La importancia de lo narrativo en la práctica clínica e investigadora en atención primaria. Similitudes y diferencias entre ambos tipos de entrevista

Las técnicas de generación de información en las investigaciones cualitativas se pueden clasificar en 3 grupos: las técnicas de conversación y narración, las técnicas de observación y participación y las técnicas de lectura y documentación. El objetivo de este artículo es mostrar cuales son las similitudes y las diferencias existentes entre las técnicas que realizan en la práctica diaria los profesional de atención primaria y las técnicas conversacionales de investigación, así como ver los puntos fuertes y los débiles que tienen los profesionales de atención primaria a la hora de enfrentarse a las técnicas conversacionales de investigación cualitativa. En el caso de la entrevista de investigación, existen diferentes tipos de entrevista y dependerá de los objetivos de la investigación, que optemos por una u otra. Los tres tipos básicos de entrevista son la estructurada, la semiestructurada y la abierta. Además, las entrevistas de investigación pueden ser individuales o grupales. En las entrevistas grupales, podemos diferenciar los grupos de discusión y los grupos focales. En el ámbito de la atención primaria son destacables las prácticas como la entrevista clínica y los grupos de educación para la salud. Las entrevistas clínicas y las entrevistas de investigación individuales, así como los grupos de educación para la salud realizados en atención primaria y las entrevistas de investigación grupales tienen elementos en común. Por ejemplo, tanto en atención primaria como en investigación cualitativa, el tipo de entrevista más utilizado es la semiestructurada. Aunque la investigación cualitativa se caracterice por aspectos como la flexibilidad, la circularidad y la reflexividad, no implica que ninguna de sus fases deba ser confusa y descuidada. Así, las entrevistas de investigación, tanto sean individuales como grupales, se deberán planificar siempre según el diseño de la investigación que estamos llevando a cabo. La mirada cualitativa no deja de estar siempre presente en la buena práctica clínica, lo cual sitúa al profesional de atención primaria en una situación de partida favorable para su implicación en la investigación cualitativa. La paciencia, la escucha activa y la suspensión del saber sanitario durante la entrevista de investigación son uno de los mejores caminos para acercarse a la comprensión de lo que nos dicen los entrevistados, desde sus propias concepciones y no desde las de los profesionales sanitarios. En conclusión, en el ámbito sanitario y, concretamente, en el de la atención primaria, encontramos actividades profesionales como las entrevistas clínicas o los grupos de educación para la salud. Estas prácticas profesionales conllevan unas habilidades que, al sanitario, le pueden ayudar en la realización de entrevistas en el marco de una investigación. Aun así, es preciso formarse en la disciplina de entrevistar, tanto si se entrevista a una persona sola o a un grupo, además de tener ciertas aptitudes y actitudes que ayuden al investigador en la difícil tarea de conseguir la información que necesita para contestar a los interrogantes de su investigación

Complex multiple risk intervention topromote healthy behaviours in peoplebetween 45 to 75 years attended inprimary health care (EIRA study): study protocol for a hybrid trial

Background:Health promotion is a key process of current health systems. Primary Health Care (PHC) is the idealsetting for health promotion but multifaceted barriers make its integration difficult in the usual care. The majority ofthe adult population engages two or more risk behaviours, that is why a multiple intervention might be moreeffective and efficient. The primary objectives are to evaluate the effectiveness, the cost-effectiveness andan implementation strategy of a complex multiple risk intervention to promote healthy behaviours in peoplebetween 45 to 75 years attended in PHC.Methods:This study is a cluster randomised controlled hybrid type 2 trial with two parallel groups comparing acomplex multiple risk behaviour intervention with usual care. It will be carried out in 26 PHC centres in Spain. Thestudy focuses on people between 45 and 75 years who carry out two or more of the following unhealthybehaviours: tobacco use, low adherence to the Mediterranean dietary pattern or insufficient physical activity level.The intervention is based on the Transtheoretical Model and it will be made by physicians and nurses in theroutine care of PHC practices according to the conceptual framework of the“5A’s”. It will have a maximum durationof 12 months and it will be carried out to three different levels (individual, group and community). Incremental costper quality-adjusted life year gained measured by the tariffs of the EuroQol-5D questionnaire will be estimated. Theimplementation strategy is based on the“Consolidated Framework for Implementation Research”, a set of discreteimplementation strategies and an evaluation framework. Discussion:EIRA study will determine the effectiveness and cost-effectiveness of a complex multiple riskintervention and will provide a better understanding of implementation processes of health promotioninterventions in PHC setting. It may contribute to increase knowledge about the individual and structural barriersthat affect implementation of these interventions and to quantify the contextual factors that moderate theeffectiveness of implementation

Previous antibiotic exposure and antibiotic resistance of commensal Staphylococcus aureus in Spanish primary care

Introduction: Commensal flora of healthy people is becoming an important reservoir of resistant bacteria. Objectives: To evaluate the relationship of previous antibiotic-dispensed and resistance pattern of strains of Staphylococcus aureus in primary care patients. Methods: A cross-sectional study was carried out in seven primary care centres in Catalonia, Spain, from October 2010 to May 2011, as part of the APRES (The appropriateness of prescribing antibiotics in primary care in Europe concerning antibiotic resistance) study. Outpatients aged 4 or more who did not present an infectious disease and had not taken antibiotic or had not been hospitalised in the previous 3 months were invited to participate. Nasal swabs were collected for S. aureus culture, and antimicrobial susceptibility testing was carried out. Antibiotics dispensed boxes in the previous 4 years were extracted from Information System for Research in Primary Care. Results: A total of 4,001 nasal swabs were collected, and 3,969 were tested for identification, 765 S. aureus were tested for resistance. Resistance rates to penicillin, azithromycin and methicillin were 87.1%, 11.6% and 1.3%, respectively, and a total of 10 MRSA strains were isolated (1.3%). Penicillin-resistant staphylococci were statistically significantly associated with the previous number of packages of penicillin dispensed (OR, 1.18; 95% CI, 1.04-1.35). Conclusion: Although no causal inference is possible, an association was observed between previous antibiotic dispensation and isolation of resistant organisms in community-dwelling individuals, mainly between packages of penicillin and penicillin-resistant staphylococci

Methodological limitations and recommendations in publications on migrant population health in Spain

El objetivo es describir las limitaciones y las recomendaciones metodológicas identificadas por los autores de artículos originales sobre inmigración y salud en España. Se realizó una revisión bibliográfica de artículos originales publicados en español e inglés entre 1998 y 2012, combinando descriptores de inmigración y salud. Se incluyeron 311 artículos; de ellos, 176 (56,6%) mencionaban limitaciones y 15 (4,8%) emitían recomendaciones. Entre las limitaciones más mencionadas destacan el reducido tamaño de las muestras, problemas de validez interna y representatividad de la muestra con infrarrepresentación o sobrerrepresentación de determinados grupos, problemas de validez de la información recogida y datos faltantes relacionados sobre todo con los instrumentos de medición, y ausencia de variables clave de ajuste o estratificación. En función de los resultados obtenidos, se proponen una serie de recomendaciones para minimizar las limitaciones habituales y avanzar en la calidad de los trabajos científicos sobre inmigración y salud en nuestro ámbito.Our objective was to describe the methodological limitations and recommendations identified by authors of original articles on immigration and health in Spain. A literature review was conducted of original articles published in Spanish or English between 1998 and 2012 combining keywords on immigration and health. A total of 311 articles were included; of these, 176 (56.6%) mentioned limitations, and 15 (4.8%) made recommendations. The most frequently mentioned limitations included the following: reduced sample sizes; internal validity and sample representativeness issues, with under- or overrepresentation of specific groups; problems of validity of the collected information and missing data mostly related to measurement tools; and absence of key variables for adjustment or stratification. Based on these results, a series of recommendations are proposed to minimise common limitations and advance the quality of scientific production on immigration and health in our setting.El Subprograma Inmigración y Salud (SIS) del CIBER de Epidemiología y Salud Pública (CIBERESP) financió la realización de la revisión bibliográfica. La Sociedad Española de Epidemiología (SEE) financió los gastos derivados de la publicación

Barriers and Facilitators for the Implementation of Primary Prevention and Health Promotion Activities in Primary Care : A Synthesis through Meta-Ethnography

Evidence supports the implementation of primary prevention and health promotion (PP&HP) activities but primary care (PC) professionals show resistance to implementing these activities. The aim was to synthesize the available qualitative research on barriers and facilitators identified by PC physicians and nurses in the implementation of PP&HP in adults. A systematic search of three databases was conducted and supported by manual searches. The 35 articles included were translated into each other and a new interpretation of the concepts extracted was generated. The factors affecting the implementation of PP&HP activities in PC according to professionals were fitted into a five-level ecological model: intrapersonal factors, interpersonal processes, institutional factors, community factors and public policy. At the intrapersonal level we find professionals' beliefs about PP&HP, experiences, skills and knowledge, and selfconcept. The attitudes and behavior towards PP&HP of patients, specialists, practice managers and colleagues (interpersonal factors) affect the feasibility of implementing PP&HP. Institutional level: PC is perceived as well-placed to implement PP&HP but workload, lack of time and referral resources, and the predominance of the biomedical model (which prioritizes disease treatment) hamper the implementation of PP&HP. The effectiveness of financial incentives and tools such as guidelines and alarms/reminders is conditioned by professionals' attitudes to them. Community factors include patients' social and cultural characteristics (religion, financial resources, etc.), local referral resources, mass-media messages and pharmaceutical industry campaigns, and the importance given to PP&HP in the curriculum in university. Finally, policies affect the distribution of resources, thus affecting the implementation of PP&HP. Research on barriers and facilitators in the implementation of PP&HP activities in multirisk management is scarce. The conceptual overview provided by this synthesis resulted in the development of practical recommendations for the design of PP&HP in PC. However, the effectiveness of these recommendations needs to be demonstrated

I have intention to get a mammogram: Stages of adoption for monitoring mammography in women of different social and cultural background

Objetivo: Describir el estadio de adopción en cuanto a la toma de decisión de hacerse controles regulares de cáncer de mama en mujeres de distinto origen sociocultural residentes en Barcelona en el año 2009. Métodos: Encuesta transversal realizada a una muestra de 960 mujeres de 45 a 69 años residentes en Barcelona en el año 2009 autóctonas e inmigrantes de países en vías de desarrollo. Se desarrolló un cuestionario telefónico. Las variables dependientes fueron los estadios de adopción en que se encontraban las mujeres según el Modelo Transteórico de las etapas de cambio: precontemplación, contemplación, acción, mantenimiento y recaída. Las variables independientes fueron: país de origen, clase social, edad, tiempo de estancia en el país de acogida, conocimiento del idioma, tener hijos, antecedentes familiares de cáncer y nivel de estudios. Se realizó un análisis descriptivo y se estimaron modelos de regresión de Poisson robusta para cada estadio con el fin de obtener las razones de prevalencia según las variables independientes y modelos multivariados para comparar los distintos estadios versus el de mantenimiento. Resultados: El 90% de las mujeres autóctonas se sitúan en el estadio de mantenimiento, 73% de las Latinoamericanas, 41% de las de Europa del Este, 47% de las chinas (47%), 58% de las filipinas, 70% de las magrebíes y 80% de las indopakistaníes. Conclusiones: Es necesario mejorar el conocimiento del cáncer de mama y su prevención trabajando conjuntamente con personas del propio colectivo sobretodo en el caso de las mujeres chinas, filipinas y de Europa del Este.Objective: To describe the stage of adoption in terms of decision making regular checkups for breast cancer in women of different sociocultural backgrounds living in Barcelona in 2009. Methods: A cross-sectional survey of a sample of 960 women aged 45 to 69 years living in Barcelona in 2009, native and immigrants from developing countries. We developed a telephone questionnaire. The dependent variables were the stages of adoption in which women were under the Transtheoretical Model: precontemplation, contemplation, action, maintenance and relapse. The independent variables were: Country of origin, social class, age, length of stay in the host country, language skills, have children, family history of cancer and educational level. We performed a descriptive analysis and regression models were estimated robust Poisson each stage in order to obtain the prevalence ratios as independent variables and multivariate models to compare the different stages versus maintenance. Results: Ninety percent of native women are in the maintenance stage, 73% of Latin American, 41% of Eastern Europe, 47% of Chinese (47%), 58% of the Philippines, 70% of Maghrebi and 80% of Pakistani-Indian. Conclusions: To improve knowledge of breast cancer and its prevention by working with people from the community itself especially in the case of Chinese women, Filipino and Eastern European women

Are we leaving someone behind? A critical discourse analysis on the understanding of public participation among people with experiences of participatory research

Participatory research (PR) is on the rise. In Spain, PR is scarce in the field of health, although there is an increasing interest in the matter. A comprehensive understanding of the meanings and practical implications of "public participation" is essential to promote participation in health research. The aim of the study is to explore the discursive positions on PR among individuals with experience in participatory processes in different areas and how this understanding translates into practice. We conducted a critical discourse analysis of 21 individuals with experience in PR and participatory processes (13 women, 8 men), mainly from the field of health and other areas of knowledge. Sixteen were Spanish and the rest were from the United Kingdom (3), United States (1), and Canada (1). Interviews were conducted in person or by telephone. The fieldwork was conducted between March 2019 and November 2019. The dominant discourses on public participation are situated along two axes situated on a continuum: the purpose of public participation and how power should be distributed in public participation processes. The first is instrumental public participation, which sees participatory research as a tool to improve research results and focuses on institutional interests and power-decision making is hold by researchers and institutions. The second, is transformative public participation, with a focus on social change and an equitable sharing of decision-making power between the public and researchers. All discursive positions stated that they do not carry out specific strategies to include the most socially disadvantaged individuals or groups. A shift in the scientific approach about knowledge, along with time and resources, are required to move towards a more balanced power distribution in the processes involving the public

La participación ciudadana en la investigación desde la perspectivade investigadores de atención primaria

Objetivo: Explorar las debilidades, amenazas, fortalezas y oportunidades (DAFO) para el desarrollo de la participación de la ciudadanía en los proyectos de investigación gestionados por el Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAPJGol) según los investigadores de atención primaria de salud de Catalu ̃na.Método: Estudio transversal realizado en 2017 con 36 equipos de investigación de atención primaria de salud acreditados por el IDIAPJGol y su personal de gestión. Se dise ̃nó y pilotó un cuestionario abierto(papel y online) para desarrollar una técnica DAFO. Se obtuvieron 65 respuestas (14 en papel y 51 online).Se realizó un análisis de contenido temático.Resultados: La mayoría de informantes considera la participación de la ciudadanía en la investigació nuna estrategia útil, innovadora, viable e imprescindible, pero exige un cambio de mentalidad y un alejamiento del paradigma jerárquico. Puede ser difícil su ejecución y complicar los estudios. Les preocupa a qué ciudadanos implicar, cómo seleccionarlos, los posibles conflictos de intereses y las necesidades deformación. Las principales propuestas para su implementación son difundir estrategias previas, fomentar la motivación y las sinergias entre ciudadanos, investigadores e instituciones, y clarificar los roles delos actores implicados. El IDIAPJGol debería elaborar recomendaciones para la participación de la ciudadanía en la investigación, incentivar su inclusión, disponer de un referente y asesorar a los equipos investigadores. Conclusiones: A pesar de los retos, desarrollar la participación de la ciudadanía en la investigación en atención primaria de salud es imprescindible y factible, pero partiendo de una estrategia participativa con todos los actores. La ciudadanía puede participar en cualquier dise ̃no y fase de la investigación adaptando cada proyecto, siendo la atención primaria un ámbito privilegiado para desarrollar la participación ciudadana en la investigación.Objective: Explore the strengths, weaknesses, opportunities and threats (SWOT) for development of public involvement in research by Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAPJGol) according to primary health care researchers in Catalonia (Spain). Methods: Cross-sectional study carried out in 2017 with 36 primary health care research teams accredited by IDIAPJGol and its management staff. An open questionnaire (paper and online) was designed and piloted to develop a SWOT technique, and 65 answers were obtained (14 in paper and 51 online). A thematic content analysis was carried out. Results: Most informants consider public involvement in research a useful, innovative, viable and essential strategy, but it requires a change of mentality and a move away from the hierarchical paradigm. It can be difficult to execute and can complicate studies. They are concerned about which citizens should be involve, how to select them, possible conflicts of interest and training needs. The main proposals for its implementation are to disseminate previous strategies, encourage motivation and synergies among citizens, researchers and institutions, and to clarify the roles of the actors involved. IDIAPJGol should develop recommendations for the public involvement in research, encourage their inclusion, have a mentor and advise the research teams. Conclusions: Despite the challenges, developing public involvement in research in primary health care is essential and feasible, what it is more should be based on a participatory strategy with all actors. The citizens can participate in any kind of design and phase of the research, adapting each project, being the primary health care a privileged area to develop the public involvement in research

Multimorbidity patterns with K-means nonhierarchical cluster analysis

This is the final version. Available on open access from BMC via the DOI in this recordAvailability of data and materials: The datasets are not available because researchers have signed an agreement with the Information System for the Development of Research in Primary Care (SIDIAP) concerning confidentiality and security of the dataset that forbids providing data to third parties. This organization is subject to periodic audits to ensure the validity and quality of the data.BACKGROUND: The purpose of this study was to ascertain multimorbidity patterns using a non-hierarchical cluster analysis in adult primary patients with multimorbidity attended in primary care centers in Catalonia. METHODS: Cross-sectional study using electronic health records from 523,656 patients, aged 45-64 years in 274 primary health care teams in 2010 in Catalonia, Spain. Data were provided by the Information System for the Development of Research in Primary Care (SIDIAP), a population database. Diagnoses were extracted using 241 blocks of diseases (International Classification of Diseases, version 10). Multimorbidity patterns were identified using two steps: 1) multiple correspondence analysis and 2) k-means clustering. Analysis was stratified by sex. RESULTS: The 408,994 patients who met multimorbidity criteria were included in the analysis (mean age, 54.2 years [Standard deviation, SD: 5.8], 53.3% women). Six multimorbidity patterns were obtained for each sex; the three most prevalent included 68% of the women and 66% of the men, respectively. The top cluster included coincident diseases in both men and women: Metabolic disorders, Hypertensive diseases, Mental and behavioural disorders due to psychoactive substance use, Other dorsopathies, and Other soft tissue disorders. CONCLUSION: Non-hierarchical cluster analysis identified multimorbidity patterns consistent with clinical practice, identifying phenotypic subgroups of patients.The project has been funded by the Instituto de Salud Carlos III of the Ministry of Economy and Competitiveness (Spain) through the Network for Prevention and Health Promotion in Primary Health Care (redIAPP, RD12/0005), by a grant for research projects on health from ISCiii (PI12/00427) and co-financed with European Union ERDF funds). Jose M. Valderas was supported by the National Institute for Health Research Clinician Scientist Award NIHR/CS/010/024