Efectividad de intervenciones en promoción de la salud y salud pública: Lecciones de casos latinoamericanos

The issue of evidence of effectiveness in public health and health promotion has occupied the attention of academics, technicians, and politicians who recognize not only its importance but the challenges that researchers must confront to obtain reliable and useful information to base public policy decisions and investment of resources. Despite the emergence of Latin American initiatives aimed at building the capacity to obtain such evidence of effectiveness, the practice is still incipient in the region and there are few relevant publications. This article is presented as a contribution and stimulus to further motivate the ongoing search for information and knowledge, concerning the relevance and scope of the practice of public health and health promotion to address adverse health conditions. For this purpose, a review of the literature was carried out, along with the compilation, documentation, and analysis of various cases of Latin American evaluations. From the product of this analysis, proposals are presented for strengthening the theoretical and evaluative practices in Latin America. El tema de evidencias de efectividad en promoción de la salud y salud pública ha ocupado la atención de académicos, técnicos y políticos, quienes reconocen no sólo su importancia, sino los desafíos que hay que enfrentar para obtener información confiable y útil que fundamente decisiones en política pública e inversión de recursos. Pese a diversas iniciativas latinoamericanas orientadas a la construcción de capacidad para obtener dichas evidencias de efectividad, esta práctica es aún incipiente en la región y son escasas las publicaciones al respecto. Este artículo surge como una contribución y una provocación para motivar la búsqueda permanente de información y conocimiento sobre la pertinencia y alcance de la práctica de la salud pública y la promoción de la salud, la comprensión de los procesos de implementación de las políticas y programas y la valoración de los resultados. Para esto, se ha realizado una revisión de literatura, así como recopilación, documentación y análisis de diversos casos de evaluación latinoamericanos. Como producto del análisis se presentan propuestas para el fortalecimiento de la teoría y la práctica evaluativa en Latinoamérica

Linking public health surveillance systems to program effectiveness evaluation

Objetivo: Se presenta la teoría, métodos y resultados de la evaluación de efectividad de una intervención para prevenir y controlar enfermedades crónicas no transmisibles (ECNT), aplicando un modelo de evaluación de efectividad de intervenciones basado en resultados de sistemas de vigilancia de factores de riesgo (FR), asociados con ECNT. La intervención evaluada corresponde a una estrategia poblacional para promocionar actividad física en la ciudad de Cali, Colombia. La evaluación utilizó los resultados del Sistema de Vigilancia de Factores de Riesgo Asociados con ECNT (SIFREC), desarrollado en Cali, así como otras fuentes de información cuantitativas y cualitativas. Métodos: El modelo de evaluación aplicado valoró la efectividad de las intervenciones con base en dos indicadores de resultados: cambios en prevalencias de FR asociados con ECNT y creación de capacidad institucional para abordar los problemas identificados. Se valoró la significancia estadística de los cambios observados en las prevalencias de FR, al igual que la calidad y el desempeño, tanto del diseño como de la implementación de la intervención. También consideró la utilidad de la información para planificar intervenciones y motivar la acción intersectorial alrededor de las ECNT. Otras variables centrales del modelo aplicado incluyen la adherencia al protocolo, la fundamentación de los cambios encontrados, variables de contexto que influyeron tanto los resultados como la implementación de la intervención y la suficiencia del tiempo para visualizar los cambios esperados. Resultados: El Modelo de Evaluación de Efectividad desarrollado permitirá que se superen limitaciones técnicas y vacíos metodológicos para obtener evidencia de efectividad de las intervenciones. Se incrementará el uso de los resultados de los sistemas de vigilancia de ECNT y se hará viable y sostenible la evaluación de efectividad de intervenciones en salud pública. Conclusión: El modelo de evaluación basado en resultados de vigilancia es una alternativa para convertir la vigilancia en una estrategia de salud pública, rebasando su concepción instrumental tradicional y convirtiéndose en insumo crítico para la formulación de políticas públicas. The formal theory, methodological approach, and results of the effectiveness evaluation of a public health intervention is presented using information from public health surveillance systems and utilizing examples from interventions seeking to prevent and control chronic non-transmittable diseases (CNTD). Objective: The effectiveness of the «Cali in Motion» program was evaluated; the objective was to reduce the prevalence of cardiovascular disease in the city of Cali, Colombia. Effectiveness was assessed by the percentage of reduction in the prevalence of physical inactivity as a risk factor for cardiovascular disease. Additionally, other criteria were considered as intermediate indicators of the success of the intervention: building institutional capacity to produce and use information in action planning across disciplines concerning CNTD. The attribution of changes to the intervention was established by taking into account criteria such as: adherence to protocol, the bases for the changes found, contextual variables that influenced both outcomes and the implementation of the intervention, and the adequacy of time for the expected changes to become evident. Method: The evaluation model combines both qualitative and quantitative information to judge the effectiveness of the intervention on a scale constructed from four variables related to quality of design and implementation of the intervention, statistical significance of changes in the prevalence of risk factors, and attribution of the changes to the intervention according to the previously noted variables. Data on the changes in the prevalence of physical inactivity were obtained from the Surveillance System of Risk Factors Associated with CNTD (SIFREC) during the period of 2005-2007, and the qualitative information was obtained by systematizing the interventions. The study population was 1,385,470 individuals over 18 years of age; after correcting for design effect and taking into account an estimated prevalence of the event, p=50%; maximum sampling error of 4.4% (e); 95% confidence level (Z=1.96); and non-response rate was estimated at 1,080 subjects sampled, but the completed surveys totaled 927. For the processing and analysis of quantitative information, the EpiInfo program (version 3.4) was used, along with the module for population surveys by Stata (version 9) and Answer Tree by SPSS® (version 15). The qualitative data analysis was performed by using the contrasting results technique for the variables studied. Results: Although the intervention was not effective in reducing the prevalence of sedentary lifestyles; and, on the contrary, it increased between 2005 and 2007, going from 73.4% to 79.5%, respectively, with CI (76.41-82.31); it did show important changes in institutional capacity to address the chronic problem of chronics by controlling risk factors such as sedentary lifestyle. Conclusion: The evaluation model based on results from a surveillance system is an alternative to account for the effectiveness of public health interventions, as well as to change surveillance into a public health strategy, going beyond its traditional instrumental conceptualization and becoming a critical input to public policy formulation

Between insurgents and loyal: the construction of political citizenship. Venezuela, 1808-1830

In the context of a renewed political and cultural history that makes visible other topics, other practices and other actors are attending a renaissance of the same. Thus, social history of power opens spaces for discussion and reflection to mean the material and symbolic processes related to the actors who interact in networks of relationships. In this perspective, the formation of new political communities in Latin America, in the context of the crisis of Hispanic monarchy, and consequently the transition to political modernity, occupies the attention and is subject of particular interest to explain other attitudes, other behaviors and other values. Thus, this paper deals the construction of political citizenship during the first decades of the nineteenth century in Venezuela. Interest focuses on the scope and limits of forms of political representation of choice, participation, and consequently of integration into political life. This approach allows demonstrate how, from different political positions assumed progressively assumed a new political culture, that seeks to legitimize the relationship rulers and ruled once declared the crisis in the Hispanic monarchy.Keywords: Venezuela, monarchical crisis, political citizenshipEn el contexto de una historia política y cultural renovada que visibiliza otros temas, otras prácticas y otros actores se asiste a un renacimiento de la misma. De esta manera, la historia social del poder abre espacios de discusión y reflexión para significar los procesos materiales y simbólicos que relacionan a los actores que interactúan en redes de relaciones. En esta perspectiva, la constitución de nuevas comunidades políticas en Iberoamérica, en el contexto de la crisis de la monarquía hispánica, y en consecuencia, el tránsito hacia la modernidad política, ocupa la atención, y es tema de interés particular para explicar otras actitudes, otros comportamientos y otros valores. Así, este artículo se ocupa de la construcción de la ciudadanía política durante las primeras décadas del siglo XIX en Venezuela. El interés se centra en los alcances y límites de las formas de representación política, de elección, de participación y de opinión, y en consecuencia, de integración a la vida política. Esta aproximación permite demostrar cómo desde las diferentes posturas políticas asumidas se resignifica progresivamente una nueva cultura política, que busca legitimar la relación gobernantes y gobernados una vez declarada la crisis de la monárquica hispánica.Palabras clave: Venezuela, crisis monárquica, ciudadanía política   

Between insurgents and loyal: the construction of political citizenship. Venezuela, 1808-1830

In the context of a renewed political and cultural history that makes visible other topics, other practices and other actors are attending a renaissance of the same. Thus, social history of power opens spaces for discussion and reflection to mean the material and symbolic processes related to the actors who interact in networks of relationships. In this perspective, the formation of new political communities in Latin America, in the context of the crisis of Hispanic monarchy, and consequently the transition to political modernity, occupies the attention and is subject of particular interest to explain other attitudes, other behaviors and other values. Thus, this paper deals the construction of political citizenship during the first decades of the nineteenth century in Venezuela. Interest focuses on the scope and limits of forms of political representation of choice, participation, and consequently of integration into political life. This approach allows demonstrate how, from different political positions assumed progressively assumed a new political culture, that seeks to legitimize the relationship rulers and ruled once declared the crisis in the Hispanic monarchy.Keywords: Venezuela, monarchical crisis, political citizenshipEn el contexto de una historia política y cultural renovada que visibiliza otros temas, otras prácticas y otros actores se asiste a un renacimiento de la misma. De esta manera, la historia social del poder abre espacios de discusión y reflexión para significar los procesos materiales y simbólicos que relacionan a los actores que interactúan en redes de relaciones. En esta perspectiva, la constitución de nuevas comunidades políticas en Iberoamérica, en el contexto de la crisis de la monarquía hispánica, y en consecuencia, el tránsito hacia la modernidad política, ocupa la atención, y es tema de interés particular para explicar otras actitudes, otros comportamientos y otros valores. Así, este artículo se ocupa de la construcción de la ciudadanía política durante las primeras décadas del siglo XIX en Venezuela. El interés se centra en los alcances y límites de las formas de representación política, de elección, de participación y de opinión, y en consecuencia, de integración a la vida política. Esta aproximación permite demostrar cómo desde las diferentes posturas políticas asumidas se resignifica progresivamente una nueva cultura política, que busca legitimar la relación gobernantes y gobernados una vez declarada la crisis de la monárquica hispánica.Palabras clave: Venezuela, crisis monárquica, ciudadanía política   

Juicios de residencia en el gobierno provincial de Maracaibo, 1765-1810

Se estudia el juicio de residencia en la dinámica social y política de Maracaibo como capital provincial en el contexto de las relaciones de obediencia, dependencia y subordinación a la imagen sacralizada del rey y a los cuerpos sociales, comunidades y grupos a los cuales pertenece el residenciado. Se consideran la autoridad y el poder en el marco de normas, códigos y valores propios de la sociabilidad tradicional del Antiguo Régimen, así como la diversidad de vínculos que relacionaban e integraban jerárquicamente al colectivo, para explicar la complejidad del funcionamiento y socialización del poder local en el ejercicio del gobierno provincial de Maracaibo durante los años 1765 a 1810

Complexity around the Colombian Childhood Cancer Law: Requirements for its Evaluation

Introduction: The complexity of health problems such as childhood cancer poses challenges in health care and in the evaluation of interventions. This situation is aggravated when policy makers and decision makers assume that a health system works in a delimited environment with defined rules. Addressing the problem of cancer in children in Colombia required the enactment of a law to contribute to the reduction of mortality from this cause. This study characterized its complex nature, evidenced the potential implications in its evaluation and proposes an evaluation scheme. Methods: Documentary research with related information available between the years 2010 and 2020. Bowen's guidelines for the analysis of the information were followed, the categories included were relevant actors, context, components, organizational levels involved and results. Results: The analysis of the problem made visible the influence of the social determinants of health, the interaction of multiple actors in various scenarios and a high degree of uncertainty in a complex health system. The response is a complex intervention, with multiple components and actors involved at different levels to achieve the proposed results. Conclusion: Evaluating this intervention implies context-sensitive approaches, a clear definition of the problem and identification of the underlying theory necessary to achieve the expected results; establishing its evaluability provides important inputs to reorient its scope and transferability; the active participation of decision makers is key to advancing in the response to the challenges encountered Keywords: Evaluation of Health Programs and Projects, neoplasms, public policy.          Introduction: The complexity of health problems such as childhood cancer poses challenges in health care and in the evaluation of interventions. This situation is aggravated if policy makers and decision makers assume that a healthcare system works in a delimited environment with defined rules. The approach to childhood cancer in Colombia required the promulgation of a law to contribute to the reduction of mortality from this cause with implications for nursing. This study characterized its complex nature, evidenced the potential implications in its evaluation and proposed an evaluation scheme. Methods: Documentary research with related information available between the years 2010 and 2020. Bowen's guidelines for the analysis of the information were followed, the categories included were relevant actors, context, components, organizational levels involved and results. Results: The analysis of the problem made visible the influence of the social determinants of health, the interaction of multiple actors in various scenarios and a high degree of uncertainty in a complex health system. The response is a complex intervention with multiple components and actors involved at different levels to achieve the proposed results. Conclusion: Evaluating this intervention implies context-sensitive approaches, a clear definition of the problem and identification of the underlying theory necessary to achieve the expected results; Establishing its evaluability provides important inputs to reorient its scope and its transferability

Complexity around the Colombian Childhood Cancer Law: Requirements for its Evaluation

Introduction: The complexity of health problems such as childhood cancer poses challenges in health care and in the evaluation of interventions. This situation is aggravated when policy makers and decision makers assume that a health system works in a delimited environment with defined rules. Addressing the problem of cancer in children in Colombia required the enactment of a law to contribute to the reduction of mortality from this cause. This study characterized its complex nature, evidenced the potential implications in its evaluation and proposes an evaluation scheme. Methods: Documentary research with related information available between the years 2010 and 2020. Bowen's guidelines for the analysis of the information were followed, the categories included were relevant actors, context, components, organizational levels involved and results. Results: The analysis of the problem made visible the influence of the social determinants of health, the interaction of multiple actors in various scenarios and a high degree of uncertainty in a complex health system. The response is a complex intervention, with multiple components and actors involved at different levels to achieve the proposed results. Conclusion: Evaluating this intervention implies context-sensitive approaches, a clear definition of the problem and identification of the underlying theory necessary to achieve the expected results; establishing its evaluability provides important inputs to reorient its scope and transferability; the active participation of decision makers is key to advancing in the response to the challenges encountered Keywords: Evaluation of Health Programs and Projects, neoplasms, public policy.          Introduction: The complexity of health problems such as childhood cancer poses challenges in health care and in the evaluation of interventions. This situation is aggravated if policy makers and decision makers assume that a healthcare system works in a delimited environment with defined rules. The approach to childhood cancer in Colombia required the promulgation of a law to contribute to the reduction of mortality from this cause with implications for nursing. This study characterized its complex nature, evidenced the potential implications in its evaluation and proposed an evaluation scheme. Methods: Documentary research with related information available between the years 2010 and 2020. Bowen's guidelines for the analysis of the information were followed, the categories included were relevant actors, context, components, organizational levels involved and results. Results: The analysis of the problem made visible the influence of the social determinants of health, the interaction of multiple actors in various scenarios and a high degree of uncertainty in a complex health system. The response is a complex intervention with multiple components and actors involved at different levels to achieve the proposed results. Conclusion: Evaluating this intervention implies context-sensitive approaches, a clear definition of the problem and identification of the underlying theory necessary to achieve the expected results; Establishing its evaluability provides important inputs to reorient its scope and its transferability

Acessibilidade Digital em Ambientes Virtuais de Aprendizagem: uma Revisão Sistemática

Information and Communication Technologies are present in people's daily lives, causing changes in entertainment, professional personal contact, and learning. E-learning courses use these resources through Virtual Learning Environments. In this context, it is essential that this environment has accessibility resources so that people with disabilities can also follow the course. This article aims to 1) To identify the studies that are being carried out with the objective of providing digital accessibility in E-learning courses; 2) To compare the selected studies to verify possible common characteristics between the researches; 3) To present the results of the analysis done, showing the similarities and differences between the researches analyzed. A systematic review was carried out with articles, using as descriptors: "Virtual learning environment", "Accessibility" and "Disability", in which 14 articles were selected. The review found that most of the studies analyzed include people with visual impairments, use Moodle as a Virtual Learning Environment, and it was identified that the W3C and WCAG accessibility guidelines are considered in almost all articles studied. Developing proposals for accessible courses requires a multidisciplinary team, with accessibility planning from its conception. This avoids rework, costs, and expands the accessibility culture. Despite the presented studies, it is observed that accessibility in E-learning courses will still have a long way to go. Keywords: E-learning. Moodle. Inclusion.  As Tecnologias da Informação e Comunicação estão presentes na vida diária das pessoas, provocando transformações no entretenimento, contato pessoal profissional e aprendizado. Cursos à distância, empregam esses recursos, por meio de Ambientes Virtuais de Aprendizagem. Neste contexto é essencial que esse ambiente possua recursos de acessibilidade para que pessoas com deficiência também possam acompanhá-lo. Este artigo tem por objetivos 1) Identificar os estudos que estão sendo realizados com o objetivo de fornecer acessibilidade digital nos cursos à distância; 2) Comparar os trabalhos selecionados para verificar possíveis características comuns às pesquisas; 3) Apresentar os resultados da comparação feita, mostrando as semelhanças e diferenças entre as pesquisas analisadas. Foi realizada uma revisão sistemática com artigos, utilizando como descritores: “Ambiente virtual de aprendizagem”, “Acessibilidade” e “Deficiência”, tendo sido selecionados 14 trabalhos. O levantamento constatou que a maioria dos trabalhos analisados contemplam pessoas com deficiência visual e utilizam o Moodle como Ambiente Virtual de Aprendizagem, além de ter sido identificado que as diretrizes para acessibilidade W3C e WCAG são contempladas em quase todas as pesquisas. Elaborar propostas de cursos acessíveis necessita de uma equipe multidisciplinar, que planeje a acessibilidade desde a sua concepção. Isto evita retrabalho, custo e amplia a cultura da acessibilidade. Apesar dos estudos apresentados, verifica-se que a acessibilidade em cursos à distância ainda terá que percorrer um longo caminho. Palavras-chave: Educação a distância. Moodle. Inclusão

Costos derivados de la atención a pacientes con enfermedad crónica no transmisible

 Antecedentes: Las enfermedades crónicas no transmisibles, son la principal causa de morbimortalidad a nivel mundial. Comportamiento similar se presenta en Colombia al igual que en Santander. Las patologías cardiovasculares en el 2010 cobraron la vida de 1527 mujeres y 1634 hombres; seguido de las neoplasias, en especial las de localización de tumores malignos que causaron la muerte a 727 mujeres y 755 hombres, estos resultados se ven reflejados en los altos costos requeridos para la atención hospitalaria, ambulatoria y domiciliaria por lo que requiere dedicación, educación y cuidado individualizado. Métodos: Se realizó una búsqueda de artículos teniendo en cuenta tiempo de publicación y las palabras claves; en las bases de datos: MEDLINE, IME, LILACS, Centro Cochrane Iberoamericano, EMBASE, CINAHL, BDIE, en el primer semestre de 2013. Identificando 55 estudios potenciales, de los cuales se seleccionaron seis artículos del comportamiento de los costos de la atención a pacientes con enfermedades crónicas no transmisibles; cabe incluir que se obtuvo información directa por parte de algunas instituciones de Bucaramanga, la cual demuestra el comportamiento de los costos frente al cuidado de enfermería y a nivel interno de cada entidad no solo del sistema de salud sino de los pacientes y cuidadores familiares. Resultados: la enfermedad crónica genera la mayor parte de los costos al Sistema de Salud, situación a tener en cuenta; así como el cuidado efectivo para la atención de pacientes que ya han sido afectados. Conclusiones: el Sistema de Salud debe implementar estrategias preventivas para la aparición de las Enfermedades Crónicas No Trasmisibles (ECNT) y las complicaciones derivadas de ellas, que contemple un cuidado efectivo para la atención de los individuos.Palabras claves: Costos, Cuidado, Enfermedad Crónica no transmisible.  Abstract  Background: Chronic noncommunicable diseases are the leading cause of morbidity and mortality worldwide. Similar behavior occurs in Colombia as in Santander. Cardiovascular diseases in 2010 claimed the lives of 1527 women and 1634 men ; followed by neoplasms, especially the localization of malignant tumors that killed 727 women and 755 men, these results are reflected in the high cost required for inpatient , outpatient and home care so requires dedication , education and individualized care. Methods: A search of articles were given at time of publication and keyword; in databases: MEDLINE, IME, LILACS, Iberoamerican Cochrane Centre, EMBASE, CINAHL, BDIE in the first half of 2013. By identifying 55 potential studies, of which six articles of behavior of costs of care were selected patients with chronic non- communicable diseases; it should include direct information was obtained by some institutions Bucaramanga, which shows the behavior of costs compared to nursing care and internally each institution not only the health system but patients and family caregivers. Results: Chronic illness generates most of the costs the health system, a situation to consider; and effective care for the care of patients who have already been affected. Conclusions: Health System must implement preventive strategies for the appearance of Chronic Non Communicable (ECNT) and complications arising from them, by providing effective care for the care of individuals.Keywords: Costs, Care, Chronic Non-Communicable Disease

Canagliflozin and renal outcomes in type 2 diabetes and nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to <90 ml per minute per 1.73 m2 of body-surface area and albuminuria (ratio of albumin [mg] to creatinine [g], >300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of <15 ml per minute per 1.73 m2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P<0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P<0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years