Chilean Primary Health Care Research Articles

Cultural competence in a primary healthcare center in Santiago de Chile: a mixed methods design.

The immigrant population in Chile is growing significantly, challenging the health care system's capacity to provide sensitive and effective care. To assess the cultural competence of Chilean primary health workers. This mixed-methods study used a quantitative scale and semi-structured interviews to examine the cultural competence of a Chilean primary health care team in their care for the international migrant population. The study pointed to specific variables that were associated with increased cultural competence, including age, intercultural life experiences, and having received relevant training. The two approaches produced largely convergent results. The dimensions of cultural competence with the highest scores on the quantitative scale were also the theoretical dimensions with the greatest discursive density in the qualitative analysis. The analysis provides a starting point for policies aimed at the development of cultural competence in the national scenario, suggesting a general direction to foster transcultural competence in health, such as formal training and the promotion of informal spaces ofsensibilization.

Latent Class Analysis in Depression, Including Clinical and Functional Variables: Evidence of a Complex Depressive Subtype in Primary Care in Chile.

Objective To establish differentiated depressive subtypes using a latent class analysis (LCA), including clinical and functional indicators in a sample of depressed patients consulted in Chilean Primary Health Care. Methods A LCA was performed on a sample of 297 depressed patients consulted in Chilean PHC. The Mini International Neuropsychiatric Interview, the Hamilton Depression Rating Scale, the Outcome Questionnaire -social role, and interpersonal subscales were as instruments. A regression analysis of the different subtypes with sociodemographic and adverse life experiences was performed. Results In a sample characterized by 87.5% of women, two, three, and four latent class models were obtained. The three-class model likely represents the best clinical implications. In this model, the classes were labeled: “complex depression” (CD) (58% of the sample), “recurrent depression” (RD) (34%), and “single depression episode” (SD) (8%). Members of CD showed a higher probability of history of suicide attempts, interpersonal, and social dysfunction. Psychiatric comorbidities differentiated the RD from SD. According to a multinomial regression model, childhood trauma experiences, recent stressful life experiences, and intimate partner violence events were associated with the CD class (p < 0.01). Limitations. The vast majority of participants were females from Chile and the sample studied was not random. So, the results may not necessarily represent outpatient clinics. Conclusions This study can provide additional evidence that depression, specifically in female gender, could be better understood as a complex heterogeneous disorder when clinical and functional indicators are studied. Furthermore, adverse life experiences starting in childhood could lead to a differentiated complex depressive subtype.

Management of unexplained: poly-consultation and hyperfrequency on Primary Health Chilean Attention. A qualitative and exploratory study

BackgroundIn Europe, Latin-America, and Asia, poly-consultation has become a complex problem for managing different healthcare systems. However, in the current literature, little attention has been paid to exploring territorial and critical analysis perspectives to manage unexplained symptoms. The purpose of this study is to analyze the socio-structural elements that underlie the users’ phenomenon of poly-consultation or hyperfrequency in the Chilean primary healthcare system (PHCS).MethodsThis paper represents qualitative data collected as part of an exploratory study that used mixed methods across three metropolitan areas of Santiago, Valparaíso, and Concepción, Chile. The study involved a sample of 24 subjects from administrative and management positions in PHC who were recruited from Family Health Care Centers, considering urban municipalities from the low, medium, and high stratum. The study collected data using one set of semi-standardized interviews during a year—data analysis using qualitative content analysis.ResultsThis article shows that poly-consultant patients provide a critical clinic category to management that cannot be cover by current biomedical models. Data showed the strain of a somatoform category, especially in the clinic and epistemological exercise. Precisely, the relevance of Chile’s case, a mixed health system, and their effects: the naturalization of collective problems managed as individual problems.ConclusionsThe study results can inform healthcare professionals and managers of developing practical and territorially based. We conclude that hyperfrequency and poly-consultation in Chile reveal relevant stratification in the territory. Those particularities open an opportunity to study quantitative methods, including current analysis categories, to develop new research.

40 Años de la Declaración de Alma Ata. Semblanza histórica del desempeño de Trabajo Social en la Atención Primaria de Salud chilena

El presente artículo conmemora los 40 años de la Declaración de la Conferencia Internacional sobre Atención Primaria realizada en Alma Ata-URSS en 1978, acuerdo internacional que transformó la atención sanitaria desde un nivel formal de atención, a una estrategia de desarrollo nacional. Su propósito original fue proporcionar las orientaciones especializadas que permitieran acercarse a la meta de asegurar a las poblaciones de todas las regiones del mundo Salud para Todos en el año 2000. En este marco y tomando como referente central la Declaración de Alma Ata, se presenta una semblanza histórica que permite revisar los principales antecedentes de la Atención Primaria chilena desde inicios de la república a la fecha, visibilizando los aportes profesionales que ha realizado Trabajo Social en el marco sanitario del país.

Validation of the Opening Minds Scale and patterns of stigma in Chilean primary health care.

ObjectivesStigma toward people with mental health problems (MHP) in primary health care (PHC) settings is an important public health challenge. Research on stigma toward MHP is relatively scarce in Chile and Latin America, as are instruments to measure stigma that are validated for use there. The present study aims to validate the Opening Minds Scale for Health Care Professionals (OMS-HC) among staff and providers in public Chilean PHC clinics, and examine differences in stigma by sociodemographic characteristics.Methods803 participants from 34 PHC clinics answered a self-administered questionnaire. Confirmatory factor analysis was completed. Average 15-item OMS-HC scores were calculated, and means were compared via t-test or ANOVA to identify group differences. Correlations of OMS-HC scores with other commonly used stigma scores were calculated to evaluate construct validity.ResultsThe 3-factor OMS-HC structure was confirmed in this population. The average OMS-HC (α = 0.69) score was 34.55 (theoretical range 15–75). Significantly lower (less stigmatizing) mean OMS-HC scores were found in those with additional training and/or personal experience with MHP.ConclusionThe validated, Spanish version of OMS-HC can be of use to further research stigma toward MHP in Chile and Latin America, advancing awareness and inspiring interventions to reduce stigma in the future.

Factors Associated with Psychiatric Comorbidity in Depression Patients in Primary Health Care in Chile.

Objective To identify the clinical and psychosocial factors associated with psychiatric comorbidity in patients consulting for depression in Primary Health Care (PHC) in Chile. Methods 394 patients with a diagnosis of major depression being treated in a Chilean PHC were evaluated using a sociodemographic and clinical interview, the mini-international neuropsychiatric interview (MINI), a childhood trauma events (CTEs) screening, the intimate partner violence (IPV) scale, the Life Experiences Survey (LES), and the Hamilton Depression Rating Scale (HDRS). Results Positive correlations were established between higher number of psychiatric comorbidities and severity of depressive symptoms (r = 0.358), frequency of CTEs (r = 0.228), frequency of IPV events (r = 0.218), frequency of recent stressful life events (r = 0.188), number of previous depressive episodes (r = 0.340), and duration of these (r = 0.120). Inverse correlations were determined with age at the time of the first consultation (r = -0.168), age of onset of depression (r = -0.320), and number of medical comorbidities (r = -0.140). Of all associated factors, early age of the first depressive episode, CTEs antecedents, and recent stressful life events explain 13.6% of total variability in psychiatric comorbidities. Conclusions A higher prevalence of psychiatric comorbidity among subjects seeking help for depression in Chilean PHCs is associated with early onset of depression, clinical severity, chronicity, and interpersonal adversity experienced since childhood.

Modelo cuantitativo para mejorar el financiamiento de la atención primaria en Chile.

ABSTRACTObjective.Propose and apply a methodology to estimate adjusted expected expenditure in each locality in the Chilean primary health care (PHC) system in 2016.Methods.First of all, expected per capita expenditure at the national level was calculated on the basis of a detailed health plan, and then a zero-sum adjustment was made to the expenditure in each locality, using the local age/sex profile and the local average socioeconomic level, years of life lost, and rurality, given their statistically significant impact on epidemiology and spending structures.Results.The model establishes a conceptual and empirical link between expected expenditure and adjustment variables; it is flexible in terms of successive improvements; and its zero-sum property facilitates discussion of the global budget. When real data for the year 2016 in Chile were used, it was found that the absolute distance between the amounts in the model and the amounts actually used that year was 7.6%, on average.Conclusions.There are simple empirical options for calculating expected expenditure across localities, for which it is very helpful to have a good estimate of expected expenditure at the national level.

Desempeño de las enfermeras en Atención Primaria de Salud: un Enfoque Fenomenológico

The objective of this study was to identify the performance of Chilean primary health care nurses. This was a qualitative study based on the approach of social phenomenology. Data collection was conducted between January and April 2013 through interviews with 13 nurses. Nurse performance showed that they experience greater professional autonomy and are closer to users; however, they suffered from professional burnout. Their expectations included the desire to be recognized for their work and better service management. Contributions of this study include the possibility of considering new designs for professional management practices in primary health care from the perspective of Chilean nurses. These designs should be based on the reorganization of work processes and by occupying spaces in macropolitics, influencing the professional performance of nurses at this level of health care.

Effectiveness of a normative nutrition intervention (diet, physical activity and breastfeeding) on maternal nutrition and offspring growth: the Chilean maternal and infant nutrition cohort study (CHiMINCs).

BackgroundMaternal obesity before and during pregnancy predicts maternal and infant risks of obesity and its associated metabolic conditions. Dietary and physical activity recommendations during pregnancy as well as weight monitoring are currently available in the Chilean primary health care system. However some of these recommendations are not updated and most of them are poorly implemented. We seek to assess the effectiveness of an intervention that enhances the implementation of updated nutrition health care standards (diet, physical activity, and breastfeeding promotion) during pregnancy on maternal weight gain and infant growth.MethodsDesign & Setting: Cluster randomized controlled trial. The cluster units will be 12 primary health care centers from two counties (La Florida and Puente Alto) from the South-East Area of Santiago randomly allocated to: 1) enhanced nutrition health care standards (intervention group) or 2) routine care (control group).Participants: Women seeking prenatal care before 15 weeks of gestation, residing within a catchment area of selected health centers, and who express that they are not planning to change residence will be invited to participate in the study. Pregnant women classified as high risk according to the Chilean norms (i.e age <16 or >40 years, multiple gestation, pre-gestational medical conditions, previous pregnancy-related issues) and/or underweight will be excluded.Intervention: Pregnant women who attend intervened health care centers starting at their first prenatal visit will receive advice regarding optimal weight gain during pregnancy and diet and physical activity counseling-support. Pregnant women who attend control health clinics will receive routine antenatal care according to national guidelines. We plan to recruit 200 women in each health center. Assuming a 20 % loss to follow up, we expect to include 960 women per arm.Main outcome measures: 1) Achievement of adequate weight gain based on IOM 2009 recommendations and adequate glycaemic control at 24-28 weeks of pregnancy according to ADA 2011, and 2) healthy infant growth during the first year of age based on WHO standards.DiscussionWe expect that the intervention will benefit the participants in achieving adequate weight gain & metabolic control during pregnancy as well as adequate infant growth as a result of an increased impact of standard nutrition and health care practices. Gathered information should contribute to a better understanding of how to develop effective interventions to halt the maternal obesity epidemic and its associated co-morbidities in the Chilean population.Trial registrationClinicaltrials.gov Identifier: NCT01916603

Measuring the Efficiency of Chilean Primary Healthcare Centres

This paper examines whether different approaches for estimating the technical efficiency of a primary healthcare centre —PHC— can have significantly different results. Although effective regulation demands the development of measures for establishing good operation levels, few studies have compared results from a data envelopment analysis —DEA— and stochastic frontier analysis —SFA—in a PHC. Furthermore, to the best of our knowledge, no studies have used Chilean nationwide data. Efficiency refers to the relation between the number of output units per input unit. Effectiveness evaluates the outcome of medical care and can be influenced by efficiency.The data that were used in this study came from 259 Chilean municipalities. We included two outputs – medical and check-up visits – and three inputs – staff, general service and drugs expenses. For the DEA, we used a variable return to scale output-oriented model. Before applying the SFA, a principal component analysis —PCA— combined the two outputs. The results were similar for both methods: the SFA efficiency averages were 70.89% and 65.83% and the DEA averages were 68.37% and 54.46% for the urban and rural municipalities, respectively. In addition to defining a frontier of “best practice”, this study merged the PCA with the SFA to form an innovative approach to combining outputs.

Validation of the Spanish version of the “Questionnaire on the treatment of approximal and occlusal caries”

To translate and validate a Spanish version of the "Questionnaire on the treatment of approximal and occlusal caries" as a method of collecting information about treatment decisions on caries management in Chilean primary health care services. The original questionnaire proposed by Espelid et al. was translated into Spanish using the forward-backward translation technique. Subsequently, validation of the Spanish version was undertaken. Data were collected from two separate samples; first, from 132 Spanish-speaking dentists recruited from primary health care services and second, from 21 individuals characterised as cariologists. Internal consistency was evaluated by the generation of Cronbach's alpha, test-retest reliability was evaluated by Cohen's kappa, convergent validity was evaluated by comparing the total scale scores to a global evaluation of treatment trends and discriminant validity was evaluated by investigating the differences in total scale scores between the Spanish-speaking dentist and cariologist samples. Cronbach's alpha indicated an internal consistency of 0.63 for the entire scale. Cohen's kappa correlation coefficient expressed a test-retest reliability of 0.83. Convergent validity determined a Pearson's correlation coefficient of 0.24 (p < 0.01). The comparison of proportions (chi-squared) indicated that discriminant validity was statistically significant (p < 0.01), using a one-tailed test. The Spanish version of the "Questionnaire on the treatment of approximal and occlusal caries" is a valid and reliable instrument for collecting information regarding treatment decisions in cariology. The clinical relevance of this study is to acquire a reliable instrument that allows for the determination of treatment decisions in Spanish-speaking dentists.

Overcoming barriers in the management of hypertension: the experience of the cardiovascular health program in chilean primary health care centers.

Objective. To assess the blood pressure control and cardiovascular risk factors (CVRFs) in a population of hypertensive patients with access to care under a government-financed program, the Cardiovascular Health Program (CHP). Design. A cross-sectional and multicenter study. Setting. 52 primary care centers, metropolitan area of Santiago, Chile. Participants. 1,194 patients were selected by a systematic random sampling from a universe of 316,654 hypertensive patients. Key Measurements. Demographic information, blood pressure (BP) measurements, and CVRF were extracted from medical records of patients followed for a 12-month period. Results. 59.7% of patients reached target BP <140/90 mmHg. More women were captured in the sampling (2.1 : 1), achieving better BP control than men. Diabetic patients (26.4%) had worse BP control than nondiabetics. Antihypertensive medications were used in 91.5%, with multidrug therapy more frequent in patients with higher BP and more difficult control. Conclusions. The success in improving the BP control to values <140/90 mmHg from 45.3% to 59.7% underscores the contribution of this program in the Chilean primary care cardiovascular preventive strategies. However, fewer hypertensive men than women were captured by this program, and it is of concern the underperforming of BP control observed in diabetics.

El programa nacional para el diagnóstico y tratamiento de depresión en atención primaria: una evaluación necesaria

Depression is highly prevalent among Chilean adults, therefore a primary care treatment program was devised.To evaluate the Program for detection, diagnosis and integral treatment of depression, implemented in Chilean Primary Health Care Centers.A three and six months follow-up study was conducted among women admitted to the program at seven primary health care centers in two regions of Chile. Socio-demographic data, treatments provided and compliance with the program were assessed. A clinical standardized interview (with ICD-10) was carried out and the intensity of depressive symptoms was evaluated using Beck Depression Inventory (BDI).The initial sample was composed by 201 women aged 25 to 65 years. At 6 months, 35% were lost from follow up. Depression was mild, moderate or severe in 12, 63 and 25% of women, respectively. The severity of depression was underestimated by primary care teams. Among women with regular and irregular attendance to medical appointments and those that abandoned treatment, BDI score decreased by 35, 37 and 13%, respectively.This primary care program for depression was effective to reduce BDI scores. Diagnostic precision of primary care teams must be improved.

Evaluation of the program for detection and treatment of depression in Chilean primary health care centers

Depression is highly prevalent among Chilean adults, therefore a primary care treatment program was devised. To evaluate the Program for detection, diagnosis and integral treatment of depression, implemented in Chilean Primary Health Care Centers. A three and six months follow-up study was conducted among women admitted to the program at seven primary health care centers in two regions of Chile. Socio-demographic data, treatments provided and compliance with the program were assessed. A clinical standardized interview (with ICD-10) was carried out and the intensity of depressive symptoms was evaluated using Beck Depression Inventory (BDI). The initial sample was composed by 201 women aged 25 to 65 years. At 6 months, 35% were lost from follow up. Depression was mild, moderate or severe in 12, 63 and 25% of women, respectively. The severity of depression was underestimated by primary care teams. Among women with regular and irregular attendance to medical appointments and those that abandoned treatment, BDI score decreased by 35, 37 and 13%, respectively. This primary care program for depression was effective to reduce BDI scores. Diagnostic precision of primary care teams must be improved.

A Multiple Stage Approach for Performance Improvement of Primary Healthcare Practice

Chilean primary healthcare practice is analyzed using a Data Envelopment Analysis (DEA) multiple stage approach. We estimate the efficiency level of 259 municipalities nationwide. Since the efficiency score by itself is of limited value for decision making, we use a multivariate tool to help explain the effect of relevant factors. First, we use a cluster analysis to homogenize the units under study. Second, we use DEA to estimate the efficiency levels, which varies from 61% to 71% for urban municipalities, and from 51% to 56% in rural ones. Third, we use bootstrap to estimate confidence intervals for the efficiency scores, and a Biplot method to identify adequate variables to include in the Tobit Model, which is our last stage. We identify six factors associated with rural municipalities' operational efficiency, and two with urban ones. Knowing the efficiency level of municipalities can help determine ways to improve their efficiency.

Guías de práctica clínica en atención primaria: Una evaluación crítica

There are doubts about the real usefulness of clinical guidelines to induce changes in practice, specially in primary health care. Those guidelines with inconsistent recommendations can even be misleading.To assess the quality of Chilean primary health care guidelines and to identify factors associated with high quality guidelines.Chilean primary care guidelines published and disseminated using any strategy 1999 and 2004 were analyzed. Each selected guideline was assessed independently by two evaluators using the Appraisal of Guidelines, Research and Evaluation (AGREE) instrument following standardized instructions. Descriptive statistics for each dimension of the AGREE instrument were calculated for each guideline.A total of 33 guidelines were retrieved. Fifteen were located using a manual search and 18 from electronic sources. Twenty four did not match our definition of guidelines, therefore only nine were included in the final assessment. There were important differences in the scores obtained by each guideline in different dimensions, with relevant methodological shortcomings. However, no significant differences in scores were found when guidelines were compared by year of elaboration.Our results suggest that previous efforts in primary health care guideline development were misdirected and that important changes are necessary to generate high quality guidelines.

Training Chilean primary health care professionals in nutrition for noncommunicable disease prevention

To assess three related issues: (1) the need for training in nutrition and prevention of noncommunicable diseases (NCDs) as perceived by primary health care (PHC) personnel in Chile, (2) those health workers' preferred sources of training to learn about that subject, and (3) reactions to some materials that were later developed to help meet the needs that were identified. In the summer of 2001 a questionnaire survey was used with PHC staff members in 3 of Chile's 13 regions in order to evaluate their perceived need for training in nutrition and NCD prevention as well as their preferred sources of continuing education. As a follow-up to the 2001 survey, in 2002, information material was prepared on using diet and physical activity to prevent NCDs. The information package was introduced through a series of workshops in all the regions of Chile. An evaluation in 2003 assessed the reactions to the new material. Four hundred thirty-one valid questionnaires from the 2001 survey were analyzed. The participants reported a strong need for further education in the area of nutrition for NCD prevention. The perceived need for further training was highest among nursing aides, and it was lowest among nutritionists. Most of the health personnel reported that patients often asked them about dietary issues, most frequently how to lose weight and how to follow a healthy diet. The sources of continuing education that the health workers had used most frequently were professional journals, information from the Ministry of Health, and courses. In comparison to the university-trained health professionals, the non-university-trained nursing aides differed significantly in their perceived need for more training, as well as the sources that they had used for continuing education (P < 0.05 for both). The evaluation in 2003 to assess the reactions to the new information material found a generally favorable response to the package. The Chilean PHC personnel perceived a strong need for training in nutrition as related to NCD prevention. In response, various activities are now being carried out, with goals that include enhancing the knowledge of PHC workers about possibilities for NCD prevention, encouraging a team approach to prevention, and offering more community-oriented services.