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Sugiharto F, Haroen H, Alya FP, Jamlaay R, Mai F, Abdillah H, Yusanti I, Assidiqy B, Nuraeni A. Health Educational Methods for Improving Self-Efficacy Among Patients with Coronary Heart Disease: A Scoping Review. J Multidiscip Healthc 2024; 17:779-792. [PMID: 38410523 PMCID: PMC10896095 DOI: 10.2147/jmdh.s455431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 02/14/2024] [Indexed: 02/28/2024] Open
Abstract
Background Coronary heart disease (CHD) is the leading cause of death and disability worldwide, with higher prevalence in low and middle-income countries. Self-efficacy (SE) is an essential element that affects a patients ability to manage their care, and low SE levels in patients with CHD can lead to poor health outcomes and quality of life. Planning suitable methods to improve SE in CHD patients is essential. Purpose This review explores health education methods to improve SE in patients with CHD. Methods Scoping review is reported based on the PRISMA Extension for Scoping Reviews (PRISMA-ScR). A literature search was conducted using relevant keywords from six primary databases, such as CINAHL Plus with Full Text and Academic Search Complete, PubMed, ScienceDirect, Scopus, Taylor and Francis, and one search engine, Google Scholar. The inclusion criteria were full-text articles in English that were accessible, research articles with experimental designs. The quality of evidence was assessed using the Joanna Briggs Institute critical appraisal checklist, and data synthesis was used thematically with an explorative, descriptive approach. Results Fifteen articles were found and included in the review. There are two types of interventions such as traditional and digital-based health education. The media used in traditional health education are booklets, pamphlets, posters, and workbooks. In addition, digital-based health education generally uses websites, social platforms, mobile applications, video players and sound clips. Conclusion This review found that traditional health education and digital-based interventions improve SE, knowledge, self-esteem and health literacy levels, in CHD patients. Health professionals, including nurses, may used both methods in improving self efficacy in CHD patients.
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Affiliation(s)
- Firman Sugiharto
- Master Study Program, Faculty of Nursing, Universitas Padjadjaran, Sumedang, West Java, Indonesia
| | - Hartiah Haroen
- Department of Community Nursing, Faculty of Nursing, Universitas Padjadjaran, Sumedang, West Java, Indonesia
| | - Fania Putri Alya
- Master Study Program, Faculty of Nursing, Universitas Padjadjaran, Sumedang, West Java, Indonesia
| | - Ruth Jamlaay
- Master Study Program, Faculty of Nursing, Universitas Padjadjaran, Sumedang, West Java, Indonesia
| | - Freda Mai
- Master Study Program, Faculty of Nursing, Universitas Padjadjaran, Sumedang, West Java, Indonesia
| | - Hadi Abdillah
- Master Study Program, Faculty of Nursing, Universitas Padjadjaran, Sumedang, West Java, Indonesia
| | - Irma Yusanti
- Master Study Program, Faculty of Nursing, Universitas Padjadjaran, Sumedang, West Java, Indonesia
| | - Birry Assidiqy
- Master Study Program, Faculty of Nursing, Universitas Padjadjaran, Sumedang, West Java, Indonesia
| | - Aan Nuraeni
- Department of Emergency and Critical Nursing, Faculty of Nursing, Universitas Padjadjaran, Sumedang, West Java, Indonesia
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Lubega M, Ogwok J, Nabunya B, Mbalinda SN. Role of community-based health clubs in promoting patients' health education for diabetes self-care management: an interventional qualitative study in a Ugandan urban setting. BMJ Open Qual 2023; 12:e002473. [PMID: 38135300 DOI: 10.1136/bmjoq-2023-002473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 12/02/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Self-care management support is a core component of the Chronic Care Model that emphasises the need for empowering and preparing patients to manage their healthcare. In diabetes mellitus (DM) management, health education towards self-care empowers patients to make day-to-day decisions on their own disease and live with a healthy lifestyle. Although several strategies have been undertaken to improve the management of DM in Uganda, little has been done to empower patients to manage their own health. Community-based health clubs have been suggested as a novel way of improving diabetes management especially in settings with uneven distribution of healthcare facilities and inaccessibility to healthcare services that limit patients' awareness of the disease and self-care management. This interventional study was aimed at exploring the role of community-based health clubs in promoting patients' health education for diabetes self-care management. METHODS A cross-sectional qualitative study was conducted among 20 participants using focus group discussions with each having six to eight members. Only patients with diabetes who seek routine diabetes healthcare services at Wakiso Health Centre IV and had participated in the 8-week community-based health clubs' health education sessions were recruited for the study. The audio-recordings were transcribed verbatim and translated into English; thematic data analysis was conducted to generate codes and themes. Similar codes were merged and a group consensus was reached on coding discrepancies. RESULTS Three major themes on the role of health clubs in promoting patients' health education were merged from the study. These include promoting sharing of experiences among patients, improving awareness of healthy self-care practices and offering sufficient patient-health worker interaction time. CONCLUSIONS This is the first publication reporting on the role of community-based health clubs in promoting patients' health education towards diabetes self-care management in Uganda. The ability to share experiences among patients, improve patients' awareness on healthy living practices and the increased health worker-patient interaction time contribute heavily to the capacity-building for self-care among patients.
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Affiliation(s)
- Martin Lubega
- Department of Nursing, Makerere University College of Health Sciences, Kampala, Uganda
| | - James Ogwok
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Brenda Nabunya
- Department of Nursing, Makerere University College of Health Sciences, Kampala, Uganda
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Stelwagen M, Westmaas A, Van Kempen A, Scheele F. In-hospital education of parents of newborns may benefit from competency-based education: A qualitative focus group and interview study among health professionals. J Clin Nurs 2023; 32:1076-1088. [PMID: 35460132 DOI: 10.1111/jocn.16334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 03/28/2022] [Accepted: 03/31/2022] [Indexed: 11/28/2022]
Abstract
AIMS/OBJECTIVES The aim of this study was to appraise health professionals' self-reported practices in educating parents of hospitalised newborns from the perspective of competency-based education and to identify areas for improvement of parental learning. BACKGROUND Patient education is essential to achieve autonomy in parents of hospitalised newborns. The literature provides descriptions of the use of various components of competency-based education in patient education. This suggests that competency-based education is a valuable concept for patient education. DESIGN A case-based qualitative study. METHODS Three focus group discussions were conducted and 28 semi-structured interviews with 45 health professionals who practice in a hospital setting that is designed to empower parents. The data were analysed with a framework analysis approach, using a framework of competency-based education themes for a combined inductive and deductive content data analysis. The recommendations of the Standards for Reporting Qualitative Research checklist were followed. FINDINGS Two themes of competency-based education emerged as evidently operationalised: (1) 'Learning climate' and (2) 'Role modeling'. Five themes emerged as incompletely operationalised: (1) 'Parent curriculum based on inter-professional consensus'; (2) 'Transparency about the competencies needed'; (3) 'Access to teaching'; (4) 'Assessing and reporting results'; and (5) 'Proficiency statements based on autonomy expectations'. Two themes did not emerge: (1) 'Empowering parents to be active learners' and (2) 'Evaluation and improvement of the education program'. CONCLUSIONS Parent education is at risk of being merely on a master-apprentice model and may be more effective if it is designed on competency-based education principles. Identified areas for improvement are empowering parents to be 'active learners' and by involving them in the evaluation and improvement of the educational program. Parent education in neonatal health care may benefit from an appraisal based on competency-based education themes. RELEVANCE TO CLINICAL PRACTICE Appraising parent education based on competency-based education principles is feasible for improving the learning process towards parent autonomy.
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Affiliation(s)
- Mireille Stelwagen
- Department of Teaching and Department of Pediatrics at OLVG Hospital, Amsterdam, The Netherlands
| | - Alvin Westmaas
- Department of Social Psychology, Maastricht University, Maastricht, The Netherlands.,Faculty of Health, University of Applied Sciences Leiden, Leiden, The Netherlands
| | - Anne Van Kempen
- Department of Pediatrics at OLVG Hospital, Amsterdam, The Netherlands
| | - Fedde Scheele
- Department of Gynecology and Department Teaching at OLVG Hospital, Health systems innovation and education at the VU University Amsterdam and Amsterdam University Medical Center, Amsterdam, The Netherlands
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Tsiamparlis-Wildeboer AHC, Feijen-De Jong EI, van Lohuizen MT, Tichelman E, de Jonge A, Scheele F. Self-management support by health care providers in prenatal Shared Medical Appointments (CenteringPregnancy©) and prenatal individual appointments. PATIENT EDUCATION AND COUNSELING 2023; 107:107579. [PMID: 36463823 DOI: 10.1016/j.pec.2022.107579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 11/20/2022] [Accepted: 11/22/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE This cross-sectional questionnaire study investigates if there a difference in the extent to which health care providers in prenatal Shared Medical Appointments (CenteringPregnancy©) and in prenatal individual appointments support self-management in patient education. It also investigates if there is a difference in the extent to which health care providers in CenteringPregnancy@ and in individual appointments pay attention to the factors of the Integrated Model for Behavioral Change (I-Change) in supporting self-management. METHODS Dutch health care providers in prenatal care were invited to fill out a questionnaire. Respondents who provided care in CenteringPregnancy© formed the CenteringPregnancy© group, the others were categorized in the individual appointments' group. After a definition of self-management and an introduction of the I-Change model, respondents were asked if they supported self-management and if they paid attention to the I-Change model for each of 17 themes of prenatal patient education. Pearson's chi-squared tests and Fisher's Exact tests were performed to compare both groups. RESULTS We included 133 respondents. Health care providers in the CenteringPregnancy@ group supported self-management to a higher extent compared to the individual appointments group. This difference was statistically significant for eight themes (body position and exercises, oral health, domestic violence, birth mechanism and premature birth, postnatal period, transition from pregnancy to parenthood, taking care of the baby and newborn's safety). In both groups, health care providers paid most attention to information or to awareness factors instead of motivation factors. CONCLUSION We found a first prove that health care providers in CenteringPregnancy@ support self-management to a higher extent than health care providers in individual appointments. This could be explained by factors as time, feelings of safety and bonding, continuity of care and emphasis on future health behaviour changes. For effective self-management support, attention to motivation factors is important. However, we found that health care providers in both groups paid more attention to information or to awareness factors than to motivation. PRACTICE IMPLICATIONS Health care providers in prenatal individual appointments should be aware of the fact that they possibly support self-management less than health care providers in CenteringPregnancy@ . Health care providers in both types of prenatal care should be aware of the fact that they pay little attention to motivation factors. They might need some skills to change their role from teaching professional to supportive leader.
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Affiliation(s)
- Anna H C Tsiamparlis-Wildeboer
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Midwifery Science, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; University of Groningen, University Medical Center Groningen, Department of General Practice & Elderly Medicine, Groningen, the Netherlands; AVAG (Academy Midwifery Amsterdam and Groningen), Groningen, the Netherlands.
| | - Esther I Feijen-De Jong
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Midwifery Science, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; University of Groningen, University Medical Center Groningen, Department of General Practice & Elderly Medicine, Groningen, the Netherlands; AVAG (Academy Midwifery Amsterdam and Groningen), Groningen, the Netherlands
| | | | - Elke Tichelman
- School of Health Care Studies, Rotterdam University of Applied Sciences, department of Midwifery Education, the Netherlands; Research Centre Innovations in Care, Rotterdam University of Applied Sciences, the Netherlands
| | - Ank de Jonge
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Midwifery Science, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; AVAG (Academy Midwifery Amsterdam and Groningen), Groningen, the Netherlands
| | - Fedde Scheele
- Vrije Universiteit Amsterdam, Athena institute for Transdisciplinary Research, Amsterdam, the Netherlands; Amsterdam UMC, the Netherlands
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Bharmal N. Social Determinants and Health Equity in Functional Medicine. Phys Med Rehabil Clin N Am 2022; 33:665-678. [DOI: 10.1016/j.pmr.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Mahajan UV, Sharma N, Maynard M, Kang L, Labak CM, Raghavan A, Sajatovic M, Hoffer A, Shammassian BH, Wright JM, Zhou X, Wright CH. Inpatient virtual shared medical appointments to improve health literacy, increase patient self-efficacy, and reduce provider burnout in acute cerebrovascular pathology patients and their caregivers: a pilot study. Neurosurg Focus 2022; 52:E12. [DOI: 10.3171/2022.4.focus21764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 04/04/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Admission to the hospital for an acute cerebrovascular condition such as stroke or brain hemorrhage can be a traumatic and disorienting experience for patients and their family members. The COVID-19 pandemic has further intensified this experience in addition to exacerbating clinician and resident burnout. To ameliorate some of these concerns, a team of resident and medical student trainees implemented a virtual shared medical appointment (vSMA) program for inpatients with acute cerebrovascular disorders and their caregivers. The authors hypothesized that an early intervention in the form of a vSMA improves patient and caregiver health literacy and preparedness while simultaneously educating clinical trainees on effective communication skills and reducing clinician burnout.
METHODS
Patients and caregivers of admitted patients were identified through a census of neurosurgery, neurocritical care, and neurology electronic medical records. A weekly 60-minute secure virtual session consisted of introductions and a 10-minute standardized presentation on cerebrovascular disease management, followed by participant-guided discussion. Participants completed presession and postsession surveys. Through this small feasibility study data were obtained regarding present challenges, both expected and unforeseen.
RESULTS
A total of 170 patients were screened, and 13 patients and 26 caregivers participated in at least 1 vSMA session. A total of 6 different healthcare providers facilitated sessions. The vSMA program received overwhelmingly positive feedback from caregivers. Survey responses demonstrated that 96.4% of caregivers and 75% of patients were satisfied with the session, 96.4% of caregivers and 87.5% of patients would recommend this type of appointment to a friend or family member, and 88.8% of providers reported feeling validated by conducting the session. The participant group had a 20% greater percentage of patients discharged home without home needs compared to the nonparticipant group. The primary obstacles encountered included technological frustrations with the consent process and the sessions themselves.
CONCLUSIONS
Implementation of a vSMA program at a tertiary care center during a pandemic was feasible. Themes caregivers expressed on the postsession survey included better understanding of caring for a stroke patient and coping with the unpredictability of a patient’s prognosis. The pandemic has precipitated shifts toward telehealth, but this study highlights the importance of avoiding marginalization of elderly and less technologically inclined populations.
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Affiliation(s)
- Uma V. Mahajan
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Neha Sharma
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Marquis Maynard
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Lei Kang
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Collin M. Labak
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Neurosurgery and
| | - Alankrita Raghavan
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Neurosurgery and
| | - Martha Sajatovic
- Neurological & Behavioral Outcomes Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Alan Hoffer
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Neurosurgery and
| | - Berje H. Shammassian
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Neurosurgery and
- Department of Neurology, Division of Neurocritical Care, University of Miami Miller School of Medicine, Miami, Florida; and
| | - James M. Wright
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Neurosurgery and
- Department of Neurosurgery, Oregon Health & Science University, Portland, Oregon
| | - Xiaofei Zhou
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Neurosurgery and
| | - Christina Huang Wright
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Neurosurgery and
- Department of Neurosurgery, Oregon Health & Science University, Portland, Oregon
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Marshall V, Jewett-Tennant J, Shell-Boyd J, Stevenson L, Hearns R, Gee J, Schaub K, LaForest S, Taveira TH, Cohen L, Parent M, Dev S, Barrette A, Oliver K, Wu WC, Ball SL. Healthcare providers experiences with shared medical appointments for heart failure. PLoS One 2022; 17:e0263498. [PMID: 35130320 PMCID: PMC8820643 DOI: 10.1371/journal.pone.0263498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 01/20/2022] [Indexed: 11/25/2022] Open
Abstract
Shared medical appointments (SMAs) offer a means for providing knowledge and skills needed for chronic disease management to patients. However, SMAs require a time and attention investment from health care providers, who must understand the goals and potential benefits of SMAs from the perspective of patients and providers. To better understand how to gain provider engagement and inform future SMA implementation, qualitative inquiry of provider experience based on a knowledge-attitude-practice model was explored. Semi-structured interviews were conducted with 24 health care providers leading SMAs for heart failure at three Veterans Administration Medical Centers. Rapid matrix analysis process techniques including team-based qualitative inquiry followed by stakeholder validation was employed. The interview guide followed a knowledge-attitude-practice model with a priori domains of knowledge of SMA structure and content (understanding of how SMAs were structured), SMA attitude/beliefs (general expectations about SMA use), attitudes regarding how leading SMAs affected patients, and providers. Data regarding the patient referral process (organizational processes for referring patients to SMAs) and suggested improvements were collected to further inform the development of SMA implementation best practices. Providers from all three sites reported similar knowledge, attitude and beliefs of SMAs. In general, providers reported that the multi-disciplinary structure of SMAs was an effective strategy towards improving clinical outcomes for patients. Emergent themes regarding experiences with SMAs included improved self-efficacy gained from real-time collaboration with providers from multiple disciplines, perceived decrease in patient re-hospitalizations, and promotion of self-management skills for patients with HF. Most providers reported that the SMA-setting facilitated patient learning by providing opportunities for the sharing of experiences and knowledge. This was associated with the perception of increased comradery and support among patients. Future research is needed to test suggested improvements and to develop best practices for training additional sites to implement HF SMA.
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Affiliation(s)
- Vanessa Marshall
- Research, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States of America
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Jeri Jewett-Tennant
- Health System Education/Opioid Data 2 Action, The Center for Health Affairs, Cleveland, Ohio, United States of America
| | - Jeneen Shell-Boyd
- Research, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States of America
| | - Lauren Stevenson
- Research, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States of America
| | - Rene Hearns
- Research, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States of America
| | - Julie Gee
- Research, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States of America
| | - Kimberley Schaub
- Research, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States of America
| | - Sharon LaForest
- Research, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States of America
| | - Tracey H. Taveira
- Medicine, Providence VA Medical Center, Providence, Rhode Island, United States of America
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, United States of America
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, United States of American
| | - Lisa Cohen
- Medicine, Providence VA Medical Center, Providence, Rhode Island, United States of America
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, United States of America
| | - Melanie Parent
- Medicine, Providence VA Medical Center, Providence, Rhode Island, United States of America
| | - Sandesh Dev
- Medicine, Southern Arizona VA Health Care System, Tucson, Arizona, United States of America
| | - Amy Barrette
- Medicine, Providence VA Medical Center, Providence, Rhode Island, United States of America
| | - Karen Oliver
- Medicine, Providence VA Medical Center, Providence, Rhode Island, United States of America
| | - Wen-Chih Wu
- Medicine, Providence VA Medical Center, Providence, Rhode Island, United States of America
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, United States of America
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, United States of American
- Medicine, Southern Arizona VA Health Care System, Tucson, Arizona, United States of America
| | - Sherry L. Ball
- Research, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States of America
- * E-mail:
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Kennedy MBB, Parish AL. Educational Theory and Cognitive Science: Practical Principles to Improve Patient Education. Nurs Clin North Am 2021; 56:401-412. [PMID: 34366160 DOI: 10.1016/j.cnur.2021.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There can be multiple barriers to implementation of patient education, yet there are also multiple modalities and opportunities for engaging patients. Using frameworks and evidence from multiple disciplines can inform nursing design of patient education approaches. This article provides an introduction to educational theory and cognitive science principles such as constructivism, metacognition, deliberate practice, and cognitive load for consideration in improving the effectiveness and outcomes of patient education.
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Affiliation(s)
| | - Abby Luck Parish
- Vanderbilt University School of Nursing, 274 SON, 461 21st Avenue South, Nashville, TN 37240, USA
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[Constructing a new institutional hegemony in the health field]. Salud Colect 2020; 16:e3360. [PMID: 33374088 DOI: 10.18294/sc.2020.3360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 12/19/2020] [Indexed: 11/24/2022] Open
Abstract
This article argues for the construction of a new institutional hegemony with a rhizomatic design based on health centers with direct relations to a network of hospitals with increasing levels of complexity, which are put at the service of these health centers and not the other way around. The proposal for these centers includes community-based teams of workers carrying out humanized practice centered on the shift from health services to care within the community, respecting the particularities and idiosyncrasies of its residents and their cultures. First, a brief historical revision of the genesis of health centers and of hospitals is presented. Second, technical recommendations to restructure models of care and institutional organization in the health field are put forth, and technical-political proposals for this new institutional hegemony are outlined, which are developed along three dimensions: organization, policy, and service and care processes. Lastly, some barriers to the construction of this new hegemony are identified.
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