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INTRODUCTION: Research on public health interventions to improve hypertension care and control in low-income and middle-income countries remains scarce. This study aims to evaluate the effectiveness and assess the process and fidelity of implementation of a multi-component intervention to reduce the gaps in hypertension care and control at a population level in low-income communes of Medellin, Colombia. METHODS AND ANALYSIS: A multi-component intervention was designed based on international guidelines, cross-sectional population survey results and consultation with the community and institutional stakeholders. Three main intervention components integrate activities related to (1) health services redesign, (2) clinical staff training and (3) patient and community engagement. The effectiveness of the intervention will be evaluated in a controlled before-after quasi-experimental study, with two deprived communes of the city selected as intervention and control arms. We will conduct a baseline and an endline survey 2 years after the start of the intervention. The primary outcomes will be the gaps in hypertension diagnosis, treatment, follow-up and control. Effectiveness will be evaluated with the difference-in-difference measures. Generalised estimation equation models will be fitted considering the clustered nature of data and adjusting for potential confounding variables. The implementation process will be studied with mixed methods. Implementation fidelity will be documented to assess to which degree the intervention components were implemented as intended. ETHICS AND DISSEMINATION: The study protocol has been approved by the Ethics Research Committee of Metrosalud in Colombia (reference 1400/5.2), the Medical Ethics Committee of the Antwerp University Hospital (reference 18/40/424) and the Institutional Review Board of the Antwerp Institute of Tropical Medicine (reference 1294/19). We will share and discuss the study results with the community, institutional stakeholders and national health policymakers. We will publish them in national and international peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER: NCT05011838.
Assuntos
Hipertensão , Colômbia , Estudos Controlados Antes e Depois , Estudos Transversais , Humanos , Hipertensão/prevenção & controle , Pobreza , Saúde PúblicaRESUMO
INTRODUCTION: Common variable immunodeficiency (CVID) is the most prevalent symptomatic humoral deficiency; however, its heterogeneous presentation makes the diagnosis difficult. The present study is aimed to verify the CVID diagnostic criteria as established by the European Society for Immunodeficiencies in 42 CVID patients from our outpatient clinic. METHODS: Information was collected from their medical records and when needed, lymphocyte subpopulations in peripheral blood (PB) were performed by flow cytometry. RESULTS: All the patients fulfilled the clinical working definition for CVID and showed decreased serum IgG and IgA at diagnosis. Over two-thirds of the patients had decreased memory B cell percentages. However, the remaining patients exhibited other quantitative B cell defects in PB. Evaluation of vaccination responses was only found in 13 records and 69% were not responsive. None of the patients were subjected to vaccination studies to both, T-cell dependent and independent antigens. The two required tests to evaluate T cell responses were performed in 84.2% of the patients and reported normal. Without the support of third-party payers, only 34.2% of our patients would have completed the required evaluations. CONCLUSIONS: Further efforts are needed to speed up CVID diagnosis in low-resourced settings, increasing the availability of the required resources and optimizing the healthcare supply chain.
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Imunodeficiência de Variável Comum , Linfócitos B , Imunodeficiência de Variável Comum/diagnóstico , Citometria de Fluxo , Humanos , Subpopulações de Linfócitos , Linfócitos TRESUMO
La literatura técnica suele presentar los Sistemas de Salud (SS) como conjuntos de recursos médicos destinados a atender enfermedades. Un análisis más amplio del tema permite caracterizar los SS como la expresión de sistemas políticos que surgen y cambian en contextos históricos diferentes, al impulso de las condiciones e intereses predominantes. Los sistemas políticos son los mismos sistemas sociales cuando los valoramos desde la perspectiva de las relaciones de poder que se establecen entre sus integrantes. Desde esta perspectiva los SS, sus agentes, discursos y dispositivos, se revelan como componentes de sistemas políticos que determinan, bajo las apariencias el tipo de gestión que se aplica a la comprensión y cuidado de la salud, y configuran "modelos de respuesta social". Este documento, describe los SS como sistemas políticos, con base en las características de la respuesta social preponderante. Se describen cinco tipologías que pueden coexistir tanto de forma sinérgica como contradictoria reflejando las condiciones e intereses predominantes en el grupo: sistemas populares, de beneficencia, de seguridad social, estatales, y privados. Al final se propone que el análisis de los aspectos formales y técnicos es por sí mismo insuficiente para explicar e intervenir la dinámica de los SS.
Technical literature usually presents Health Systems (HS) as sets of medical resources aimed at treating diseases. A broader analysis of the subject allows us to characterize HS as the expression of political systems, which arise and change in different historical contexts, driven by prevailing conditions and interests. Political systems are the same social systems when we value them from the perspective of the power relations established among their members. From this perspective, HS, their agents, discourses, and devices, are revealed as components of political systems that determine, under appearances, the type of management that people applied to understand and care for their health, and configure "models of social response." In this document, the analysis of HS is based on the characteristics of the prevailing social response. We describe five typologies that can coexist, both synergistically and contradictory, reflecting the prevailing conditions and interests in the group: popular, charity, social security, state, and private systems. In the end, it is proposed that the analysis of the formal and technical aspects is by itself insufficient to explain HS and intervene in their dynamics
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Humanos , Sistemas Políticos , Administração de Serviços de Saúde , Sistemas de Saúde , Setor Privado , Previdência Social , Sistemas Públicos de SaúdeRESUMO
OBJECTIVES: To assess hypertension prevalence and the extent and associated factors of hypertension diagnosis, follow-up, treatment and control gaps in low-income urban Medellin, Colombia. METHODS: We randomly sampled 1873 adults aged 35 or older. Unaware hypertensive individuals were defined as those without previous diagnosis whose average blood pressure was equal to or above 140/90 mmHg. For aware hypertensive patients, control was delimited as average blood pressure below 140/90 if under 59 years old or diabetic, and as less than 150/90 otherwise. We used logistic regression to identify care gap-associated factors. RESULTS: Hypertension prevalence was 43.5% (95% CI 41.2-45.7). We found 28.2% aware and 15.3% unaware hypertensive individuals, which corresponds to a 35.1% (95% CI 31.9-38.5) underdiagnosis. This gap was determined by age, sex, education and lifestyle factors. 14.4% (95% CI 11.6-17.6) of aware hypertensive patients presented a follow-up gap, 93.4% (95% CI 90.9-95.2) were prescribed antihypertensive drugs, but 38.9% (95% CI 34.7-43.3) were not compliant. The latter was strongly associated with follow-up. The hypertension control gap in aware hypertensive patients, 39.0% (95% CI: 34.9-43.2), was associated with being older, having diabetes, weakly adhering to pharmacological treatment and receiving poor non-pharmacological advice. Overall, 60.4% (95% CI 57.0-63.8) of aware and unaware hypertensive participants had either diagnosed but uncontrolled or undiagnosed hypertension. CONCLUSIONS: We found high hypertension prevalence coupled with, from an international perspective, encouraging awareness and control figures. Still, there remains ample room for improvement. Our findings can assist in designing integrated primary healthcare measures that further strengthen equitable and effective access to hypertension care and control.
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Disparidades em Assistência à Saúde , Hipertensão/epidemiologia , Aceitação pelo Paciente de Cuidados de Saúde , Adulto , Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea , Colômbia/epidemiologia , Feminino , Humanos , Hipertensão/prevenção & controle , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Prevalência , Fatores de Risco , Fatores Socioeconômicos , Inquéritos e Questionários , População UrbanaRESUMO
Background Hypertension requires life-long medical care, which may cause economic burden and even lead to catastrophic health expenditure. Objective To estimate the extent of out-of-pocket expenditure for hypertension care at a population level and its impact on households' budgets in a low-income urban setting in Colombia. Methods We conducted a cross-sectional survey in Santa Cruz, a commune in the city of Medellin. In 410 randomly selected households with a hypertensive adult, we estimated annual basic household expenditure and hypertension-attributable out-of-pocket expenditure. For socioeconomic stratification, we categorised households according to basic expenditure quintiles. Catastrophic hypertension-attributable expenditure was defined as out-of-pocket expenditure above 10% of total household expenditure. Results The average annual basic household expenditure was US dollars at purchasing power parity (USD-PPP) $12,255.59. The average annual hypertension-attributable out-of-pocket expenditure was USD-PPP $147.75 (95% CI 120.93-174.52). It was incurred by 73.9% (95% CI 69.4%-78.1%) of patients, and consisted mainly of direct non-medical expenses (76.7%), predominantly for dietary requirements prescribed as non-pharmacological treatment and for transport to attend health care consultations. Medical out-of-pocket expenditure (23.3%) was for the most part incurred for pharmacological treatment. Hypertension-attributable out-of-pocket expenditure represented on average 1.6% (95% CI 1.3%-1.9%) of the total annual basic household expenditure. Eight households (2.0%; 95% CI 1.0%-3.8%) had catastrophic health expenditure; six of them belonged to the two lowest expenditure quintiles. Payments related to dietary requirements and transport to consultations were critical determinants of their catastrophic expenditure. Conclusions Out-of-pocket expenditure for hypertension care is moderate on average, but frequent, and mainly made up of direct non-medical expenses. Catastrophic health expenditure is uncommon and affects primarily households in the bottom socioeconomic quintiles. Financial protection should be strengthened by covering the costs of chronic diseases-related dietary requirements and transport to health services in the most deprived households. Abbreviations NCDs: Non-communicable diseases; LMICs: Low and middle-income countries; WHO: World Health Organization; HTN: hypertension; CVDs: Cardiovascular diseases; OOPE: out-of-pocket expenditure; USD-PPP: US dollars at purchasing power parity; CI: Confidence interval.
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Gastos em Saúde/estatística & dados numéricos , Hipertensão/economia , Adulto , Orçamentos , Doenças Cardiovasculares , Doença Crônica , Colômbia/epidemiologia , Estudos Transversais , Características da Família , Feminino , Serviços de Saúde , Humanos , Hipertensão/epidemiologia , Renda , Masculino , Pessoa de Meia-Idade , Pobreza/estatística & dados numéricos , Gravidez , Projetos de PesquisaRESUMO
RESUMEN Actualmente, la sociedad se ha enfocado en la tenencia de mascotas para adquirirlas por compañía desestimando el deber de atender sus necesidades y hacerse responsable de sus acciones, debido a esto, grupos sociales sensibles a esta problemática, promueven cambios culturales y han influenciado los gobiernos de países de América Latina con el fin de formular e implementar directrices para proteger a las mascotas. En el presente artículo se comparan aspectos esenciales de las normativas de protección de mascotas de cuatro países de América Latina, Colombia, Chile, Uruguay y México. Se realizó una revisión narrativa de la literatura publicada y de los sitios web de los entes gubernamentales responsables de la formulación y puesta en marcha de las normativas de los cuatro países, con el propósito de establecer una comparación entre su contenido y su desempeño. Mediante esta revisión se identificaron diferencias en cuanto a los objetivos de las directrices y el proceso de su formulación. Se describen, además, los actores que intervinieron en el proceso de formulación, estructura, objeto y los resultados más importantes reportados en cada país a partir de la implementación de estas normativas.
ABSTRACT Nowadays, society is focused on acquiring pets for the purpose of companionship, disregarding the duty of attending their needs and take responsibility for their actions. Consequently, social groups sensitive to this problem promote cultural changes and exert pressure on the governments of Latin American countries in order to formulate and implement guidelines to protect pets. This article compares essential aspects of pet protection regulations in four countries in Latin America, Colombia, Chile, Uruguay and Mexico. A narrative review of published literature and the websites of the government entities responsible for the formulation and implementation of the regulations in the four countries was carried out with the purpose of establishing a comparison between their content and their performance. Through this review, differences regarding the objectives of the guidelines and the process of their formulation were identified. The actors that intervened in the process of formulation, structure, object, and what is more important, results reported in each country since the implementation of these regulations are also described.
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Bem-Estar do Animal , Animais , Animais DomésticosRESUMO
Resumen Objetivos: Describir el estado del arte sobre estudios epidemiológicos que evalúen asociaciones de riesgo entre el cáncer colorrectal y la diabetes tipo 2, y las políticas de salud pública internacionales y colombianas encaminadas a reducir tales patologías. Metodología: Revisión sistemática cualitativa sobre estudios epidemiológicos que evalúen asociaciones de riesgo entre el cáncer colorrectal y la diabetes tipo 2, publicados en idioma español e inglés en PubMed®, United States National Library of Medicine (u.s nlm®), Embase®, Literatura Latinoamericana y del Caribe en Ciencias de la Salud (Lilacs®) y Scientific Electronic Library Online (SciELO®), antes del 30 de junio de 2019. Adicionalmente, se describen las políticas internacionales y nacionales para el control de la diabetes y el cáncer colorrectal. Resultados: De 251 estudios evaluados para elegibilidad, se incluyeron 32 investigaciones originales tipo casos y controles, cohorte prospectivo y retrospectivo, retrospectivos con enfoque de casos y controles, retrospectivos con enfoque casos-cohorte, al mostrar asociaciones de riesgo de padecer cáncer de colon o recto en individuos diabéticos tipo 2. Existen cinco normatividades internacionales para el control de diabetes y cáncer, y dos normatividades colombianas de control de ambas patologías. Conclusiones: La evidencia epidemiológica a nivel mundial señala que individuos con diabetes tipo 2 poseen mayor riesgo de padecer cáncer de colón o recto, en comparación con los no diabéticos, en una forma dependiente de la etnicidad y el sexo. Las políticas de salud pública internacionales y colombianas no han logrado reducir significativamente la carga de ambas patologías, ni los factores de riesgo comunes entre ambas condiciones, y tampoco reconocen los nexos epidemiológicos y biológicos entre la diabetes tipo 2 y el cáncer colorrectal.
Abstract Objective: Describe the state of the art on epidemiological studies that assess risk associations between colorectal cancer and type 2 diabetes, and Colombian and international public health policies to reduce these pathologies. Methodology: Qualitative systematic review on epidemiological studies that assess risk associations between colorectal cancer and type 2 diabetes, published in Spanish and English in PubMed®, United States National Library of Medicine (U.S NLM®), Embase®, Literatura Latinoamericana y del Caribe en Ciencias de la Salud (Lilacs®) and Scientific Electronic Library Online (SciELO®), before 30 June 2019. Furthermore, we describe the international and national policies for the control of diabetes and colorectal cancer. Results: Of 251 studies assessed for eligibility, we included 32 original case-control studies, prospective and retrospective cohort studies, retrospective studies with a case-control approach and retrospective studies with a case-cohort approach as they showed risk associations for colon or rectal cancer in type 2 diabetic individuals. There are five international regulations for the control of diabetes and cancer, and two Colombian regulations for the control of both pathologies. Conclusions: The global epidemiological evidence indicates that individuals with type 2 diabetes have an increased risk of cancer of the colon or rectum, compared with non-diabetics, dependent on ethnicity and sex. International and Colombian public health policies have not been able to significantly reduce the burden of both pathologies, nor the common risk factors between both conditions, nor recognize the epidemiological and biological links between type 2 diabetes and colorectal cancer.
Resumo Objetivo: Descrever o estado da arte relacionado aos estudos epidemiológicos que avaliam associações de risco entre o câncer colorretal e o diabetes tipo 2, e as políticas de saúde pública colombianas e internacionais encaminhadas à redução de tais patologias. Metodologia: Revisão sistemática qualitativa sobre estudos epidemiológicos que avaliem associações de risco entre o câncer colorretal e o diabetes tipo 2, publicados nos idiomas espanhol e inglês em PubMed®, United States National Library of Medicine (U.S NLM®), Embase®, Literatura Latinoamericana y del Caribe em Ciencias de la Salud (Lilacs®) e Scientific Electronic Library Online (SciELO®), antes de 30 de junho de 2019. Adicionalmente são descritas as políticas nacionais e internacionais para o controle do diabetes e o câncer colorretal. Resultados: Dos 251 estudos avaliados para elegibilidade foram incluídas 32 pesquisas originais tipo casos e controles, coorte prospectivo e retrospectivo, retrospectivos com foco de casos e controles, retrospectivos com foco casos-coorte, ao mostrar associações de risco de sofrer câncer de cólon ou reto em pacientes diabéticos tipo 2. Existem cinco regulamentos internacionais para o controle de diabetes e câncer e dois regulamentos colombianos de controle para ambas as patologias. Conclusões: A evidencia epidemiológica a nível mundial mostra que pacientes com diabetes tipo 2 possuem um risco maior de sofrer câncer de cólon ou reto, em comparação com os não-diabéticos, numa forma dependendo da etnia e do sexo. As políticas de saúde pública colombianas e internacionais ainda não conseguiram diminuir significativamente a carga de ambas as patologias, nem os fatores de risco comuns entre ambas as condições, além de não reconhecerem os nexos epidemiológicos e biológicos entre o diabetes tipo 2 e o câncer colorretal.
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Abstract Introduction: The safety climate (SC) measurement in the hospitals, is essential for the development of a patient safety policy (PSP). Information about SC in the operating rooms is scarce. Objective: To measure the dimensions of SC in Colombian Operating Rooms according to characteristics of surgical staff. Methods: Cross-sectional study. The Hospital Survey on Patient Safety and an additional module for operating rooms were administered to healthcare workers in 6 high-complexity hospitals in the Metropolitan Area of Medellín (Colombia). The positive responses percentage for each dimension was measured. Differences by profession and type of contract were analyzed. Results: A total of442 participants were included. The workers in the operating rooms perceive a weak SC in terms of non-punitive response to error and workload (49.4% and 59.3% positive responses, respectively). Differences were found between physicians and nurses with lower scores in nursing for dimensions related to patient care. Anesthesiologists present low scores in events reporting. There are also differences by the type of work contract. Conclusion: Despite the PSP, the perception of a punitive culture to error, with a high workload. Recognizing differences between the groups within the surgical units helps to focus interventions strengthening the patient safety.
Resumen Introducción: La medición del clima de seguridad (CS) en las instituciones de salud es parte fundamental del desarrollo de una política de seguridad del paciente (PSP). Existe poca información acerca de la medición de clima de seguridad en las unidades quirúrgicas. Objetivo: Medir las dimensiones del CS en las unidades quirúrgicas de seis instituciones de salud colombianas según las características del personal. Métodos: Estudio de corte transversal. El cuestionario sobre seguridad del paciente en los hospitales (HSOPS) más la adición de un módulo para unidades quirúrgicas se aplicó al personal de seis hospitales de III nivel de Medellín (Colombia). Se midió el porcentaje de respuestas positivas para cada dimensión del CS. Se analizaron las diferencias por profesión y tipo de contratación. Resultados: Se incluyeron 442 participantes. El personal de las unidades quirúrgicas percibe un CS débil en respuesta no punitiva al error y carga de trabajo (49,4 % y 59,3 % de respuestas positivas respectivamente). Se encontraron diferencias entre personal médico y de enfermería con puntajes más bajos de percepción de CS en enfermería para aquellas dimensiones relacionadas con cuidado del paciente. Los anestesiólogos presentan puntajes bajos en el reporte de eventos. Existen además diferencias según el tipo de contrato de trabajo. Conclusiones: A pesar de la implementación de políticas de seguridad del paciente, persiste la percepción de una cultura punitiva frente al error, con una carga de trabajo elevado. El reconocimiento de las diferencias entre los grupos en las unidades quirúrgicas permitirá focalizar intervenciones que fortalezcan la seguridad del paciente.
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Humanos , Masculino , Feminino , Segurança do Paciente , Instalações de Saúde , Salas Cirúrgicas , Carga de Trabalho , Pessoal de Saúde , Anestesiologistas , Assistência ao Paciente , HospitaisRESUMO
Resumen En Colombia el cáncer es un problema de salud pública. Su incidencia y mortalidad afectan tanto a la población adulta como a la población pediátrica. Desde el año 2010 el país se viene preparando para afrontar este problema. El Instituto Nacional de Cancerología (INC) ha realizado investigaciones para caracterizar epidemiológicamente el cáncer, así como otros factores que inciden en su letalidad. Las leyes 1384 y 1388 de 2010 fijaron las bases para el control integral del cáncer y designaron al INC para asesorar al Ministerio de Salud y Protección Social en esta tarea. Se analizó el contenido del plan, con base en una guía elaborada por la Facultad de Salud Pública de la Universidad de Antioquia. Debido a la importancia del problema y la complejidad de la política, se concluye: solo con un sistema estricto de monitoreo, una evaluación permanente de las actividades del plan y la aplicación de correctivos oportunos, Colombia podría alcanzar las metas en el control del cáncer.
Abstract In Colombia, cancer is a public health problem. Its incidence and mortality affects both adult and pediatric population. Since 2010 the country has been preparing to address this problem. The National Cancer Institute (NCI) has conducted research to characterize epidemiologically cancer as well as other factors that influence their lethality. 1384 and 1388 laws of 2010 laid the foundation for comprehensive cancer control and designated the INC to advise the Ministry of Health and Social Protection in this task. We analyzed the contents of the plan, based on a guide developed by the School of Public Health at the University of Antioquia. Because of the importance of the problem and the complexity of the policy concludes: Only a strict monitoring system, continuous evaluation and timely corrective plan of activities, Colombia could reach targets in cancer control.
Resumo Na Colômbia, o câncer é um problema de saúde pública. A incidência e a mortalidade afectar ambos os adultos e a população pediátrica. Desde 2010 o país tem vindo a preparar para resolver este problema. O Instituto Nacional do Câncer (INC) realizou uma pesquisa para caracterizar epidemiologicamente câncer, bem como outros fatores que influenciam sua letalidade. 1384 e 1388 leis de 2010 lançou as bases para o controle integral de câncer eo INC nomeado para assessorar o Ministério da Saúde e Protecção Social nesta tarefa. o conteúdo do plano foi analisado, com base em um guia desenvolvido pela Escola de Saúde Pública da Universidade de Antioquia. Devido à importância do problema e da complexidade da política, ele conclui: Colômbia poderia atingir as metas para o controle do câncer se aplicado rigoroso sistema de monitorização, uma avaliação contínua das actividades do plano ea implementação de medidas corretivas adequadas.