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Introducción: La interrupción voluntaria del embarazo (IVE) permite decidir frente a la maternidad. La Causal Violación (CV) para la IVE es legal en algunos países, esta tiene gran complejidad psicosocial por su relación con la violencia sexual. El objetivo de esta revisión es analizar las normativas que regulan la IVE por CV en un grupo de países latinoamericanos. Métodos: Se seleccionaron países con regulaciones vigentes para IVE en CV. Se realizó un análisis documental temático, focalizado en aspectos relevantes para el acceso efectivo a IVE. Resultados: Hay diferencias en requisitos de acceso, como límites de edad gestacional, necesidad de denuncia, evaluación del relato y consentimiento informado. También en la organización de los servicios, destacando los plazos para realizar la interrupción, la red de atención, la objeción de conciencia y su regulación. Conclusiones: Existen diferencias sustanciales entre países, se han encontrado elementos que pueden favorecer o proteger el acceso, siendo clave en las normativas la visualización de las mujeres como sujetas de derecho. Destaca el cuestionamiento a la autonomía de niñas y mujeres, límites restrictivos de edad gestacional y objeción de conciencia. No basta con una disposición legal cuando las normativas imponen múltiples barreras de acceso

Introduction Healthcare fragmentation, a main cause for delay in cancer diagnosis and treatment, contributes to high mortality in Latin America (LA), particularly among disadvantaged populations. This research focuses on integrated care interventions, which have been limitedly implemented in the region. The objective is to evaluate the contextual effectiveness of scaling-up an integrated care intervention to improve early diagnosis of frequent cancers in healthcare networks of Chile, Colombia and Ecuador.Methods and analysis This research is two pronged: (A) quasi-experimental design (controlled before and after) with an intervention and a control healthcare network in each LA country, using an implementation-effectiveness hybrid approach to assess the intervention process, effectiveness and costs; and (B) case study design to analyse access to diagnosis of most frequent cancers. Focusing on the most vulnerable socioeconomic population, it develops in four phases: (1) analysis of delays and barriers to early diagnosis (baseline); (2) intervention adaptation and implementation (primary care training, fast-track referral pathway and patient information); (3) intracountry evaluation of intervention and (4) cross-country analysis. Baseline and evaluation studies adopt mixed-methods qualitative (semistructured individual interviews) and quantitative (patient questionnaire survey) methods. For the latter, a sample size of 174 patients with cancer diagnosis per healthcare network and year was calculated to detect a proportions difference of 15%, before and after intervention (α=0.05; β=0.2) in a two-sided test. A participatory approach will be used to tailor the intervention to each context, led by a local steering committee (professionals, managers, policy makers, patients and researchers).Ethics and dissemination This study complies with international and national legal stipulations on ethics. It was approved by each country’s ethical committee and informed consent will be obtained from participants. Besides the coproduction of knowledge with key stakeholders, it will be disseminated through strategies such as policy briefs, workshops, e-tools and scientific papers IntroductionHealthcare fragmentation, a main cause for delay in cancer diagnosis and treatment, contributes to high mortality in Latin America (LA), particularly among disadvantaged populations. This research focuses on integrated care interventions, which have been limitedly implemented in the region. The objective is to evaluate the contextual effectiveness of scaling-up an integrated care intervention to improve early diagnosis of frequent cancers in healthcare networks of Chile, Colombia and Ecuador.Methods and analysisThis research is two pronged: (A) quasi-experimental design (controlled before and after) with an intervention and a control healthcare network in each LA country, using an implementation-effectiveness hybrid approach to assess the intervention process, effectiveness and costs; and (B) case study design to analyse access to diagnosis of most frequent cancers. Focusing on the most vulnerable socioeconomic population, it develops in four phases: (1) analysis of delays and barriers to early diagnosis (baseline); (2) intervention adaptation and implementation (primary care training, fast-track referral pathway and patient information); (3) intracountry evaluation of intervention and (4) cross-country analysis. Baseline and evaluation studies adopt mixed-methods qualitative (semistructured individual interviews) and quantitative (patient questionnaire survey) methods. For the latter, a sample size of 174 patients with cancer diagnosis per healthcare network and year was calculated to detect a proportions difference of 15%, before and after intervention (alpha=0.05; beta=0.2) in a two-sided test. A participatory approach will be used to tailor the intervention to each context, led by a local steering committee (professionals, managers, policy makers, patients and researchers).Ethics and disseminationThis study complies with international and national legal stipulations on ethics. It was approved by each country's ethical committee and informed consent will be obtained from participants. Besides the coproduction of knowledge with key stakeholders, it will be disseminated through strategies such as policy briefs, workshops, e-tools and scientific papers.

Although fragmentation in the provision of services is considered an obstacle to effective health care, there is scant evidence on the impact of interventions to improve care coordination between primary care and secondary care in terms of continuity of care—i.e. from the patient perspective—particularly in Latin America (LA). Within the framework of the Equity-LA II project, interventions to improve coordination across care levels were implemented in five Latin American countries (Brazil, Chile, Colombia, Mexico and Uruguay) through a participatory action research (PAR) process. This paper analyses the impact of these PAR interventions on the cross-level continuity of care of chronic patients in public healthcare networks. A quasi-experimental study was performed with measurements based on two surveys of a sample of patients with chronic conditions (392 per network; 800 per country). Both the baseline (2015) and evaluation (2017) surveys were conducted using the CCAENA questionnaire. In each country, two comparable public healthcare networks were selected, one intervention and one control. Outcomes were cross-level continuity of information and clinical management continuity. Descriptive analyses were conducted, and Poisson regression models with robust variance were fitted to estimate changes. With differences between countries, the results showed improvements in cross-level continuity of clinical information (transfer of clinical information) and clinical management continuity (care coherence). These results are consistent with those of previous studies on the effectiveness of the interventions implemented in each country in improving care coordination in Brazil, Chile and Colombia. Differences between countries are probably related to particular contextual factors and events that occurred during the implementation process. This supports the notion that certain context and process factors are needed to improve continuity of care. The results provide evidence that, although the interventions were designed to enhance care coordination and aimed at health professionals, patients report improvements in continuity of care.

Healthcare coordination is considered key to improving care quality. Although participatory action research (PAR) has been used effectively to bridge the gap between evidence and practice in other areas, little is known about the key success factors of its use in healthcare organizations. This article analyses the factors influencing the implementation of PAR interventions to improve clinical coordination from the perspective of actors in public healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay. A qualitative, descriptive-interpretative study was conducted in each country’s healthcare network. Focus groups and semi-structured individual interviews were conducted to a criterion sample of: local steering committee (LSC) (29), professional platform (PP) (28), health professionals (49) and managers (28). Thematic content analysis was conducted, segmented by country and themes. The PAR process led by the LSC covered the return of baseline results, selection of problems and interventions and design, implementation and adjustment of the intervention, with PP. Interventions were implemented to improve communication and clinical agreement between primary and secondary care. Results reveal that contextual factors, the PAR process and the intervention’s content influenced their implementation, interacting across time. First, institutional support providing necessary resources, and professionals’ and managers’ willingness to participate, emerge as contextual pivotal factors, influenced by other factors related to: the system (alignment with policy and political cycle), networks (lack of time due to work overload and inadequate working conditions) and individuals (not knowing each other and mutual mistrust). Second, different characteristics of the PAR process have a bearing, in turn, on institutional support and professionals’ motivation: participation, flexibility, consensual decision-making, the LSC’s leadership and the facilitating role of researchers. Evidence is provided that implementation through an adequate PAR process can become a factor of motivation and cohesion that is crucial to the adoption of care coordination interventions, leading to better results when certain contextual factors converge.

Despite relational continuity (RC) with the doctor being key to care quality for chronic patients, particularly in fragmented healthcare systems, like many in Latin America (LA), little is known about RC and its attributes, particularly regarding specialists. Aim: We aim to analyse chronic patients’ perceptions of RC with primary (PC) and secondary (SC) care doctors, and record changes between 2015 and 2017 in the public healthcare networks of six LA countries. An analysis of two cross-sectional studies applying the CCAENA questionnaire to chronic patients (N = 4881) was conducted in Argentina, Brazil, Chile, Colombia, Mexico, and Uruguay. The dependent variables of RC with PC and SC doctors were: consistency, trust, effective communication, and synthetic indexes based on RC attributes. Descriptive and multivariate analyses were performed. Although the RC index was high in 2015, especially in PC in all countries, and at both levels in Argentina and Uruguay, low perceived consistency of PC and SC doctors in Colombia and Chile and of SC doctors in Mexico revealed important areas for improvement. In 2017 the RC index of SC doctors increased in Chile and Mexico, while SC doctors’ consistency in Colombia decreased. This study reveals important gaps in achieving RC with doctors, particularly in SC, which requires further structural and organisational reforms.

Background Finding new strategies for care integration has become a policy priority for many fragmented health systems in Latin America. Although the implementation of interventions through a participatory action research (PAR) approach is considered to be more effective in achieving organizational change, its application is scarce. This study, part of the research project Equity-LA II, aims to analyze the impact of PAR interventions on care coordination across levels, and key aspects for their sustainability and transferability, from the stakeholder viewpoint in healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay. Different interventions were designed and implemented through a PAR process to improve communication and clinical agreement between primary care and secondary care doctors: joint meetings to discuss clinical cases and/or training; shared care guidelines; offline virtual consultations; a referral and reply letter; and an induction program. Methods A qualitative, descriptive-interpretative study was conducted in the healthcare network of each country. Focus groups and semi-structured individual interviews were conducted with a criterion sample of participants: local steering committee (29) and professional platform members (28), other health professionals (49) and managers (28). Thematic content analysis was conducted, segmented by country and type of intervention. Results Informants highlighted that joint meetings based on reflexive methods contributed substantially to improving contextually relevant elements of clinical management coordination – communication in patient follow-up, clinical agreement, appropriateness of referrals – and also administrative coordination. The meetings, alongside the PAR process, also helped to improve interaction between professionals – knowing each other personally and mutual trust – thus fostering willingness to collaborate. The PAR approach, moreover, served to spread awareness of the coordination problems and need for intervention, encouraging greater commitment and interest in participating. No noteworthy contributions were identified in remaining interventions due to low uptake. A necessary condition for the sustainability and replicability was that PAR process had to be used appropriately in a favourable context. Conclusions Evidence is provided on the substantial contribution of interventions to improving locally relevant clinical coordination elements and professional interaction when implemented through an adequate PAR process (in terms of time, method and participation levels), a necessary condition for their sustainability and replicability.

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.

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.

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.

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.

Objective: To analyse the care continuity across levels of care perceived by patients with chronic conditions in public healthcare networks in six Latin American countries (Argentina, Brazil, Chile, Colombia, Mexico and Uruguay), and to explore associated factors. Method: Cross-sectional study by means of a survey conducted to a random sample of chronic patients in primary care centres of the study networks (784 per country) using the questionnaire Cuestionario de Continuidad Asistencial Entre Niveles de Atención (CCAENA)©. Patients had at least one chronic condition and had used two levels of care in the 6 months prior to the survey for the same medical condition. Descriptive analysis and multivariable logistic regression were carried out. Results: Although there are notable differences between the networks analysed, the results show that chronic patients perceive significant discontinuities in the exchange of clinical information between primary care and secondary care doctors and in access to secondary care following a referral; as well as, to a lesser degree, regarding clinical coherence across levels. Relational continuity with primary care and secondary care doctors and information transfer are positively associated with care continuity across levels; no individual factor is systematically associated with care continuity. Conclusions: Main perceived discontinuities relate to information transfer and access to secondary care after a referral. The study indicates the importance of organisational factors to improve chronic patients’ quality of care. Resumen: Objetivo: Analizar la continuidad asistencial entre niveles de atención percibida por pacientes con enfermedades crónicas en redes sanitarias públicas de seis países latinoamericanos (Argentina, Brasil, Chile, Colombia, México y Uruguay) y explorar los factores asociados. Método: Estudio transversal mediante una encuesta realizada a una muestra aleatoria de pacientes crónicos en los centros de atención primaria de las redes de estudio (784 por país) utilizando el Cuestionario de Continuidad Asistencial Entre Niveles de Atención (CCAENA©). Los pacientes presentaban al menos una afección crónica y habían utilizado dos niveles de atención en los 6 meses anteriores a la encuesta por el mismo motivo. Se realizaron un análisis descriptivo y una regresión logística multivariante. Resultados: Aunque existen diferencias notables entre las redes analizadas, los resultados muestran que los pacientes crónicos perciben discontinuidades significativas en el intercambio de información clínica entre médicos de atención primaria y secundaria, y en el acceso a la atención secundaria tras una derivación, así como, en menor medida, en la coherencia clínica entre niveles. La continuidad de relación con los médicos de atención primaria y secundaria, y la transferencia de información, se asocian de manera positiva con la continuidad asistencial en ambos niveles; ningún factor individual se asocia sistemáticamente con la continuidad asistencial. Conclusiones: Las principales discontinuidades percibidas se relacionan con la transferencia de información y el acceso a la atención secundaria después de una derivación. El estudio indica la importancia de los factores organizativos para mejorar la calidad de la atención de los pacientes crónicos.

Antecedentes: La introduccion de mecanismos de coordinacion de la atencion entre los niveles de atencion tiene como objetivo mejorar la coordinacion clinica y la calidad de la atencion. La evidencia sobre su impacto es limitada y casi inexistente en America Latina. Nuestro objetivo es describir el grado de conocimiento y uso de los mecanismos de coordinacion de la atencion entre los niveles de atencion en seis redes publicas de salud de America Latina. Metodos: Estudio transversal basado en una encuesta que utiliza el cuestionario COORDENA (mayo-octubre de 2015) con medicos de atencion primaria (PC) y atencion secundaria (SC) de redes publicas de salud en Argentina, Brasil, Chile, Colombia, Mexico y Uruguay (348 medicos / pais ) Variables: grado de conocimiento y uso de la coordinacion de la informacion (carta de referencia / respuesta (RRL), informe de alta, telefono, correo electronico) y mecanismos de coordinacion del manejo clinico (guias clinicas compartidas (CG), reuniones conjuntas). Se realizaron analisis descriptivos. Resultados: El conocimiento de los mecanismos de coordinacion de la informacion clinica fue relativamente alto entre los medicos de ambos niveles de atencion y paises (del 44.2 al 100%) y tambien del uso frecuente de RRL (59 al 97.5%). Hubo una mayor variabilidad entre los niveles de atencion y los paises en el uso de informes de alta (12.3% en PC en Colombia a 74.7% en SC en Mexico) y telefono (1.3% en PC en Colombia a 64% en SC en Argentina). El conocimiento y el uso de CG fueron limitados en ambos niveles, excepto en Chile y Mexico. Se observo una variacion considerable en el conocimiento (3.7% Uruguay a 83.7% Chile) y participacion (17.8% Chile a 76.2% Brasil) en reuniones clinicas conjuntas. Las dificultades mas frecuentes en el uso de mecanismos fueron: los medicos no envian los informes RRL o de alta, los CG son dificiles de aplicar y las reuniones conjuntas no cumplen con las expectativas. Conclusiones: Excepto por los mecanismos de coordinacion de la informacion, existe un conocimiento limitado y, ademas de la carta de referencia / respuesta, tambien un uso limitado de los mecanismos de coordinacion de la atencion entre los niveles de atencion en las redes estudiadas. Este problema debe abordarse para mejorar su impacto. Mensajes clave: Esta es la primera encuesta que evalua el mecanismo de coordinacion de la atencion, el conocimiento y el uso por parte de los medicos de atencion primaria y secundaria en las redes publicas de atencion medica de America Latina. Estos resultados revelan un conocimiento limitado y el uso de algunos mecanismos de coordinacion de la atencion y margen de mejora. The Author (s) 2018. Publicado por Oxford University Press en nombre de la Asociacion Europea de Salud Publica. Todos los derechos reservados.

To analyze the level of knowledge and use, and the characteristics of use, of care coordination mechanisms in public healthcare networks of six Latin America countries.

To analyze the level of knowledge and use, and the characteristics of use, of care coordination mechanisms in public healthcare networks of six Latin America countries.Cross-sectional study based on a survey using the COORDENA® questionnaire with primary and secondary care doctors (348 doctors/country) of public healthcare networks in Argentina, Brazil, Chile, Colombia, Mexico and Uruguay (May-October 2015). Analyzed variables: degree of knowledge and use of information coordination (referral/reply letter, discharge report, phone, e-mail) and of clinical management coordination (shared clinical guidelines, joint meetings) mechanisms. Descriptive analyses were conducted.Knowledge of clinical information coordination mechanisms was high in both care levels and analyzed networks as was the use of referral/reply letter. There was greater variability in the use of discharge reports (from 40.0% in Brazil to 79.4% in Mexico) and, except for Argentina, a low reception reported by primary care doctors stands out (12.3% in Colombia and 55.1% in Uruguay). In contrast, knowledge of clinical management coordination mechanisms was limited, especially among secondary care doctors. It is noteworthy, however, that adherence to clinical guidelines was high (from 83.1% in Mexico to 96.8% in Brazil), while participation in joint meetings varied widely (from 23.7% in Chile to 76.2% in Brazil). The difficulties reported in the use of the mechanisms are related to structural and organizational factors.The limited knowledge and use of coordination mechanisms shows insufficient diffusion and implementation. Strategies to increase its use are needed, including the related factors.

An adequate use of referral and reply letters - the main form of communication between primary care (PC) and out-patient secondary care (SC) - helps to avoid medical errors, test duplications and delays in diagnosis. However, it has been little studied to date in Latin America. The aim is to determine the level and characteristics of PC and SC doctors' use of referral and reply letters and to explore influencing factors in public healthcare networks of Argentina, Brazil, Chile, Colombia, Mexico and Uruguay. A cross-sectional study was conducted through a survey of PC and SC doctors working in public healthcare networks (348 doctors per country). The COORDENA questionnaire was applied to measure the frequency of use and receipt of referral and reply letters, quality of contents, timeliness and difficulties in using them. Descriptive analyses were conducted and a multivariate logistic regression model was generated to assess the relationship between frequent use and associated factors. The great majority of doctors claim that they send referral letters to the other level. However, only half of SC doctors (a higher proportion in Chile and Mexico) report that they receive referral letters and

CUESTIONARIO DE CONTINUIDAD ENTRE NIVELES DE ATENCIÓN (CCAENA-ARGENTINA)

CUESTIONARIO DE CONTINUIDAD ENTRE NIVELES DE ATENCIÓN (CCAENA-COLOMBIA)

Improving coordination between primary care (PC) and secondary care (SC) has become a policy priority in recent years for many Latin American public health systems looking to reinforce a healthcare model based on PC. However, despite being a longstanding concern, it has scarcely been analyzed in this region. This paper analyses the level of clinical coordination between PC and SC experienced by doctors and explores influencing factors in public healthcare networks of Argentina, Brazil, Chile, Colombia, Mexico and Uruguay. A cross-sectional study was carried out based on a survey of doctors working in the study networks (348 doctors per country). The COORDENA questionnaire was applied to measure their experiences of clinical management and information coordination, and their related factors. Descriptive analyses were conducted and a multivariate logistic regression model was generated to assess the relationship between general perception of care coordination and associated factors. With some differences between countries, doctors generally reported limited care coordination, mainly in the transfer of information and communication for the follow-up of patients and access to SC for referred patients, especially in the case of PC doctors and, to a lesser degree, inappropriate clinical referrals and disagreement over treatments, in the case of SC doctors. Factors associated with a better general perception of coordination were: being a SC doctor, considering that there is enough time for coordination within consultation hours, job and salary satisfaction, identifying the PC doctor as the coordinator of patient care across levels, knowing the doctors of the other care level and trusting in their clinical skills. These results provide evidence of problems in the implementation of a primary care-based model that require changes in aspects of employment, organization and interaction between doctors, all key factors for coordination. © 2017 The Authors

Chile, together with El Salvador, Malta and Nicaragua has the most restrictive abortion laws. In these countries there is very little information on pregnancies that end in abortions. An analysis is made of official information regarding hospital discharges for abortion in Chile between 2001 and 2010, classified according to age and according to the WHO ICD 10. The Chilean Ministry of Health’s Statistics Office (DEIS) collected the data. In 334,485 hospital discharges for abortion, Ectopic Abortion (O00), the Hydatidiform Mole (O01) and Other Abnormal Products of Conception (O02) corresponded to 37.2% of hospital discharges. Spontaneous Abortion (O03) reached 15% and Non Specified Abortion (O06) reached 35.5% and most probably included complications of induced abortions. 77% of hospital discharges corresponded to women between 20 and 34 years of age. Adolescents correspond to 11% of hospital discharges. In the annual average of 33,500 hospital discharges, Other Abnormal Products of Conception (O02), Other Abortions (O05), and Non Specified Abortions (O05) contribute to 72.7% of hospital discharges. This is explained by incomplete diagnoses, by means of the omission of induced abortion as this would mean jail for the woman and legal red-tape for the health personnel involved. Maternal mortality has not fallen. Abortion Mortality and Fatality rates do not change. There is a discrepancy between the law and hospital discharge diagnoses for abortion. The antiabortion law remains unheeded and obeys an ideological bias that brings damage and abuse to Chilean women. The aim of this study is to gain better information from a country that does not allow abortion under any circumstance, and its usefulness to countries in similar situations, together with its negative consequences on woman’s health and rights.

BACKGROUND: There are legal regulations about sexual and reproductive rights of adolescents. However, this legal framework (LF) may have contradictory elements: there are laws assuring confidentiality and access to contraception at any age but there are other laws that consider any sexual contact with an adolescent younger than 14 a sexual assault, whose report to the legal authorities in mandatory. AIM: To explore the knowledge and clinical practice of primary health care (PHC) providers regarding prevention of teenage pregnancy. MATERIAL AND METHODS: Qualitative study collecting data using semi-structured interviews made to midwives and directors of PHC centers. Analysis of the data was based on Grounded Theory. RESULTS: There is a differentiated clinical care for pregnancy prevention among adolescents if they are over 14 years old. This is due to the LF, specifically to the sexual crime’s law (19,927) and the law about regulation of the fertility (20,418). The differences affect health care, access and counseling about contraception and confidentiality. Healthcare of teenagers under the age of 14 is perceived as problematic for providers, due to the possible legal implications. CONCLUSIONS: The LF causes insecurity on health care providers and derives in a differentiated clinical approach according to the patient´s age. This is a barrier to provide timely and confidential access to counseling and contraception. Language: es

"Introduccion Aunque la fragmentacion en la provision de atencion medica se considera un obstaculo importante para una atencion efectiva, la evidencia sobre las mejores practicas en la coordinacion de la atencion en America Latina es escasa. El objetivo del proyecto Equity-LA financiado por el 7PM es evaluar la efectividad de diferentes estrategias de integracion de la atencion para mejorar la coordinacion entre los niveles de atencion y la calidad de la atencion relacionada en seis sistemas de atencion medica: Argentina, Brasil, Chile, Colombia, Mexico y Uruguay. Metodos y analisis: Un estudio cuasi experimental controlado antes y despues que toma un enfoque de investigacion de accion participativa. En cada pais, se seleccionaron dos redes sanitarias comparables (intervencion y control). El estudio consta de cuatro fases: 1) Estudio de linea de base para establecer el desempeno de la red en la coordinacion y continuidad de la atencion, utilizando a) metodos cualitativos: entrevistas semiestructuradas y grupos focales de administradores de salud, profesionales y usuarios; yb) metodos cuantitativos: dos encuestas por cuestionario con muestras de 173 medicos de atencion primaria y secundaria y 392 usuarios con afecciones cronicas por red; tamano de muestra calculado para detectar una diferencia de proporcion de 15% y 10%, antes y despues de la intervencion (? = 0.05; ? = 0.2 en una prueba de dos lados); 2) Seleccion participativa ascendente, diseno e implementacion de estrategias de atencion compartida, un proceso dirigido por el comite directivo local; 3) Evaluacion de la efectividad de las intervenciones que aplican el mismo diseno que en el estudio de linea de base y los factores asociados; 4) Analisis comparativo entre paises. Resultados y relevancia El proyecto generara evidencia para informar la formulacion de politicas sobre las mejores practicas de integracion entre la atencion primaria y secundaria en diferentes tipos de sistemas de salud en America Latina, con especial referencia a las enfermedades cronicas, y sobre el efecto de los nuevos enfoques organizacionales en la calidad de la atencion, en diferentes contextos de asistencia sanitaria tambien relevantes para los sistemas sanitarios europeos. Mensajes clave Existe poca evidencia sobre las mejores practicas en coordinacion de la atencion en America Latina Los resultados sobre la coordinacion de la atencion pueden depender del factor contextual y del proceso. The Author 2015. Publicado por Oxford University Press en nombre de la Asociacion Europea de Salud Publica. Todos los derechos reservados."

CUESTIONARIO DE CONTINUIDAD ENTRE NIVELES DE ATENCIÓN (CCAENA-URUGUAY)

CUESTIONARIO DE CONTINUIDAD ENTRE NIVELES DE ATENCIÓN (CCAENA-MX)

QUESTIONÁRIO DE CONTINUIDADE ENTRE NÍVEIS DE ATENÇÃO (CCAENA-BRASIL)

CUESTIONARIO DE CONTINUIDAD ENTRE NIVELES DE ATENCIÓN (CCAENA-CHILE)

There are legal regulations about sexual and reproductive rights of adolescents. However, this legal framework (LF) may have contradictory elements: there are laws assuring confidentiality and access to contraception at any age but there are other laws that consider any sexual contact with an adolescent younger than 14 a sexual assault, whose report to the legal authorities in mandatory.To explore the knowledge and clinical practice of primary health care (PHC) providers regarding prevention of teenage pregnancy.Qualitative study collecting data using semi-structured interviews made to midwives and directors of PHC centers. Analysis of the data was based on Grounded Theory.There is a differentiated clinical care for pregnancy prevention among adolescents if they are over 14 years old. This is due to the LF, specifically to the sexual crime’s law (19,927) and the law about regulation of the fertility (20,418). The differences affect health care, access and counseling about contraception and confidentiality. Healthcare of teenagers under the age of 14 is perceived as problematic for providers, due to the possible legal implications.The LF causes insecurity on health care providers and derives in a differentiated clinical approach according to the patient´s age. This is a barrier to provide timely and confidential access to counseling and contraception.

Objetivo. Identificar dificultades para el acceso a atención e información en anticoncepción de adolescentes desde percepciones y experiencias de trabajadores de la salud de Huechuraba, en la Región Metropolitana de Chile. Métodos. Este estudio cualitativo y descriptivo incorporó principios de investigación acción participativa involucrando a equipos de atención en el levantamiento y análisis de información, con generación de propuestas de mejora. Se realizaron 17 entrevistas individuales semiestructuradas y una entrevista grupal, con profesionales y técnicos involucrados en la atención de adolescentes en centros de salud de la comuna. Resultados. Trabajadores de la salud percibían dificultades en la llegada de adolescentes a los centros por razones relacionadas a factores culturales, falta de información y de actividades de salud en la comunidad. Existen requisitos administrativos y tramitaciones que obstaculizan el acceso a la atención. Se evidenciaron falencias en el manejo e interpretación de normas de regulación de la fertilidad y de la legislación vigente y ausencia de marcos explicativos que reconociesen el género y derechos sexuales y reproductivos de los adolescentes. Conclusiones. Existe poca visibilidad de los adolescentes y sus necesidades, y contradicciones entre los discursos y las prácticas, con ausencia de definiciones y acuerdos para el acceso a anticoncepción y consejería que consideren contextos sociales y culturales. Urge la implementación de acciones de capacitación para trabajadores de la salud en género y derechos sexuales y reproductivos, junto con espacios de reflexión para generar abordajes articulados y efectivos. Se requieren esfuerzos de difusión del programa y realización de actividades en espacios comunitarios, junto con otros sectores comunales.