INNOVATION FOR POVERTY REDUCTION WITH INCLUSION IN THE ANDEAN REGION.Panorama Andino - Learning from case studies on locally promoted innovation experiences

N° ISBN - 978-2-7380-1284-5International audienceAgricultural systems in the Andes are going through significant amounts of transformation and are being affected by new dynamics (i.e. globalization, climate change, migration, urbanization). In this context, local communities are developing creative responses and adjustments to these changes through the innovation of agricultural systems. What is the true innovation system that exists in the region? This question recognizes that there is a new reality evolving within innovation systems in the region in response to these new dynamics. Searching to answer this question, the Consortium for the Sustainable Development of the Andes Eco-Region, CONDESAN, is conducting a regional study and synthesis process on innovation of agricultural systems in the Andes, denominated Panorama Andino. The objective of this study is to identify and learn about innovation processes that have had an effect over socio-economic wellbeing of rural populations (poverty reduction with inclusion). The study and synthesis process will permit a deeper knowledge about the practices followed by people who innovate more and what do they do differently from others to produce something new. We expect to learn more about how existing environments (natural, social, cultural, human, political, economical) exercise influence over the occurrence or non-occurrence of an innovation process. Additionally, through mapping all the actors within the innovation processes with their links and synergies, we hope to better understand what actors participate in processes that result in poverty reduction with inclusion. Finally, we expect to identify the role agricultural policies in the region have on innovation systems. We want to understand if policies are encouraging, are becoming barriers to innovation or, are simply not working. Recommendations on how to move forward with innovation at regional level will come out of this analysis

Factores sociales que condicionan y limitan el impulso de iniciativas de turismo rural, promovidas por actores locales, en contextos de Nueva Ruralidad: La experiencia de la Asociación Artística Cultural Piel de Sal en Maras, Cusco

Desde el año 2010, un grupo de pobladores de Maras, en Cusco, impulsa una iniciativa de turismo que consiste en la revaloración de los activos culturales del pueblo, a través de la cultura viva y los talentos locales. Bajo el Marco de los Capitales Comunitarios, la presente investigación realiza un estudio de caso, con metodología cualitativa, a la iniciativa impulsada por la Asociación Artística Cultural Piel de Sal Maras para determinar los factores sociales que condicionan o limitan el impulso y la consolidación de iniciativas de Turismo Rural, impulsadas por los actores locales, en contextos de Nueva Ruralidad. Se evidencia que, para impulsar la actividad turística, es necesaria la construcción y gestión un capital social, que permita el desarrollo de la cohesión entre los pobladores/socios, así como la construcción de las conexiones que facilitan el acceso a los medios y canales de promoción y comercialización. Los capitales cultural y humano permiten asegurar los talentos, capacidades y competencias necesarias para la consolidación y la sostenibilidad de la experiencia y la propia construcción del capital social. El capital financiero, permite adaptar y mejorar activos, invirtiendo en mejoras que se traducen la calidad del servicio ofrecido y que, sumado a la implementación de los demás capitales logra asegurar la consolidación de la experiencia. Sin embargo, para lograr que el esfuerzo, asociado a la construcción de todos los capitales se traduzca en la sostenibilidad de las iniciativas, es necesario que el capital político, a nivel de instituciones que tienen un rol dentro de la actividad turística, trabajen de manera articulada y puedan generar las condiciones mínimas necesarias para que iniciativas turísticas, impulsadas por pobladores locales, puedan consolidarse y sostenerse en el tiempo

Frommelt Attitude Toward Care of the Dying Scale Form B: Validation for Spanish health professionals

The present study has been supported by the Spanish Ministry of Education through a University Faculty Training contract granted to R.H.H. (FPU15/02487).Objective. The aim of this study is to culturally adapt and validate the Frommelt Attitude Toward Care of the Dying Scale Form B (FATCOD-B) in Spanish health professionals. Method. A cultural adaptation and scale validation was carried out to evaluate the validity of appearance, content and construct, reliability and feasibility. The psychometric validation of the FATCOD-B was carried out on a sample of 2,446 Spanish physicians, nurses, psychologists, and social workers and students of these disciplines, between January 2017 and December 2018. This sample was selected by intentional sampling. Descriptive statistics were used to characterize the sample. An exploratory multi-group factor analysis was performed, internal consistency was evaluated by calculating Cronbach’s α and stability by test–retest. Results. A total of 2,446 people participated in the study, 1,134 students and 1,312 professionals. The exploratory multi-group factor analysis revealed a two-dimensional factor structure, with a total of 17 items retained in the model from the 30 of the original scale. The results showed that this version has adequate reliability (α = 0.79) and for each subscale, and stability (ICC = 0.843, p < 0.001). Significance of results. FATCOD has been used with physicians and nurses from different countries. However, no reports have been found in the literature of its use with psychologists and social workers. It is important to have an instrument that allows us to know the attitudes of these professionals since they are all directly involved in the care of patients at the end of their lives and their families. The Spanish version of FATCOD-B has proven to be a reliable and valid instrument for its use in Spanish health professionals while allowing comparisons between disciplines.Spanish Government FPU15/0248

Frailty, Complexity, and Priorities in the Use of Advanced Palliative Care Resources in Nursing Homes

Background and objectives: This study aimed to determine the frailty, prognosis, complexity, and palliative care complexity of nursing home residents with palliative care needs and define the characteristics of the cases eligible for receiving advanced palliative care according to the resources available at each nursing home. Materials and Methods: In this multi-centre, descriptive, and crosssectional study, trained nurses from eight nursing homes in southern Spain selected 149 residents with palliative care needs. The following instruments were used: the Frail-VIG index, the case complexity index (CCI), the Diagnostic Instrument of Complexity in Palliative Care (IDC-Pal), the palliative prognosis index, the Barthel index (dependency), Pfeiffer’s test (cognitive impairment), and the Charlson comorbidity index. A consensus was reached on the complexity criteria of the Diagnostic Instrument of Complexity in Palliative Care that could be addressed in the nursing home (no priority) and those that required a one-off (priority 2) or full (priority 1) intervention of advanced palliative care resources. Non-parametric tests were used to compare non-priority patients and patients with some kind of priority. Results: A high percentage of residents presented frailty (80.6%), clinical complexity (80.5%), and palliative care complexity (65.8%). A lower percentage of residents had a poor prognosis (10.1%) and an extremely poor prognosis (2%). Twelve priority 1 and 14 priority 2 elements were identified as not matching the palliative care complexity elements that had been previously identified. Of the studied cases, 20.1% had priority 1 status and 38.3% had priority 2 status. Residents with some kind of priority had greater levels of dependency (p < 0.001), cognitive impairment (p < 0.001), and poorer prognoses (p < 0.001). Priority 1 patients exhibited higher rates of refractory delirium (p = 0.003), skin ulcers (p = 0.041), and dyspnoea (p = 0.020). Conclusions: The results indicate that there are high levels of frailty, clinical complexity, and palliative care complexity in nursing homes. The resources available at each nursing home must be considered to determine when advanced palliative care resources are required

The influence of health care providers’ emotions on clinical judgment regarding diagnosis of the terminally ill

In Spain, the dying process is sometimes described as «bad» or even «awful». There are many reasons for this situation, the most important being the difficulties health care professionals have to face with death and their lack of ability to help and assist patients to go through the dying process. The influence of the current cultural context regarding death and the way people die is paired with other factors. These factors are both clinical and professional in nature such as for example: the moment of diagnosis of a terminally ill patient that entails important emotional implications for the health care professionals, the patient and their family. All these factors have a direct influence on the health care assistance. We conducted Grounded Theory-based, phenomenological, qualitative research using a final sample of 42 indepth interviews with doctors and nurses from different fields in Granada (Spain) in order to understand their point of view, as health care providers, on the assistance given to terminally ill patients. The results were analysed with Atlas-tí software using thematic coding. The results show the effect the emotional factor has on the clinical judgment of health care professionals and support the need for broader and more comprehensive study. En España, el proceso de morir se describe con frecuencia como «malo» o incluso como «muy malo». Entre los motivos, destacan las dificultades de los profesionales de la salud para afrontar la muerte y para asistir y acompañar en el proceso de morir a sus enfermos. A la influencia del contexto cultural actual en cuanto al sentido de la muerte y al modo de morir, se unen situaciones de carácter clínico y profesional como el momento del diagnóstico de una enfermedad terminal, con importantes implicaciones emocionales para el profesional, el enfermo y la familia, y un efecto directo en la respuesta asistencial a la situación. Planteamos un estudio cualitativo de tipo fenomenológico, fundamentado en la Grounded Theory, sobre una muestra final de 42 entrevistas en profundidad a médicos y enfermeros de diferentes ámbitos asistenciales de la provincia de Granada (España), para conocer, en su propio contexto, el punto de vista de los profesionales implicados en la atención al enfermo terminal. Los datos se analizaron con el software ATLAS.tí siguiendo una codificación temática. Los resultados muestran el efecto que el factor emocional tiene en el juicio clínico del profesional y justifican la necesidad de ampliar y profundizar en su estudio

A New Approach to the Identification of Palliative Care Needs and Advanced Chronic Patients among Nursing Home Residents

This research was supported by the Andalusian CICYE project AP-0105-2016.Results belong to one of the objectives for a Doctoral Tesis study of the Clinic Medicine and Public Health Doctoral Program of the University of Granada. We would like to thank all the participants and professionals who participated.Background: Proper planning of Palliative Care in nursing homes requires advanced knowledge of the care needs that residents show. The aim of the study was to evaluate Palliative Needs and other conditions such as fragility, complexity, and prognosis and also to suggest new indicators for the establishment of the resident's advanced chronic condition. Methods: Cross-sectional study conducted in 149 nursing homes Complex Chronic residents evaluated by trained professionals. Palliative Care Needs, assessed by the NECPAL ICO-CCOMS (c) tool, and fragility, case and palliative complexity and prognosis were evaluate through a comprehensive assessment. Descriptive analyses and association measures were performed setting the statistical significance at 0.05. Results: More than 50% of the residents had positive Surprise Question and other Palliative Needs and were classified as Advanced Chronic Patients. Distress and/or Severe Adaptative Disorder was the most frequent need shown by the residents and significant differences in levels of frailty and other characteristics, were found between the Positive and the Negative Surprise Question Groups. Statistically significant correlations were also found between aspects of both groups. Conclusions: Nursing homes residents show Palliative Needs regardless of the response to the Surprise Question of the NECPAL tool. Other characteristics such as presence of an intermediate level of frailty are suggested as a new perspective to identify advanced chronic patients among nursing homes residents.Junta de Andalucia AP-0105-201

Cultural Adaptation, Validation, and Analysis of the Self-Efficacy in Palliative Care Scale for Use with Spanish Nurses

The aim of the present study is to validate the Self-Efficacy in Palliative Care Scale (SEPC) in Spanish nursing professionals and students, to describe their levels of self-e cacy, and to determine the influencing factors. A validation study and a cross-sectional descriptive study were carried out, with the data analysed using contrast tests and multiple linear regression; 552 nurses and 440 nursing students participated. The Spanish version consists of 23 items and has a high degree of reliability (alpha = 0.944). Confirmatory factor analysis revealed one additional factor (i.e., management of psychosocial and spiritual aspects) in comparison to the original scale. Contrast tests revealed that the mean SEPC score was higher in professionals than in students (p < 0.001) and that the professionals who had higher levels of self-efficacy were older (p < 0.001), had more previous training (p < 0.001), and had more experience in end-of-life care (p = 0.001). The linear analysis results confirm a significant association between age and previous training in end-of-life care. The Spanish version of the SEPC is a reliable tool for both nursing professionals and students. The level of self-efficacy of both groups is moderate and is influenced by age, experience, and training in end-of-life care.The present study has been supported by the Spanish Ministry of Education through a University Faculty Training contract granted to RHH (FPU15/02487)

The concept of death in children aged from 9 to 11 years: Evidences through inductive and deductive analysis of drawings

The objective of the research was to analyze children’s conceptualization of death through drawings, using a mixed approach, which combines deductive and inductive qualitative analysis. The sample consisted of 99 children aged 9–11 years, who were asked to elaborate a drawing about their idea of death and to explain it to the researchers. Drawings were coded basing on Tamm and Granqvist’s model (deductive analysis) and codes and categories were created and modified (inductive analysis). Three main categories were identified in the analysis and four sub-categories were modified and/or created: causes of death, good death, anxiety-fear and symbolization

Prospective Evaluation of Intensity of Symptoms, Therapeutic Procedures and Treatment in Palliative Care Patients in Nursing Homes

The aim of the study is to evaluate the intensity of symptoms, and any treatment and therapeutic procedures received by advanced chronic patients in nursing homes. A multi-centre prospective study was conducted in six nursing homes for five months. A nurse trainer selected palliative care patients from whom the sample was randomly selected for inclusion. The Edmonton Symptoms Assessment Scale, therapeutic procedures, and treatment were evaluated. Parametric and non-parametric tests were used to evaluate month-to-month differences and differences between those who died and those who did not. A total of 107 residents were evaluated. At the end of the follow-up, 39 had (34.6%) died. All symptoms (p < 0.050) increased in intensity in the last week of life. Symptoms were more intense in those who had died at follow-up (p < 0.05). The use of aerosol sprays (p = 0.008), oxygen therapy (p < 0.001), opioids (p < 0.001), antibiotics (p = 0.004), and bronchodilators (p = 0.003) increased in the last week of life. Peripheral venous catheters (p = 0.022), corticoids (p = 0.007), antiemetics (p < 0.001), and antidepressants (p < 0.05) were used more in the patients who died. In conclusion, the use of therapeutic procedures (such as urinary catheters, peripheral venous catheter placement, and enteral feeding) and drugs (such as antibiotics, anxiolytics, and new antidepressant prescriptions) should be carefully considered in this clinical setting.This paper has been partially supported by the Junta de Andalucía, by project FQM-235 and the Andalusian CICYE project AP-0105-201

NUrsing Homes End of Life care Program (NUHELP): developing a complex intervention

This study has been totally funded by Consejeria de Salud, Junta de Andalucia (Fundacion Publica Andaluza Progreso y Salud, Proyecto AP-0105-2016). Funding has been received for data collection, analysis and interpretation of data and manuscript writing.Background: Nursing homes are likely to become increasingly important as end-of-life care facilities. Previous studies indicate that individuals residing in these facilities have a high prevalence of end-of-life symptoms and a significant need for palliative care. The aim of this study was to develop an end-of-life care program for nursing homes in Spain based on previous models yet adapted to the specific context and the needs of staff in nursing homes in the country. Methods: A descriptive study of a complex intervention procedure was developed. The study consisted of three phases. The first phase was a prospective study assessing self-efficacy in palliative care (using the SEPC scale) and attitudes towards end-of-life care (using the FATCOD-B scale) among nursing home staff before and after the completion of a basic palliative care training program. In the second phase, objectives were selected using the Delphi consensus technique, where nursing home and primary care professionals assessed the relevance, feasibility, and level of attainment of 42 quality standards. In phase 3, interventions were selected for these objectives through two focus group sessions involving nursing home, primary care, and palliative care professionals. Results: As a result of the training, an improvement in self-efficacy and attitudes towards end-of-life care was observed. In phase 2, 14 standards were selected and grouped into 5 objectives: to conduct a comprehensive assessment and develop a personalized care plan adapted to the palliative needs detected; to provide information in a clear and accessible way; to request and record advance care directives; to provide early care with respect to loss and grief; to refer patients to a specialized palliative care unit if appropriate, depending on the complexity of the palliative care required. Based on these objectives, the participants in the focus group sessions designed the 22 interventions that make up the program. Conclusions: The objectives and interventions of the NUHELP program constitute an end-of-life care program which can be implemented in nursing homes to improve the quality of end-of-life care in these facilities by modifying their clinical practice, organization, and relationship with the health system as well as serving as an example of an effective health intervention program.Consejeria de Salud, Junta de Andalucia (Fundacion Publica Andaluza Progreso y Salud) AP-0105-201