% CI 1.64-2.22) in care households. CONCLUSIONS: While endogeneity cannot be confidently excluded as an explanation for the findings, this study indicates that older people's needs for care have a discernable impact on household economics, controlling for baseline indicators of long-term economic status. Although living, typically, in multigenerational family units, older people have not featured prominently in global health and development agendas. Population ageing will rapidly increase the number of households where older people live, and their societal significance. Building sustainable long-term care systems for the future will require some combination of improved income security in old age; incentivisation of informal care through compensation for direct and opportunity costs; and development of community care services to support, and, where necessary, supplement or substitute the central role of informal caregivers

The utilisation of health research in policy-making: Concepts, examples and methods of assessment

The importance of health research utilisation in policy-making, and of understanding the mechanisms involved, is increasingly recognised. Recent reports calling for more resources to improve health in developing countries, and global pressures for accountability, draw greater attention to research-informed policy-making. Key utilisation issues have been described for at least twenty years, but the growing focus on health research systems creates additional dimensions. The utilisation of health research in policy-making should contribute to policies that may eventually lead to desired outcomes, including health gains. In this article, exploration of these issues is combined with a review of various forms of policy-making. When this is linked to analysis of different types of health research, it assists in building a comprehensive account of the diverse meanings of research utilisation. Previous studies report methods and conceptual frameworks that have been applied, if with varying degrees of success, to record utilisation in policy-making. These studies reveal various examples of research impact within a general picture of underutilisation. Factors potentially enhancing utilisation can be identified by exploration of: priority setting; activities of the health research system at the interface between research and policy-making; and the role of the recipients, or 'receptors', of health research. An interfaces and receptors model provides a framework for analysis. Recommendations about possible methods for assessing health research utilisation follow identification of the purposes of such assessments. Our conclusion is that research utilisation can be better understood, and enhanced, by developing assessment methods informed by conceptual analysis and review of previous studies

A journey without maps—Understanding the costs of caring for dependent older people in Nigeria, China, Mexico and Peru

Purpose of the study: Populations in Latin America, Asia and sub-Saharan Africa are rapidly ageing. The extent to which traditional systems of family support and security can manage the care of increased numbers of older people with chronic health problems is unclear. Our aim was to explore the social and economic effects of caring for an older dependent person, including insight into pathways to economic vulnerability. Design & methods: We carried out a series of household case studies across urban and rural sites in Peru, Mexico, China and Nigeria (n = 24), as part of a cross-sectional study, nested within the 10/66 Dementia Research Group cohort. Case studies consisted of in-depth narrative style interviews (n = 60) with multiple family members, including the older dependent person. Results: Governments were largely uninvolved in the care and support of older dependent people, leaving families to negotiate a ‘journey without maps’. Women were de facto caregivers but the traditional role of female relative as caregiver was beginning to be contested. Household composition was flexible and responsive to changing needs of multiple generations but family finances were stretched. Implications: Governments are lagging behind sociodemographic and social change. There is an urgent need for policy frameworks to support and supplement inputs from families. These should include community-based and residential care services, disability benefits and carers allowances. Further enhancement of health insurance schemes and scale-up of social pensions are an important component of bolstering the security of dependent older people and supporting their continued social and economic participation

Grand Challenges: Improving HIV Treatment Outcomes by Integrating Interventions for Co-Morbid Mental Illness.

In the fourth article of a five-part series providing a global perspective on integrating mental health, Sylvia Kaaya and colleagues discuss the importance of integrating mental health interventions into HIV prevention and treatment platforms. Please see later in the article for the Editors' Summary

Developing mental health research in sub-Saharan Africa: capacity building in the AFFIRM project.

BACKGROUND: There remains a large disparity in the quantity, quality and impact of mental health research carried out in sub-Saharan Africa, relative to both the burden and the amount of research carried out in other regions. We lack evidence on the capacity-building activities that are effective in achieving desired aims and appropriate methodologies for evaluating success. METHODS: AFFIRM was an NIMH-funded hub project including a capacity-building program with three components open to participants across six countries: (a) fellowships for an M.Phil. program; (b) funding for Ph.D. students conducting research nested within AFFIRM trials; (c) short courses in specialist research skills. We present findings on progression and outputs from the M.Phil. and Ph.D. programs, self-perceived impact of short courses, qualitative data on student experience, and reflections on experiences and lessons learnt from AFFIRM consortium members. RESULTS: AFFIRM delivered funded research training opportunities to 25 mental health professionals, 90 researchers and five Ph.D. students across 6 countries over a period of 5 years. A number of challenges were identified and suggestions for improving the capacity-building activities explored. CONCLUSIONS: Having protected time for research is a barrier to carrying out research activities for busy clinicians. Funders could support sustainability of capacity-building initiatives through funds for travel and study leave. Adoption of a train-the-trainers model for specialist skills training and strategies for improving the rigor of evaluation of capacity-building activities should be considered