OBJECTIVES: The effectiveness of community level interventions depends to a great extent on adherence. Currently, information on factors related to adherence in older adults from developing countries ...is scarce. Our aim was to identify factors associated to adherence to a physical activity intervention in older adults from a post-transitional middle income country. DESIGN, SETTING AND PARTICIPANTS: Using a combination of quantitative and qualitative methods we studied 996 older Chilean subjects (65–67.9 years at baseline) with low to medium socioeconomic status from 10 health centers randomized to receive a physical activity intervention as part of the CENEX cluster trial (ISRCTN48153354). MEASUREMENTS: Using a multilevel regression model, the relationship between adherence (defined a priori as attendance at a minimum of 24 physical activity classes spread over at least 12 months) and individual, intervention-related and contextual factors was evaluated. We also conducted 40 semi-structured interviews with older adults (n=36) and instructors (n=4). Transcripts of the interviews were analyzed using content analysis to identify barriers and facilitators to adherence. RESULTS: Adherence to physical activity intervention was 42.6% (CI 95% 39.5 to 45.6). Depression, diabetes mellitus, percentage of impoverished households and rate of arrests for violent crimes in the neighborhood predicted less adherence (p<0.05) while being retired, participation in physical activity prior to the intervention, and green areas per habitant were positively associated with adherence (p<0.05). The qualitative interviews identified three primary barriers to adherence: current health problems, lack of time due to commitments for caring for family members, and being employed, and two primary facilitators to adherence: the health benefits attributed to the intervention and the opportunity the classes provided for social interaction with others. CONCLUSION: In order to enhance effectiveness of community exercise interventions, strategies to improve participation should be targeted to older adults from deprived areas and those with psychological and medical conditions.
To characterize antifungal prescribing patterns, including the indication for antifungal use, in hospitalized children across the United States.
We analyzed antifungal prescribing data from 32 ...hospitals that participated in the SHARPS Antibiotic Resistance, Prescribing, and Efficacy among Children (SHARPEC) study, a cross-sectional point-prevalence survey conducted between June 2016 and December 2017.
Inpatients aged <18 years with an active systemic antifungal order were included in the analysis. We classified antifungal prescribing by indication (ie, prophylaxis, empiric, targeted), and we compared the proportion of patients in each category based on patient and antifungal characteristics.
Among 34,927 surveyed patients, 2,095 (6%) received at least 1 systemic antifungal and there were 2,207 antifungal prescriptions. Most patients had an underlying oncology or bone marrow transplant diagnosis (57%) or were premature (13%). The most prescribed antifungal was fluconazole (48%) and the most common indication for antifungal use was prophylaxis (64%). Of 2,095 patients receiving antifungals, 79 (4%) were prescribed >1 antifungal, most often as targeted therapy (48%). The antifungal prescribing rate ranged from 13.6 to 131.2 antifungals per 1,000 patients across hospitals (
< .001).
Most antifungal use in hospitalized children was for prophylaxis, and the rate of antifungal prescribing varied significantly across hospitals. Potential targets for antifungal stewardship efforts include high-risk, high-utilization populations, such as oncology and bone marrow transplant patients, and specific patterns of utilization, including prophylactic and combination antifungal therapy.
Abstract
Background
Despite the effectiveness of Participatory Action Research (PAR) in reducing the gap between evidence and practice, its use to improve care integration is rare. The aim is to ...analyze the factors influencing the implementation of PAR interventions to improve clinical coordination in public health services networks of Brazil, Chile, Colombia, Mexico and Uruguay.
Methods
A qualitative, descriptive-interpretative study was conducted in participating healthcare networks of each country. Focus groups and individual semi-structured interviews were conducted to a criteria sample of participants: members of Local Steering Committee (LSC)(29), professionals’ platform (PP)(28), other professionals (49) and managers(28). Thematic content analysis was performed, segmented by country and themes.
Results
Findings reveal that contextual factors, the PAR process and interventions’ content were determinants in the implementation, interacting over time, and differing among experiences. On the one hand, institutional support (providing the necessary resources) together with the interest of professionals and managers in participating, emerged as influencing factors influenced by other factors related to: the system (alignment with policies; electoral cycle), networks (lack of time due to work overload; precarious employment conditions) and individuals (limited mutual knowledge and mistrust). On the other, some characteristics of the PAR process facilitated institutional support and motivation: professionals’ participation in all activities, design flexibility and shared decision-making - also present when interventions were based on mutual adjustment - the LSC’s leadership and the facilitating role of the research team.
Conclusions
Evidence is provided that when some contextual elements converge the implementation of interventions through PAR processes can turn into a factor of motivation and cohesion, determinant for the adoption of clinical coordination interventions.
Key messages
Contributes to fill the knowledge gap in factors influencing the implementation of PAR interventions in healthcare.
Provides a framework for analysis and recommendations for their implementation.
Abstract
Background
Evaluation of interventions to improve clinical coordination across care levels is scarce in Latin America.
Aim
to evaluate the effectiveness of interventions implemented through ...participatory action research in improving clinical coordination between care levels in public healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay.
Methods
Quasi-experimental study (controlled before and after design). Comparable networks, one intervention (IN) and one control (CN), were selected in each country. Baseline (2015) and evaluation (2017) surveys were conducted applying COORDENA® questionnaire to a sample of primary (PC) and secondary (SC) care doctors (174 doctors/network/year). Designed interventions promoted clinical agreement and communication across levels for patients’ follow-up. Outcome variables: a) intermediate: interactional and organizational factors; b) final: experience of clinical management coordination (care consistency and patients’ follow-up) and general perception of coordination between levels. Poisson regression models were estimated.
Results
Intermediate: interactional factors -personal knowledge and trust on the other care level-increased significantly in Brazil’ and Chile’ INs; and organizational factors -managers’ support- in the INs of Colombia and Mexico. Comparing to CN in 2017, INs of Brazil, Chile, Colombia and Mexico showed significant differences in some factors.
Final: care consistency items -agreement over the treatments- improved in the INs of Brazil, Colombia and Uruguay; and patients’ follow-up in the INs of Chile and Mexico. General perception of clinical coordination increased in the INs of Brazil, Colombia and Mexico. Compared to CN in 2017, only Brazil showed significant differences.
Conclusions
Improvements in intermediate and final care coordination results, consistent with expected results, were observed in all the INs. Reduced implementation time and some process and context factors may have limited their impact.
Key messages
First study assessing the effectiveness of participatory interventions in improving clinical coordination between care levels in public healthcare networks of Latin America.
Results showed changes in the intermediate and final clinical coordination results in the intervention networks. Longer implementation and evaluation times are expected to achieve greater impact.
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