[Insight on how to assess and improve the response to the COVID-19 pandemic]

The COVID-19 pandemic has hit Spain particularly hard, despite being a country with a developed economy and being praised for the robustness of its national health system. In order to understand what happened and to identify how to improve the response, we believe that an independent multi-disciplinary evaluation of the health, political and socio-economic spheres is essential. In this piece we propose objectives, principles, methodology and dimensions to be evaluated, as well as outlining the type of results and conclusions expected. Inspired by the requirements formulated by the WHO Independent Panel for Pandemic Preparedness and Response and by experiences in other countries, we detail the multidimensional aspects to be evaluated. The goal is to understand key aspects in the studied areas and their scope for improvement in terms of preparedness, governance, regulatory framework, national health system structures (primary care, hospital, and public health), education sector, social protection schemes, minimization of economic impact, and labour framework and reforms for a more resilient society. We seek to ensure that this exercise serves not only at present, but also that in the future we are better prepared and more agile in terms of our ability to recover from any pandemic threats that may arise.

Comunicación, participación y liderazgo en la percepción del clima emocional en un hospital universitario de Andalucía, España

El objetivo de este artículo es conocer y analizar la valoración del personal de un hospital universitario de Andalucía, España, sobre el clima emocional, el tipo de liderazgo ejercido y la calidad de la información y comunicación interna, así como recoger sus propuestas de mejora. El estudio realizado con 730 profesionales facultativos, enfermeros y auxiliares, usa metodología cuantitativa y cualitativa. Los resultados reflejan la existencia de un clima emocional medio-bajo, que se correlaciona con el estilo de liderazgo y la percepción sobre el grado de información y comunicación. Se observan diferencias estadísticamente significativas en los resultados, en función de las categorías profesionales, así como de la unidad o servicio hospitalario. Las demandas de los y las profesionales reflejan una valoración positiva de sus responsables, aunque se evidencia la necesidad de más habilidades propias de un estilo de liderazgo orientador, participativo y afiliativo.

[Emotional climate and internal communication in a clinical management unit compared with two traditional hospital services]

BACKGROUND AND OBJECTIVE

The aim of this study is to compare the emotional climate, quality of communication and performance indicators in a clinical management unit and two traditional hospital services.

MATERIAL AND METHODS

Quantitative study.

INSTRUMENT

questionnaire of 94 questions.

PARTICIPANTS

83 health professionals (63 responders) from the clinical management unit of breast pathology and the hospital services of medical oncology and radiation oncology.

ANALYSIS

descriptive statistics, comparison of means, correlation and linear regression models.

RESULTS

The clinical management unit reaches higher values compared with the hospital services about: performance indicators, emotional climate, internal communication and evaluation of the leadership. An important gap between existing and desired sources, channels, media and subjects of communication appear, in both clinical management unit and traditional services.

CONCLUSIONS

The clinical management organization promotes better internal communication and interpersonal relations, leading to improved performance indicators.

[Patients' opinions and expectations about the dialysis care process]

BACKGROUND

To determine the experiences and needs of patients on dialysis, in order to identify critical points of the care process and develop proposals for improvement.

METHODS

Qualitative study using semistructured interviews with 22 patients on hemodialysis and peritoneal dialysis, from the Andalusian Health Service. Discourse analysis, using the SERVQUAL model. Triangulation of results.

RESULTS

The diagnostic stage is described as the hardest moment as it requires acceptance of the disease. During hemodialysis, we see both positive adaptation and the perception of a diminished quality of life. The technique of peritoneal dialysis is evaluated positively, enabling greater independence, despite requiring more responsibility for self care. The contact with patients' organizations or the provision of a counseling service are valued as an aid in the process. With respect to different dimensions of the SERVQUAL model, human treatment and professional competence are valued. The critical points are lack of coordination, malfunctioning of transportation and lack of transparency in the management of waiting lists. Shortcomings in dealing with informal caregivers and the level of knowledge of professionals from areas other than Nephrology, also appear as deficiencies.

CONCLUSIONS

The main proposals for improving the dialysis process are: attention to psychosocial aspects, the improvement of organizational aspects such as transport, and greater attention to informal caregivers.

[Opinions and expectations of patients with health problems associated to asbestos exposure]

BACKGROUND

The prevalence of diseases related to asbestos exposure requires the development of monitoring programs and specific health care protocols. The aim of this study is to determine the opinions and expectations of former workers of an asbestos factory, in order to adapt the care process to the needs of the affected population, and to learn about the activity of the association that represents them.

METHODS

Qualitative study. Focus groups with former employees of a corrugated asbestos factory, members of the association AVIDA (Seville). Recording and transcription of interviews. Discourse analysis with Nudist Vivo 1.0.

RESULTS

All respondents have health problems, including asbestosis, lung cancer and mesothelioma. Through the association, they are involved in an ongoing process of negotiation with the public administration, to improve healthcare, achieve recognition as having an occupational disease and the payment of compensation. The lack of monitoring and continuity in care is designated as the major problem in the current care process. They welcome the creation of special care units, the good treatment received and the quality of technical instruments in the public health system. On the contrary, they criticize the difficulties in finding an accurate diagnosis, the lack of continuity of care, and the bureaucratic difficulties and lack of specific care directed to affected relatives. The participants' expectations highlight their intention to participate in the development of future programs and protocols.

CONCLUSIONS

This study confirms the multifactor nature of diseases related to asbestos exposure and the importance of determining the needs and demands of the affected population in order to improve health care.

Area deprivation and mortality in the provincial capital cities of Andalusia and Catalonia (Spain)

OBJECTIVE

To study the linkage between material deprivation and mortality from all causes, for men and women separately, in the capital cities of the provinces in Andalusia and Catalonia (Spain).

METHODS

A small-area ecological study was devised using the census section as the unit for analysis. 188,983 Deaths occurring in the capital cities of the Andalusian provinces and 109,478 deaths recorded in the Catalan capital cities were examined. Principal components factorial analysis was used to devise a material deprivation index comprising the percentage of manual labourers, unemployment and illiteracy. A hierarchical Bayesian model was used to study the relationship between mortality and area deprivation.

MAIN RESULTS

In most cities, results show an increased male mortality risk in the most deprived areas in relation to the least depressed. In Andalusia, the relative risks between the highest and lowest deprivation decile ranged from 1.24 (Malaga) to 1.40 (Granada), with 95% credibility intervals showing a significant excess risk. In Catalonia, relative risks ranged between 1.08 (Girona) and 1.50 (Tarragona). No evidence was found for an excess of female mortality in most deprived areas in either of the autonomous communities.

CONCLUSIONS

Within cities, gender-related differences were revealed when deprivation was correlated geographically with mortality rates. These differences were found from an ecological perspective. Further research is needed in order to validate these results from an individual approach. The idea to be analysed is to identify those factors that explain these differences at an individual level.

Inconsistent condom use among socially excluded heroin users

The study focused in sexual behaviour among socially excluded heroin users, identifying factors associated with inconsistent condom use. Data was collected in the cities of Granada and Seville between July and October 2000, through a structured questionnaire, to 391 participants. Twenty two and 15% of participants have made consistent use of condoms in vaginal sex in the last year with occasional and regular partners respectively. There is a greater likelihood of inconsistent condom use with occasional partners among users who had had oral sex, and who does not know if their partner(s) inject or injected drugs. For regular partners those who have an injecting partner and do not speak with their sexual partners about AIDS have a higher probability to do not use always a condom. For both groups, when always the partner is who propose the use of condoms (when used) and not themselves, the risk not to use it is near 4 times more than when themselves propose to use it. Speaking about condoms and AIDS with mate, partners and family, and learning to negotiate the use of condoms seems to be the most important strategies to be approached for this sample, from the social and health care system in order to promote a protected sex.

Factors associated with reported hepatitis C and HIV among injecting drug users in ten European cities

BACKGROUND

To analyze self-reported prevalence of HCV and HIV in a sample of socially excluded injecting drug users, as well as factors associated with the presence of these diseases.

METHODS

Cross-sectional study. Data were collected with a structured, face-to-face questionnaire by outreach workers and privileged access interviewers in 1131 participants who had injected heroin and/or cocaine over the past year (71.5% men; mean age, 30 years) from Seville and Granada, Spain; Cologne, Germany; Vienna, Austria; Brussels, Belgium; Athens, Greece; Dublin, Ireland; London, England; Lisbon, Portugal and Perugia, Italy.

RESULTS

Among the total sample, 595 (52.6%) participants reported HCV-positive status and 143 (12.6%) HIV-positive status. Multivariate analysis for HCV showed that women are at less risk than men, and that longer drug use, injecting while in prison, sharing needles, and reported positive status for tuberculosis, HBV, HIV or sexually-transmitted disease are positively associated with HCV. Participants reporting positive HIV status were generally older, had injected drugs while in prison, had completed less than 8 years of schooling, were divorced, had no regular employment, and declared infection with tuberculosis, sexually-transmitted disease and HCV.

CONCLUSIONS

The highest incidences of HCV and HIV were reported by participants in a poorer social and health situation. Drug addicts must cope not only with their addiction but also with the process of social exclusion they are immersed in. To the greatest extent possible, any course of action for this group should be built into integrated, coordinated plans that take a broad approach to the main issues involved.

Controlled trial of prescribed heroin in the treatment of opioid addiction

AIM

This study aimed to assess the efficacy of the prescription of intravenous diacetylmorphine (DAM) versus oral methadone with medical and psychosocial support, with a view of improving physical and mental health as well as social integration among socially excluded, opioid-dependent individuals for whom standard treatments have failed.

DESIGN

This study used an open, randomized controlled trial.

SETTING

This study took place in Granada, Spain.

PARTICIPANTS

Sixty-two opioid-dependent participants were randomized, 31 in each treatment group, and 50 of them were analyzed. The participants were recruited directly from the streets, through peer outreach, in well-known meeting places for drug-addicted individuals.

INTERVENTIONS

Participants in the experimental group received injected DAM, twice a day, plus oral methadone, once a day, for 9 months. The control group received only oral methadone, once a day. The two groups received an equivalent opioid dosage. The average DAM dosage was 274.5 mg/day (range: 15-600 mg), and an average methadone dosage was 42.6 mg/day (range: 18-124 mg). The daily methadone dosage in the control group was 105 mg/day (range: 40-180 mg). Comprehensive clinical, psychological, social, and legal support was given to both groups.

MEASUREMENTS

The following were measured in this study: general health, quality of life, drug-addiction-related problems, nonmedical use of heroin, risk behavior for HIV and HCV, and psychological, family, and social status.

FINDINGS

Both groups improved with respect to the total domain assessed. Those in the experimental group showed greater improvement in terms of physical health (the improvement was 2.5 times higher; p = .034) and risk behavior for HIV infection (the improvement was 1.6 times higher; p = .012). In addition, this group decreased its street heroin use from 25 days/month to 8 days/month as seen on the Addiction Severity Index (p = .020), as well as the number of days free from drug-related problems (the improvement was 2.1 times higher; p = .004) or involvement in crime (from 11 days/month to <1 day/month; p = .096 between groups).

CONCLUSIONS

These findings support the hypothesis that, under the same conditions, DAM could be safely delivered, in our context. Also, in physical health, HIV risk behavior, street heroin use, and days involved in crime, DAM plus methadone was more efficacious than methadone alone. This implies that this treatment could provide an effective alternative for the treatment of socially excluded, opioid-dependent patients with severe physical and mental health problems because of drug addiction, when all available previous treatments have failed.

[Dietary behavior disorders: opinions and expectancies on prevention and treatment strategies from the perspective of the several social actors]

AIMS

The prevalence increase of Eating Disorders in the last decades emphasizes the necessity to develop strategies from the public healthcare system which include the perspective of the principal implicated social actors. The present study aims to know their opinions and expectations regarding the prevention and treatment of Eating Disorders.

METHODS

Realization of 5 focus groups (with relatives, adolescents, professionals from the health and educational sector, representatives from institutions and support groups) and 14 semi-structured interviews (with Eating Disorder patients and relatives) about strengths and weaknesses of actual prevention and treatment programs, expectations of change and suggestions for improvement. Analysis of contents and triangulation of results.

RESULTS

The absence of resources and knowledge about Eating Disorders, the scarcity of transversal programs and insufficient coordination were named as the main weaknesses whereas interdisciplinary pilot programs were positively valued. As principal demands, major endowment of human and material resources, increased coverage of specialized services, promotion of specific training and improvement of coordination was asked for. Regarding prevention, preference toward an unspecific approach to the subject in order to hinder imitation between young people was highlighted. The care in Day Hospitals was considered one of the most appropriate treatment modalities for the characteristics of this disease being valued the potentially therapeutic effect of contact between Eating Disorder patients. The support network, the education field and the family were named as other important pillars in a multidisciplinary approach to the disease. There was also a demand for the development of combined programs.

CONCLUSIONS

The discussion of different psychotherapeutic approaches, the role of support groups in the caring network as well as the post-hospital follow-up were identified as issues open to future research.

Drugs and social exclusion in ten European cities

AIM

To describe social characteristics seen among socially excluded drug users in 10 cities from 9 European countries, and identify which social exclusion indicators (i.e. housing, employment, education) are most closely linked to intravenous drug use.

DESIGN

Cross-sectional survey.

SETTING

Interviews were held in social services centers, town halls, streets, squares and other usual meeting points of the target population.

PARTICIPANTS

The sample comprises 1,879 participants who have used heroin and/or cocaine and certain derivatives (92.3%) over the last year. Males accounted for 69.7% of the sample, and the mean age was 30.19 years. Participants were recruited in 10 cities: Seville and Granada, Spain; Cologne, Germany; Vienna, Austria; Brussels, Belgium; Athens, Greece; Dublin, Ireland; London, England; Lisbon, Portugal, and Perugia, Italy.

MEASUREMENTS

Structured face-to-face questionnaire, conducted by privileged access interviewers.

RESULTS

Cannabis, heroin and cocaine are the most widely used substances. In the total sample, 60.2% injected drugs during the last year, 45.9% reported having hepatitis C; 54.9% have been in prison; 14.2% are homeless; 11.3% have a regular job, and 35.2% are involved in illegal activities. Hierarchical logistic regression analysis (injectors and non-injectors) showed that older participants have a greater likelihood of injecting than younger ones. Social exclusion variables associated with intravenous drug use are incarceration, homelessness, irregular employment, and delinquency. Participants who abandoned or were expelled from a drug treatment program are at greater risk of injecting drugs than participants who have never had treatment, are currently in treatment or have been released.

CONCLUSION

Personal, social, and economic conditions are all linked in a process of social exclusion that compounds problem drug misuse. Given the findings of this study, we believe that there is a clear need for specific programs targeting specific groups, i.e., distinct strategies must be set in place, in line with the profile and needs of the patient in each context.

[The experimental drug prescription program in Andalusia [PEPSA]: procedure for recruiting participants]

In this field note we describe the steps followed in the process of recruiting participants for the experimental drug prescription program in Andalusia (PEPSA). This trial is a comparative, randomized, open study of the difference between intravenous heroin treatment and oral methadone for socially excluded, opiate-dependent patients, in whom other available treatments have been unsuccessful. Because this is a hidden and hard-to-reach population, a specific approach was planned to put as many patients as possible in touch with the program. A previous study of the target population's distribution in the City of Granada was performed and the city was divided into three areas. Potential participants were interviewed in squares, soup kitchens and methadone dispensaries by outreach workers and peers, who suggested they make an appointment with a PEPSA physician. Peer-driven intervention was a crucial instrument in this recruitment procedure, allowing greater access to the target population. Furthermore, this approach allowed contact with drug users who do not attend health and social services. The work of the outreach team involved educating these users in harm reduction and offering them health and social alternatives beyond the clinical trial.

Biotechnological applications of green fluorescent protein

Since its first use as a reporter gene in 1994, green fluorescent protein (GFP) has served as the researcher's agent: slipping, virtually undetected, into unseen spaces, reporting back valuable information, and securing the delivery of precious cargo through hostile domains. GFP's strength lies in its small size, formidable stability, and relative ease of use. It requires only oxygen and an energy source to do its work, which can be supplied at low cost and high precision, respectively. With such a low threshold for use, GFP is often the first line of inquiry into an unknown space. Here is provided a brief compendium of GFP's contributions to biotechnology. They are linked by a need for a level of information that was previously inaccessible, both spatially and temporally. Protein fusions, transcriptional reporters, whole-organism visualization, and various other screening applications are reviewed with respect to biotechnological applications. Germane molecular improvements to GFP are also discussed.

Expression of an anaplerotic enzyme, pyruvate carboxylase, improves recombinant protein production in Escherichia coli

Anaplerotic enzyme reactions are those which replenish tricarboxylic acid intermediates that are withdrawn for the synthesis of biomass. In this study, we examined recombinant protein production in Escherichia coli containing activity in an additional anaplerotic enzyme, pyruvate carboxylase. In batch fermentations, the presence of pyruvate carboxylase resulted in 68% greater production of the model protein, beta-galactosidase, 41% greater cell yield, and 57% lower acetate concentration. We discuss why these results indicate that acetate concentration does not limit cell growth and protein synthesis, as predicted by other researchers, and suggest instead that the rate of acetate formation represents an inefficient consumption of glucose carbon, which is reduced by the presence of pyruvate carboxylase.

[Condom use among the young engaging in vaginal intercourse]

OBJECTIVE

To describe young people's use of condoms in penetrative vaginal intercourse, and to identify the factors associated with this use.

METHOD

The information was collected using a self-administered questionnaire put in 1,000 people between 14 and 24 years of age resident in the region of Andalusia (Spain). The results of the sample were representative and the trust interval was 95%. A bivariante analysis was carried out and hierarchical logistic regression equations were adjusted to verify associations between the dependent variable use of the condom in the vaginal intercourse and the variables proposed from PRECEDE model (predisposing, enabling, and reinforcing). The adjustment of the model was of a 38%, according to the Nagelkerke's statistic.

RESULTS

Of the people surveyed, 750 had affective and/or sexual relations with physical contact, and 63% of these had vaginal intercourse (47% of all surveyed). Of those, people that only had vaginal intercourse once (12% of all surveyed), 83% (10,3% of all surveyed) used a condom, whereas, people that had sex more than once (34% of all surveyed), 49% always used a condom (16,9% of all surveyed). The variables associated with always using a condom were: intention of safe behaviour with their regular partner and low frequency of practice. The variables associated with never using a condom were: living emancipated, having an external locus of control (thinking that becoming infected depends upon external factors), low number of zones of the body identified as pleasure-sensitive, thinking that a condom is not necessary if one trusts his or her partner, intention of unsafe behaviour with their regular partner, and not talking with the partner about preventive methods before having sex.

DISCUSSION

The most associated factors with using or not a condom in vaginal intercourse are predisposing (attitudes, values and believes) that are related with the kind of sexual partner. Interventions (based on the young active participation) are suggested to make them perceived the compatibility between the trust with the partner and the use of condom, and put in doubt the false safety given by a partner perceived as habitual.

[Motivation and incentives: different perceptions of administrators and professionals. Evaluation Team of the Materno-Infantile Health Program]

OBJECTIVE

To find the views of Primary Care District managers and Health Centre (HC) professionals in Andalusia on systems of motivation and incentive in use in this autonomous community.

DESIGN

A descriptive study which uses qualitative and quantitative methodology.

SETTING

Primary Care districts and Health Centres in Andalusia.

PARTICIPANTS

Primary Care district managers (51) and HC professionals (91).

MATERIAL AND METHODS

Information-gathering: self-administered questionnaire (managers) and focus groups (professionals).

ANALYTICAL TECHNIQUES

Non-parametric tests to compare means and analysis of contents of discourse. Field-work. July 1994 and February 1995.

RESULTS

55% of the district managers thought that the incentive systems in use were inadequate and insufficient. Enabling professionals to be trained is the main motivating and incentive mechanism in place. Variable productivity was the next most common mechanism. However, variable productivity, in the view of the professionals, was the main demotivating factor of recent years. Professionals thought that the economic rewards of the incentives system were slight, the target variables were unsuitable, there were no objective evaluation mechanisms and the economic differences between the incentives earned by managers and professionals were too great.

CONCLUSIONS

The District managers indicated that improvements in the incentives systems used are needed. The HC professionals affirmed that the Andalusian incentives system has demotivated Primary Care teams and has had little effect on orienting professional practice.

[The attitudes of primary care physicians towards the opening of health centers]

OBJECTIVE

To measure doctors' attitudes to the opening of Health Centres.

DESIGN

Descriptive study. SITE. Primary Care services on the island of Gran Canaria.

PARTICIPANTS

Doctors with tenure.

MAIN MEASUREMENTS AND RESULTS

From a self-administered Likert type questionnaire, it could be observed that the proportion of those polled who did not reply was linked to the number who had a "Fiscal Licence" (Odds Ratio O.R. = 6.26), a ratio which did not disappear when stratified by age (O.R. = 5.88 for those less than or equal to 40 and O.R. = 3.08 for those greater than 40). The scale presented high internal consistency (Cronbach alpha 0.937), indicating favorable attitudes from doctors integrated into Health Centres and both positive and negative attitudes in doctors of a traditional cut. Those specialising in Family Medicine, those under 40 years old, those who had no other health job and those connected with Trades Unions showed more favorable attitudes.

CONCLUSIONS

Individual and group characteristics are linked to different attitudes. The knowledge, evaluation and behaviour components of doctor's attitudes must be improved, by involving the reference groups of both individuals and groups.

Protective immunity to malaria. Studies with cloned lines of Plasmodium chabaudi chabaudi and P. berghei in CBA/Ca mice. II. The effectiveness and inter- or intra-species specificity of the passive transfer of immunity with serum

Serum was obtained from CBA/Ca mice infected, reinfected or superinfected with parasites taken one or two syringe passages from cryopreserved reference stabilates derived from cloned lines of the AS or CB isolates of P.c. chabaudi. Serum was also collected from mice superinfected with parasites derived from a cloned line of P. berghei KSP-11. When injected into normal syngeneic recipients subsequently challenged with homologous or heterologous parasites, these sera mediated some or all of the following modifications to the breakthrough parasitaemias which invariably occurred (i) an extension of the pre-patent period (ii) an extension of the time taken for the parasitaemia to reach 2% (iii) a reduction of peak parasitaemia (iv) protraction of the initial peak of parasitaemia. These modifications were particularly evident with serum from superinfected mice and to a lesser extent with serum from animals reinfected once after recovery from a primary infection. Serum taken during the course of such a primary infection produced extended pre-2% periods, other effects being only marginal. Serum mediated modifications produced by reinfection and superinfection serum appeared largely species-specific with a limited degree of cross-reactivity. Intraspecific specificity was also apparent with serum from P.c. chabaudi AS or CB reinfected or superinfected mice, although marginal cross-immunity was again observed. When analysed by the fluorescent antibody technique on smears of methanol fixed parasitized erythrocytes, reinfection and superinfection sera were almost totally cross-reactive both within and across species. Preliminary evidence that parasites breaking through the effects of these sera may constitute a phenotypic antigenic variant is presented and possible mechanisms for the parasitaemia modifying effects of the various sera discussed.

Drug synergy in experimental African trypanosomiasis

The possibilities of trypanocidal drug synergy have been examined in vitro and in vivo using a monomorphic laboratory strain of Trypanosoma rhodesiense. Twenty-seven different drug pair combinations were chosen from among 12 representative trypanocides on the basis of surmized or reported synergy, evidence of collateral sensitivity in resistant strains, and known differences in modes of action or in field use. In vitro synergy test were made with a transfer plate technique which allows direct isobol determination by microtest tray superimposition. All pairs showing synergy in vitro were tested further in mice. Statistically significant synergy was shown only by suramin and tryparsamide, suramin and Puromycin, and suramin and Berenil. Although six other pairs, of which three contained suramin, showed higher than addictive cure rates, these rates fell short of statistical significance.