Barreiras e facilitadores da implementação do Programa Famílias Fortes no Nordeste do Brasil segundo gestores : uma análise de contexto baseada em abordagens de avaliação de processo

Dissertação (mestrado)—Universidade de Brasília, Instituto de Psicologia, Programa de Pós-graduação em Psicologia Clínica e Cultura, 2018.O uso indevido de substâncias por adolescentes representa um fenômeno preocupante em diversos países. Nas últimas décadas, tem sido desenvolvidos programas preventivos com a finalidade de abordar os problemas decorrentes do seu uso indevido a partir da redução dos fatores de risco e da promoção dos fatores de proteção. O Programa Famílias Fortes (PFF) foi desenvolvido no Reino Unido e adaptado para o Brasil como uma das estratégias para a evitação, redução ou adiamento no uso de substâncias entre jovens e para redução de outros comportamentos de risco à saúde em crianças e adolescentes por meio do fortalecimento de vínculos familiares. A implementação do PFF pode ser considerada complexa, pois exige articulação ao nível municipal, estadual e federal para sua entrega. A abordagem da avaliação de processo tem sido qualificada como adequada para avaliar programas classificados como complexos, por reconhecer os entraves para uma avaliação robusta e buscar albergar elementos tanto da implementação, como dos mecanismos de mudança quanto do contexto. Esta dissertação, composta por dois manuscritos, almeja abordar aspectos conceituais sobre a avaliação de processo de intervenções complexas em saúde e examinar como o contexto facilitou ou dificultou a pré-implementação e implementação do PFF no Nordeste do Brasil. O primeiro manuscrito apresenta uma revisão narrativa da avaliação de processo na área da saúde. Evidencia-se seu desenvolvimento histórico, principais conceitos e abordagens frequentemente utilizadas na área, como a Teoria Realística e Teoria do Processo da Normalização. Conclui-se que ambas as teorias oferecem estruturas de avaliação consistentes, que podem ser utilizadas para descrever e avaliar implementações, além de auxiliar na customização de intervenções complexas a diferentes contextos. No segundo manuscrito, foi aplicada a avaliação de processo para analisar os fatores contextuais e processuais considerados barreiras e facilitadores em cada fase de pré-implementação e implementação do PFF no Nordeste do Brasil. O estudo foi realizado, por meio de entrevistas e grupos focais, com 26 profissionais responsáveis pela gestão, supervisão e implementação do Programa. Os relatos indicam a existência de mais empecilhos para a implementação do que elementos facilitadores. A análise de contexto identificou como principais barreiras: contexto político desfavorável (19%), agentes de implementação pouco engajados ou sensibilizados (12%) e estratégias de implementação ineficazes (10%), enquanto que os elementos mais facilitadores foram: elaboração e utilização de estratégias eficazes (16%), contexto político favorável (14%) e agentes de implementação envolvidos e sensibilizados com o Programa. Os relatos indicam que a implementação exitosa do PFF exige um bom funcionamento prévio das redes intersetoriais e eficácia no gerenciamento de pessoas, na distribuição de poder e na gestão dos recursos financeiros. Esses resultados ajudam a compreender os desafios em implementar em larga escala programas de prevenção para o país. Sugere-se a construção de um manual de implementação do PFF e a comparação dos dados encontrados com estudos de avaliação de efetividade. Concluiu-se que seria essencial para o aprimoramento da qualidade da implementação a promoção de uma cultura de prevenção em territórios de alta vulnerabilidade, como no caso do Nordeste brasileiro, onde geralmente é dada prioridade à urgência.Undue use of substances by adolescents is a worrying phenomenon in several countries. In the last decades, preventive programs are being developed with the purpose of approaching problems arising from substance misuse by reducing risk factors and promoting protection factors. The Strengthening Families Program (SFP) was developed in the United Kingdom and adapted to Brazil as one of the strategies for avoidance, reduction or postponement of substance use among youngsters and to reduce other health risk-related behaviors in children by strengthening family ties. The implementation of SFP can be considered complex, since it requires articulation at the municipal, state and federal levels for its delivery. The process evaluation approach has been described as efficient to evaluate programs classified as complex, recognizing the obstacles to a robust evaluation and seeking to accommodate elements of both implementation and change mechanisms as well as context. This dissertation, composed of two manuscripts, aims to address conceptual aspects about the process evaluation of complex interventions in health realm and to examine how context acts as a facilitator or as a barrier to pre-implementation and implementation of SFP in Northeast Brazil. The first manuscript of this dissertation aims to present a narrative review of process evaluation in health area, its historical development, main concepts and approaches frequently used in process evaluation, such as the Realistic Theory and Nomalization Process Theory, are evidenced. It is concluded that both theories offer consistent evaluation frameworks, which can be used to describe and evaluate implementations, as well as assist in the customization of complex interventions to different contexts. At the second manuscript, process evaluation approach is applied to analyze the contextual and procedural factors considered barriers and facilitators in each phase of the pre-implementation and implementation of SFP in the Northeast region of Brazil. The study was conducted through interviews and focus groups with 26 professionals responsible for the management, supervision and implementation of the Program. Reports indicate that there are more obstacles to implementation than facilitating elements. Context analysis identified as main barriers: unfavorable political context (19%), poorly engaged implementation agents (12%) and ineffective implementation strategies (10%), while the most facilitating elements were: effective strategies (16%), favorable political context (14%) and implementation agents engaged and sensitized with the Program. Reports indicate that successful implementation of the Program requires good pre-existing intersectoral networks and effectiveness in people management, power distribution and financial resource management. These results help to understand the challenges in implementing large-scale prevention programs in Brazil. It is recommended to elaborate a SFP implementation manual and to compare data found in results-based studies. It was concluded that it would be essential for the improvement of the quality of implementation to promote a culture of prevention in territories of high vulnerability, as is the case of Northeastern Brazil, where priority is generally given to urgency

Barriers and facilitators in the Strengthening Families Program (SFP 10–14) implementation process in northeast Brazil : a retrospective qualitative study

This study analyzed contextual barriers and facilitators in the implementation of Strengthening Families Program (SFP 10–14), Brazilian version, a family-based preventive program focused on the prevention of risk behaviors for adolescent health. SFP 10–14 was implemented between 2016 and 2017 for socioeconomically vulnerable families in four Northeast Brazilian states as a tool of the National Drug Policy. A retrospective qualitative study was carried out in which 26 implementation agents participated. Data from 16 individual interviews and two group interviews were analyzed through content analysis. The most recurrent barriers were the group facilitators’ working conditions, weak municipal administration, precarious infrastructure, inadequate group facilitator training methodologies, low adherence of managers and professionals, and funding scarcity. The conditions highlighted as favorable to the implementation were proper intersectoral coordination, engagement of involved actors, awareness of public agency administrators, municipal management efficacy, and efficient family recruitment strategies. Favorable political contexts, engagement of implementation agents, and intersectoral implementation strategies were identified as central to the success of the implementation of SFP 10–14, especially in the adoption of the intervention, community mobilization, and intervention delivery stages. Further studies should combine contexts, mechanisms, and results for a broad understanding of the effectiveness of this intervention in the public sector

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Barriers and Facilitators in the Strengthening Families Program (SFP 10–14) Implementation Process in Northeast Brazil: A Retrospective Qualitative Study

This study analyzed contextual barriers and facilitators in the implementation of Strengthening Families Program (SFP 10–14), Brazilian version, a family-based preventive program focused on the prevention of risk behaviors for adolescent health. SFP 10–14 was implemented between 2016 and 2017 for socioeconomically vulnerable families in four Northeast Brazilian states as a tool of the National Drug Policy. A retrospective qualitative study was carried out in which 26 implementation agents participated. Data from 16 individual interviews and two group interviews were analyzed through content analysis. The most recurrent barriers were the group facilitators’ working conditions, weak municipal administration, precarious infrastructure, inadequate group facilitator training methodologies, low adherence of managers and professionals, and funding scarcity. The conditions highlighted as favorable to the implementation were proper intersectoral coordination, engagement of involved actors, awareness of public agency administrators, municipal management efficacy, and efficient family recruitment strategies. Favorable political contexts, engagement of implementation agents, and intersectoral implementation strategies were identified as central to the success of the implementation of SFP 10–14, especially in the adoption of the intervention, community mobilization, and intervention delivery stages. Further studies should combine contexts, mechanisms, and results for a broad understanding of the effectiveness of this intervention in the public sector

Advocacy strategies to improve decision-making in public policies: a rapid scoping review [PROTOCOL]

This rapid scoping review aims to identify advocacy interventions that seek to impact public policies by promoting institutional and/or organizational changes

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study (Intensive Care Medicine, (2021), 47, 2, (160-169), 10.1007/s00134-020-06234-9)

The original version of this article unfortunately contained a mistake. The members of the ESICM Trials Group Collaborators were not shown in the article but only in the ESM. The full list of collaborators is shown below. The original article has been corrected