RESUMEN
BACKGROUND: Chronic kidney disease (CKD) is increasing worldwide, and the majority of the CKD burden is in low- and middle-income countries (LMICs). However, there is wide variability in global access to kidney care therapies such as dialysis and kidney transplantation. The challenges health professionals experience while providing kidney care in LMICs have not been well described. The goal of this study is to elicit health professionals' perceptions of providing kidney care in a resource-constrained environment, strategies for dealing with resource limitations, and suggestions for improving kidney care in Guatemala. METHODS: Semi-structured interviews were performed with 21 health professionals recruited through convenience sampling at the largest public nephrology center in Guatemala. Health professionals included administrators, physicians, nurses, technicians, nutritionists, psychologists, laboratory personnel, and social workers. Interviews were recorded and transcribed in Spanish. Qualitative data from interviews were analyzed in NVivo using an inductive approach, allowing dominant themes to emerge from interview transcriptions. RESULTS: Health professionals most frequently described challenges in providing high-quality care due to resource limitations. Reducing the frequency of hemodialysis, encouraging patients to opt for peritoneal dialysis rather than hemodialysis, and allocating resources based on clinical acuity were common strategies for reconciling high demand and limited resources. Providers experienced significant emotional challenges related to high patient volume and difficult decisions on resource allocation, leading to burnout and moral distress. To improve care, respondents suggested increased budgets for equipment and personnel, investments in preventative services, and decentralization of services. CONCLUSIONS: Health professionals at the largest public nephrology center in Guatemala described multiple strategies to meet the rising demand for renal replacement therapy. Due to systems-level limitations, health professionals faced difficult choices on the stewardship of resources that are linked to sentiments of burnout and moral distress. This study offers important lessons in Guatemala and other countries seeking to build capacity to scale-up kidney care.
Asunto(s)
Actitud del Personal de Salud , Asignación de Recursos para la Atención de Salud , Hospitales Especializados/organización & administración , Servicio Ambulatorio en Hospital/organización & administración , Insuficiencia Renal Crónica/terapia , Agotamiento Profesional , Toma de Decisiones Clínicas , Guatemala , Hospitales Especializados/normas , Humanos , Servicio Ambulatorio en Hospital/normas , Diálisis Peritoneal , Personal de Hospital/psicología , Investigación Cualitativa , Calidad de la Atención de Salud , Diálisis Renal , Estrés PsicológicoRESUMEN
BACKGROUND: Up to one half of the population in Africa, Asia and Latin America has little access to high-quality biomedical services and relies on traditional health systems. Medical pluralism is thus in many developing countries the rule rather than the exception, which is why the World Health Organization is calling for intercultural partnerships to improve health care in these regions. They are, however, challenging due to disparate knowledge systems and lack of trust that hamper understanding and collaboration. We developed a collaborative, patient-centered boundary mechanism to overcome these challenges and to foster intercultural partnerships in health care. To assess its impact on the quality of intercultural patient care in a medically pluralistic developing country, we conducted and evaluated a case study. METHODS: The case study took place in Guatemala, since previous efforts to initiate intercultural medical partnerships in this country were hampered by intense historical and societal conflicts. It was designed by a team from ETH Zurich's Transdisciplinarity Lab, the National Cancer Institute of Guatemala, two traditional Councils of Elders and 25 Mayan healers from the Kaqchikel and Q'eqchi' linguistic groups. It was implemented from January 2014 to July 2015. Scientists and traditional political authorities collaborated to facilitate workshops, comparative diagnoses and patient referrals, which were conducted jointly by biomedical and traditional practitioners. The traditional medical practices were thoroughly documented, as were the health-seeking pathways of patients, and the overall impact was evaluated. RESULTS: The boundary mechanism was successful in discerning barriers of access for indigenous patients in the biomedical health system, and in building trust between doctors and healers. Learning outcomes included a reduction of stereotypical attitudes towards traditional healers, improved biomedical procedures due to enhanced self-reflection of doctors, and improved traditional health care due to refined diagnoses and adapted treatment strategies. In individual cases, the beneficial effects of traditional treatments were remarkable, and the doctors continued to collaborate with healers after the study was completed. Comparison of the two linguistic groups illustrated that the outcomes are highly context-dependent. CONCLUSIONS: If well adapted to local context, patient-centered boundary mechanisms can enable intercultural partnerships by creating access, building trust and fostering mutual learning, even in circumstances as complex as those in Guatemala. Creating multilateral patient-centered boundary mechanisms is thus a promising approach to improve health care in medically pluralistic developing countries.
Asunto(s)
Diversidad Cultural , Atención a la Salud/organización & administración , Medicina Tradicional , Atención Dirigida al Paciente/métodos , Cultura , Atención a la Salud/métodos , Guatemala , Humanos , Indígenas Centroamericanos/etnología , Medicina Tradicional/métodos , Atención Dirigida al Paciente/organización & administraciónRESUMEN
Typical resuspension activities within the home, such as walking, have been estimated to contribute up to 25% of personal exposures to PM10. Chamber studies have shown that for moderate walking intensities, flooring type can impact the rate at which particles are re-entrained into the air. For this study, the impact of residential flooring type on incremental average daily (24 h) time-averaged exposure was investigated. Distributions of incremental time-averaged daily exposures to fine and coarse PM while walking within the residential micro-environment were predicted using CONTAM, the multizone airflow and contaminant transport program of the National Institute of Standards and Technology. Knowledge of when and where a person was walking was determined by randomly selecting 490 daily diaries from the EPA's consolidated human activity database (CHAD). On the basis of the results of this study, residential flooring type can significantly impact incremental time-averaged daily exposures to coarse and fine particles (α=0.05, P<0.05, N=490, Kruskal-Wallis test) with high-density cut pile carpeting resulting in the highest exposures. From this study, resuspension from walking within the residential micro-environment contributed 6-72% of time-averaged daily exposures to PM10.