Health services play a crucial role in reaching the 90-90-90 target of controlling the HIV epidemic. This study evaluates the organization of Brazilian health services in improving, monitoring, and retention in HIV care and adherence support. Percentage variation (PV) was used to compare the responses by services to an evaluation questionnaire on organizational quality (Qualiaids) in 2007 and 2010. The study analyzed the 419 services that completed the questionnaire in 2007 (83.1% of respondents) and 2010 (63.6%). Management actions of retention and support although increased in the period, but remained at low rates, for example: systematic meetings for case discussion (32.7% in 2010; PV = 19.8%) and recording of missed medical appointments (35.3%; PV = 36.8%). Patient care actions related to adherence to ART remained largely exclusive to the attending physician. The supply of funds and resources from the Federal Government (medicines and specific HIV tests) remained high for the vast majority of the services (~90%). It will not be possible to achieve a significant decrease in HIV transmission as long as retention in treatment is not a priority in all the health services.
The persistence of bio-medically oriented practices and the mismatch between training and work are identified as the challenges for the rolling out of Primary Health Care (PHC) in Brazil.This paper analyzes work changes in PHC after following specialization level training courses on community and family health, from the point of view of the trained professionals. It is a qualitative study carried on from 2011 to 2013 in the Federal District (DF) involving doctors, nurses and dentists. Data was collected with the use of digital questionnaires, semistructured interviews and focal groups. From the thematic content analysis, two categories emerged: "a universe of knowledge has opened up" and a "new way of doing things in an adverse working environment". The context of the PHC in DF is a constraint but the training had the potential to generate professional competences. Teamwork has been neglected in professional training [12][13][14] in spite of the ample consensus of its fundamental role in implementing comprehensive actions. COMUNICAÇÃO SAÚDE EDUCAÇÃO 2016; 20(58):691-702The contradictions between professional practices and training call for revisiting the educational strategies 15 to incorporate the dialectic relations between labor and education. Complexity of health issues and of the actions that such issues demand, show the urgent need to develop pedagogic processes encompassing political, organizational and operational competences at all levels of the health system, thus breaking apart with the point of view that looks down on PHC while overrating technologically dense techniques developed in the secondary and tertiary levels of health care.It is therefore a main task to put together teams able to act in synergy with different social policies and existing resources, taking into account the multiple factors that affect the quality of life of populations, and at the same time the imperatives of universal and democratic access to health, the interactions with other levels of care, the working conditions and the diversity of stakeholders that are needed to make SUS a reality. To effectively implant a model that goes beyond the biomedical approach, there is a need to make changes in the day-by-day context of work and in the professionals' mindset about the mode of production in health.In this context, an array of graduate courses have being supported through grants of the Ministries of Health and Education since the 90's as a strategy to train professionals able to perform competently in HFS, following the NPPHC.Working in PHC, using knowledge and practices to face problems that are frequently rooted outside the health area, demands specific competence. This competence may be characterized as a dialectic combination of different ingredients that integrate how to act, i.e. "the mastery of the precedent norms" 16 , to be willing to act, " to be motivated to adhere to a collective project" and to be able to act, " to be capable of facing the environment's restrictions" 17.Taking into account the fact that there is no...
Resumo O texto apresenta a experiência da Escola de Aperfeiçoamento do Sistema Único de Saúde (EAPSUS), que, como a Escola Superior em Ciências da Saúde e a Escola Técnica de Saúde de Brasília, é mantida pela Fundação de Ensino e Pesquisa em Ciências da Saúde. As Escolas atuam de modo complementar na formação em saúde no DF. Alinhada aos princípios e às diretrizes da Política Nacional de Educação Permanente em Saúde, a EAPSUS é responsável pela educação de servidores da SES e propõe como referencial a Pedagogia da Problematização. Busca incorporar ensino e aprendizado às necessidades dos serviços tornando profissionais atores reflexivos e construtores de alternativas de ação. Apresenta no seu escopo de atuação um recorte singular que lhe confere certa especificidade como escola de governo, por propor ações educativas contextualizadas. A educação é componente estratégico de um desenho ambicioso que alinha conceitos, diretrizes e instrumentos com o planejamento estratégico das unidades e com o Plano de Saúde do DF. A FEPECS conforma uma escola de saúde pública por contemplar em suas vertentes o ensino superior e a pós-graduação, o ensino profissionalizante e a qualificação de trabalhadores e gestores do SUS do Distrito Federal, constituindo-se lócus de desenvolvimento da política distrital de formação na área de saúde.
OBJECTIVE To present the development and validation of the WebAd-Q Questionnaire, a self-report instrument to monitor adherence to antiretroviral therapy in HIV/AIDS centers in Brazil.METHODS The WebAd-Q is an electronic questionnaire that has three questions about the use of antiretrovirals in the last week. It was constructed from interviews and focus groups with 38 patients. Its validity was tested in a study with a sample of 90 adult patients on antiretroviral therapy for at least three months. We used electronic monitoring bottles, pill counting, and self-report interview to compare adherence. The WebAd-Q was answered on the sixtieth day, twice, with at least one hour of interval. The viral load of the patients was obtained from the service records. We have analyzed the agreement between the answers to the WebAd-Q, the associations, and the correlations with viral load and performance compared to other measures of adherence.RESULTS Among the invited patients, 74 (82.2%) answered the WebAd-Q. No difficulties were reported to answer the questionnaire. The average answer time was 5 min 47 sec. The set of three questions of the WebAd-Q obtained agreement of 89.8%, with Kappa of 0.77 (95%CI 0.61–0.94). The non-adherence answers of the WebAd-Q were associated with detectable viral load. We obtained moderate viral load correlations with the non-adherence scale according to the WebAd-Q. For the three questions of the WebAd-Q, patients with non-adherence answers were also reported as less adherent according to the other measures of adherence.CONCLUSIONS The WebAd-Q answered all the issues considered relevant in the validation of questionnaires, was well understood by patients, was associated with viral load, and obtained good agreement and good performance compared to the other measures. The feasibility analysis of its implementation still depends on a national study on its applicability.
Introduction:Patient adherence to antiretroviral therapy (ART) is critical for HIV treatment success. Monitoring rates of adherence in public HIV outpatient care facilities can improve outcomes in Brazil where ART is universally available.Methods:We conducted a national cross-sectional survey of ART adherence in 2010. Participants were selected using a multistage probability sample. First, HIV outpatient care facilities were stratified according to 7 Organizational Quality Classification (OQC) groups and regions. Second, 1 or 2 facilities were selected per region for each OQC group. Finally, patients were randomly selected at each facility. In a first component, patients were invited to answer to a web-based questionnaire (WebAd-Q), a validated self-reported tool that includes 3 questions on adherence to ART in the past 7 days (time scheduling—timing, drug regimen—medication, and pill counts—dose), herein named indicators of potential nonadherence (IPN). In addition, a subsample of participants were interviewed in order to obtain further data on sociodemographic and clinical characteristics (second component). The proportion of each IPN was estimated using weighted data to account for the sampling design with 95% confidence interval (CI) and descriptive analysis was carried out.Results:Fifty-five facilities were chosen and 2424 patients completed the WebAd-Q in the first component of the study, while 598 patients were interviewed for the second component. The weighted proportions of the IPN were 50.9%, 31.8%, and 19.5%, for timing, medication, and dose, respectively, while11.7% had all 3 indicators, varying from 5.9% in the Southeast and 21.9% in the Northeast regions. Overall, 61.1% of the patients had at least 1 IPN (95% CI: 58.5–63.7%). Patients reporting depression symptoms, illicit drug use and those who missed medical appointments had worse nonadherence outcomes.Conclusions:Overall, there was a high proportion of all indicators IPN and timing was the main component associated with low adherence. Although these indicators may not necessarily indicate individual nonadherence, they represent a worrisome scenario in the public Brazilian HIV care facilities. On a routine basis, these facilities can identify gaps in providing counseling and ART orientation to their clientele and develop innovative strategies to prevent nonadherence.
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