In Chile, colorectal cancer (CRC) is the fourth cause of death by cancer. Few studies have evaluated the role of contextual and individual socio-economic variables associated with premature death by ...CRC (<70 years). We analyzed the association between socio-economic factors (at individual and contextual levels) and premature death from CRC in Santiago de Chile.
This was a cross-sectional study.
We analyzed deaths from CRC between 2014 and 2018 using data published by the Ministry of Health. Individual predictors were sex, marital status, and educational level. Contextual variable included the Social Priority Index (SPI) of the commune where the deceased lived. The association was assessed through multilevel logistic regression models.
During the period, 4762 deaths occurred (51.7% women); 39.3% were premature. At the individual level, male sex (odds ratio OR 1.36; 95% confidence interval CI 1.20–1.53) and single marital status (OR 1.45; 95% CI 1.24–1.68) were associated with premature death from CRC. Primary or lower education was a protective factor (OR 0.53; 95% CI 0.47–0.60). At the contextual level, communes with a higher SPI were three times more at risk than those with a lower SPI (OR 3.13; 95% CI 2.15–4.57).
This study showed that individual and contextual socio-economic variables are related to premature death from CRC. Residing in communes with greater socio-economic vulnerability was associated with greater risk. To reduce this gap, it is urgent to design and implement structural policies to reduce social inequities and improve access to health care.
Aim
Climate change is transforming mountain summit plant communities worldwide, but we know little about such changes in the High Andes. Understanding large‐scale patterns of vegetation changes ...across the Andes, and the factors driving these changes, is fundamental to predicting the effects of global warming. We assessed trends in vegetation cover, species richness (SR) and community‐level thermal niches (CTN) and tested whether they are explained by summits' climatic conditions and soil temperature trends.
Location
High Andes.
Time period
Between 2011/2012 and 2017/2019.
Major taxa studied
Vascular plants.
Methods
Using permanent vegetation plots placed on 45 mountain summits and soil temperature loggers situated along a ~6800 km N‐S gradient, we measured species and their relative percentage cover and estimated CTN in two surveys (intervals between 5 and 8 years). We then estimated the annual rate of changes for the three variables and used generalized linear models to assess their relationship with annual precipitation, the minimum air temperatures of each summit and rates of change in the locally recorded soil temperatures.
Results
Over time, there was an average loss of vegetation cover (mean = −0.26%/yr), and a gain in SR across summits (mean = 0.38 species m2/yr), but most summits had significant increases in SR and vegetation cover. Changes in SR were positively related to minimum air temperature and soil temperature rate of change. Most plant communities experienced shifts in their composition by including greater abundances of species with broader thermal niches and higher optima. However, the measured changes in soil temperature did not explain the observed changes in CTN.
Main conclusions
High Andean vegetation is changing in cover and SR and is shifting towards species with wider thermal niche breadths. The weak relationship with soil temperature trends could have resulted from the short study period that only marginally captures changes in vegetation through time.
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.
Abstract
Background
Given the problems generated by health care fragmentation, the coordinated provision of health care has become a priority, particularly in Latin America. This communication ...analyses the strategies for improving clinical coordination proposed by primary and secondary care doctors from public health service networks in six countries of the region (Argentina, Brazil, Chile, Colombia, Mexico and Uruguay), and their changes between 2015 and 2017.
Methods
Two cross-sectional survey-based studies (2015 and 2017) were analysed with application of the COORDENA questionnaire to a total of 4311 primary and secondary care doctors from two public health service networks in each country. A descriptive analysis was carried out, stratified by country and year, of the suggestions proposed in the open question ‘What do you propose to improve clinical coordination between primary and secondary care doctors in the network?
Results
In all countries, the introduction or improvement of strategies and mechanisms that facilitate interaction and mutual knowledge between professionals at different care levels were highlighted, especially joint meetings, direct communication mechanisms (such as telephone and/or e-mail) and strategies to strengthen the use of the referral and counter-referral sheet. Less frequently, other organisational strategies aimed at strengthening the primary care model, improving access to secondary care and coordinating the management level of the network, were also suggested.
Conclusions
The results contribute to generate recommendations for the improvement of clinical coordination in health systems, based on the suggestions of doctors, a perspective that is not usually considered in the design and implementation of interventions in health services. The need to promote strategies based on mutual feedback in the design of public health policies stands out.
Key messages
• The design of effective interventions aimed at improving coordination requires doctors’ participation.
• Strategies based on mutual feedback and communication should be promoted by healthcare organisations to improve clinical coordination.
Abstract
Background
Finding new strategies for care integration has become a priority for many health systems in Latin America. Although the implementation of interventions through a participatory ...action research (PAR) approach is considered effective, its application in health services is scarce.
Aim
to analyse impact of PAR interventions on care coordination, and aspects for sustainability and transferability in public healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay.
Methods
A qualitative, descriptive-interpretative study was conducted in each healthcare network. Focus groups and individual semi-structured interviews were conducted to a criteria sample of Local Steering Committee (29), Platform of professionals (28), professionals (49) y managers (28). A thematic content analysis was conducted, segmented by country and themes. Different interventions were designed and implemented through a PAR process: joint meetings to discuss clinical cases and/or training; shared care guidelines; offline virtual consultations; a (back) referral form; and an induction program.
Results
Informants highlighted that joint meetings based on reflexive methods contributed substantially to improving contextually relevant elements of clinical coordination - communication in patient follow-up, clinical agreement, appropriateness of referrals - and administrative coordination. The meetings, alongside the PAR process, helped to improve interaction between professionals, fostering willingness to collaborate. No significant contributions were identified in the remaining interventions due to the low uptake. A necessary condition for the sustainability and replicability of the interventions was that the PAR process had to be used appropriately in a favorable context.
Conclusions
Evidence is provided on the significant contribution of interventions to improving locally relevant clinical coordination elements and professional interaction when implemented through an adequate PAR process.
Key messages
It contributes to fill the gap regarding the impact of PAR interventions on care coordination. A key aspect for impact and sustainability is an adequate use of PAR approach in a favourable context.
Abstract
Background
Evaluation of interventions to improve continuity of care across care levels is scarce in Latin America. The
Aim
to analyse the impact of implemented interventions on the ...perception of continuity of care of chronic patients in public health care networks of five LA countries (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 CCAENA questionnaire® to a sample of patients with chronic conditions (392/network; 784/country/year). Result variables: information continuity (exchange of clinical information) and clinical management continuity (repetition of exams, accessibility of primary care (PC) and secondary care (SC), perception of agreement between PC and SC doctors and of collaboration between PC and SC doctors. Descriptive analysis were conducted, and chi-square test was calculated to determine significant changes.
Results
An increase in the perception of continuity of information between care levels was observed in the IN of all countries, but Colombia. Clinical management continuity: decrease in the repetition of exams and increase in accessibility of consultation with the specialist in all countries but Mexico. The accessibility of PC doctor decreased in the IN in all countries. No differences in the perception of agreement between PC and SC doctors regarding diagnosis, treatment and recommendations were found. The perception of collaboration between PC and SC doctors increased in the five countries.
Conclusions
Consistent with expected results, the level of perceived information continuity and clinical management continuity increased in the IN, with differences between countries. Further multivariate analyses will be conducted to explore the differences between the IN and CN.
Key messages
Provides a cross-country comparison of the perception of continuity of care in patients with chronic conditions. Contributes to fill the knowledge gap on the effectiveness of participatory interventions improving continuity of care.
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.
PDF
