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El contexto representa un conjunto de circunstancias que rodean una situación y, sin las cuales, esta no puede comprenderse en forma correcta. La relación médico paciente está enmarcada en un vínculo contextual. En la práctica cotidiana del médico de familia la atención del paciente se realiza de manera integral, sin disociar el cuerpo del contexto. En este artículo los autores desarrollan el abordaje contextual como herramienta diagnóstica y se describen con detalle dos instrumentos útiles para ponerla en práctica: la evaluación contextual y la entrevista de FOCO (Familia, Orientación y Contexto). (AU)

The context represents a set of circumstances that surround a situation without which it can not be properly understood.The patient-physician relationship is framed in a contextual link. In the daily practice of the family physician, patient careis carried out in an integral manner, without dissociating the body from the context. In this article the authors develop the contextual approach as a diagnostic tool and describe in detail two useful instruments to put it into practice: the contextual assessment and the FOCO interview (Family, Orientation and Context). (AU)

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RESUMEN La formación de un médico de nuevo modelo en Cuba surge de forma experimental por la necesidad que tenía la población de recibir una atención médica integral. Como siempre nuestro comandante con sus ideas revolucionarias plantea la necesidad de su creación para que cada familia cubana contara con un médico y una enfermera que les brindara apoyo y cuidado desde el punto de vista clínico, epidemiológico y social. El municipio de Colón fue el primero en implementar este novedoso programa en la provincia de Matanzas. Con el objetivo de dar a conocer el surgimiento y desarrollo del mismo en esta ciudad es que se realiza el siguiente trabajo (AU).

SUMMARY The training of a new model doctor in Cuba arises experimentally because of the need of the population to receive comprehensive medical care. As always, our commander with his revolutionary ideas raised the need for its creation so that each Cuban family would have a doctor and a nurse who could provide support and care from a clinical, epidemiological and social point of view. The municipality of Colón was the first to implement this novel program in the province of Matanzas. With the aim of publicizing its emergence and development in our city, the authors wrote the following article (AU).

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OBJECTIVE: To evaluate whether quality improvement (QI) capacity-building in affiliated primary care practices could increase well care visit uptake. STUDY DESIGN: Partners For Kids (PFK) is an accountable care organization caring for pediatric Medicaid beneficiaries in Ohio. PFK QI specialists recruited practices to develop QI projects around increasing well care visit rates (proportion of eligible children with well care visits during calendar year) for children aged 3-6 years and adolescents. The QI specialists supported practice teams in implementing interventions and collecting data through monthly or bimonthly practice visits. RESULTS: Ten practices, serving more than 26 000 children, participated in QI projects for a median of 8.5 months (IQR 5.3-17.6). Well care visit rates in the QI-engaged practices significantly improved from 2016 to 2018 (P < .001 for both age groups). Over time, well care visit rates for 3- to 6-year-old children increased by 11.8% (95% CI 5.4%-18.2%) in QI-engaged practices, compared with 4.1% (95% CI 0.1%-7.4%) in non-engaged practices (P = .233). For adolescents, well care visit rates increased 14.3% (95% CI -2.6% to 31.2%) compared with 5.4% (95% CI 1.8%-9.0%) in QI-engaged vs non-engaged practices over the same period (P = .215). Although not statistically significant, QI-engaged practices had greater magnitudes of rate increases for both age groups. CONCLUSIONS: Through practice facilitation, PFK helped a diverse group of community practices substantially improve preventive visit uptake over time. QI programs in primary care can reach patients early to promote preventive services that potentially avoid costly downstream care.

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RESUMO Objetivo Avaliar a presença e extensão dos atributos essenciais e derivados da atenção primária em saúde no programa de controle da hanseníase, sob a ótico médica. Métodos Trata-se de um estudo de avaliação de programas de saúde, com foco na hanseníase, tendo como púbico alvo os médicos atuantes nas ações de controle do programa de hanseníase nas unidades de saúde da atenção primária. Foi utilizado um questionário, elaborado e validado em outro estudo, para medir a presença e a extensão dos atributos da atenção primária à saúde no controle da doença. Os dados foram inseridos em um banco de dados e posteriormente receberam uma análise estatística e descritiva. Esse estudo foi aprovado sob o parecer CEP n° 1.128.385. Resultados Na análise dos escores gerais e dos atributos essenciais observou-se que o município do estudo apresentou alta orientação para as ações de controle da han-seníase. Os atributos acesso, orientação comunitária e orientação profissional receberam médias abaixo do ponto de corte, demonstrando fragilidades existentes nos itens que compõe esse atributo. Conclusão Apesar das fragilidades identificadas, o município de estudo apresenta alta orientação para o desenvolvimento das ações de controle da hanseníase, segundo a avaliação dos médicos atuantes na atenção primária.(AU)

ABSTRACT Objective To assess the presence and extent of essential attributes derived from primary health care in a leprosy control program. Materials and Methods This is an assessment of health programs, focused on leprosy and targeted at doctors working on control actions in a leprosy program of primary health care units. A questionnaire developed and validated in another study was used to measure the presence and scope of primary health care attributes in disease control. Data were entered into a database and statistical and descriptive analysis was carried out. This study was approved within the framework of CEP No. 1.128.385. Results Overall scores and essential attributes of leprosy control actions showed a high exposure to leprosy control actions in the studied city. Community's access, orientation and guidance attributes averaged below the cutoff point, demonstrating the existing weaknesses in the items that make up these attributes. Conclusion Despite the weaknesses identified, the study showed high orientation towards the development of leprosy control actions, according to the assessment made by doctors working in primary care.(AU)

RESUMEN Objetivo Evaluar la presencia y alcance de los atributos esenciales derivados de la atención primaria de la salud en el programa de control de la lepra, desde la óptica médica. Métodos Se trata de una evaluación de los programas de salud, centrados en la lepra, teniendo como público objetivo los médicos que trabajan en las acciones de control de la lepra en el programa de las unidades de salud de atención primaria. Se utilizó un cuestionario desarrollado y validado en otro estudio, para medir la presencia y alcance de los atributos de la atención primaria de salud en el control de la enfermedad. Los datos se introdujeron en una base de datos y más tarde se realizó el análisis estadístico y descriptivo. Este estudio fue aprobado en el marco del CEP N°. 1.128.385. Resultados Las puntuaciones globales y los atributos esenciales de las acciones de control de la lepra tuvieron una puntuación alta, en la ciudad del estudio. Los atributos de acceso, orientación y guía de la comunidad tuvieron un promedio por debajo del punto de corte, lo que demuestra las deficiencias existentes en los elementos que componen estos atributos. Conclusión A pesar de las debilidades identificadas, el estudio mostró una alta orientación en el desarrollo de acciones de control de la lepra, de acuerdo con la evaluación de los médicos que trabajan en atención primaria.(AU)

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Es muy frecuente, en la práctica ambulatoria de los médicos de familia, que los pacientes nos consulten por problemas de salud que están directamente relacionados con su contexto y su familia. En este sentido, ocupamos un lugar fundamental para evaluar esos aspectos y orientar a nuestros pacientes en la resolución de los problemas. Para llevar a cabo la tarea es preciso contar con tiempo, estar interesado y recibir cierto entrenamiento. Los médicos de familia del Hospital Italiano de Buenos Aires desarrollamos un dispositivo específico denominado FOCO (familia, orientación y contexto) con el objeto de brindar a nuestros pacientes asesoramiento, contención, orientación y, eventualmente, tratamiento de aspectos psicosociales, contextuales o familiares, y nos resulta de gran utilidad en la práctica clínica para el abordaje de estas consultas. Además, creemos que este dispositivo sirve también para poder plasmar en la historia clínica aspectos habitualmente no transcriptos en ella, relacionados con el encuentro clínico. En esta oportunidad presentaremos el caso de una familia con una madre muy temerosa que solicita, ante cualquier problema de salud, interconsultas a especialistas y estudios complementarios para "cuidar bien" a sus hijos. El abordaje del caso incluye el uso del dispositivo FOCO mencionado. (AU)

It is very frequent in Family Physicians practices, to receive consultations where the context of the patient and his family are directly related to their health problems. We have a fundamental place to evaluate these aspects and guide our patients in the resolution of these problems. To carry out this task is necessary to have time, be interested and receive some training. The family doctors of the Hospital Italiano de Buenos Aires developed a specific device called FOCO (Family, Orientation and COntext) in order to provide our patients with advice, containment, guidance and, eventually, treatment of psychosocial, contextual or family aspects. In addition, we believe that this device also serves to be able to translate in clinical history aspects usually not transcribed in it, related to the clinical encounter. We present the case of a family with a fearful mother who thinks that "more is better" in the care of their children and their approach through the FOCO device. (AU)

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Since 1988, Brazil has built a national health system procuring a response that meets universal health care. The government created the Family Health Strategy (FHS) to help improve access to health services through primary health care teams developing interdisciplinary actions. Scarcity of doctors with family medicine (FM) competencies in Brazil limits the FHS effectiveness. The lack of family physicians can be traced primarily to the medical schools where training supports other specialties besides FM. Innovation is required to bring students to the specialty and medical marketplace. The authors relate their experience and advances in designing alternatives to seize solutions to address challenges related to strategic aspects of FM that can improve medical education practices. Challenges presented exemplify means to expose students to key principles of FM practice such as continuity, commitment and longitudinal care, together with other attributes of FM practice such as team work and interprofessional action. A key asset in overcoming the challenges for primary health care through improved FM practice is the exposure of students to FM practitioners that mentor student practices as role models in different settings where health care is provided.

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OBJECTIVE: To assess the presence and extent of essential attributes derived from primary health care in a leprosy control program. MATERIALS AND METHODS: This is an assessment of health programs, focused on leprosy and targeted at doctors working on control actions in a leprosy program of primary health care units. A questionnaire developed and validated in another study was used to measure the presence and scope of primary health care attributes in disease control. Data were entered into a database and statistical and descriptive analysis was carried out. This study was approved within the framework of CEP No. 1.128.385. RESULTS: Overall scores and essential attributes of leprosy control actions showed a high exposure to leprosy control actions in the studied city. Community's access, orientation and guidance attributes averaged below the cutoff point, demonstrating the existing weaknesses in the items that make up these attributes. CONCLUSION: Despite the weaknesses identified, the study showed high orientation towards the development of leprosy control actions, according to the assessment made by doctors working in primary care.

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Introducción: se conoce que la mujer con síndrome de ovario poliquístico tiene mayor riesgo de desarrollar complicaciones cardiometabólicas, pero también existen evidencias de que sus familiares son más propensos a estas. Objetivo: identificar la frecuencia de componentes del síndrome metabólico en familiares de mujeres con síndrome de ovario poliquístico. Métodos: se realizó un estudio descriptivo transversal en el Instituto Nacional de Endocrinología durante el periodo de 2012 al 2014, que incluyó 25 mujeres con síndrome de ovario poliquístico y 36 de sus familiares (casos), y 50 mujeres sin síndrome de ovario poliquístico y 65 de sus familiares (controles). En los familiares se indagó sobre antecedentes de hipertensión arterial, diabetes mellitus, dislipidemia, se tomó la tensión arterial, el peso y talla. Se realizó prueba de tolerancia a la glucosa oral midiendo glucemia e insulinemia (exceptuando a los que padecían diabetes mellitus), colesterol y triglicéridos. Se determinaron frecuencias y se empleó chi2 para las comparaciones. Resultados: el 76,0 por ciento de las mujeres con síndrome de ovario poliquístico refirió un familiar con diabetes mellitus, el 80,0 por ciento con hipertensión arterial y el 20,0 por ciento con algún trastorno lipídico. En las mujeres sanas el 28,0 por ciento tuvo algún familiar con diabetes mellitus, el 36,0 por ciento con hipertensión arterial y con dislipidemia el 12,0 por ciento. Según la prueba de tolerancia a la glucosa oral, se diagnosticó glucemia alterada en ayunas en 16,7 por ciento de los familiares de las mujeres con síndrome de ovario poliquístico y 12,3 por ciento de los familiares de las sanas, con tolerancia a la glucosa alterada hubo 19,4 por ciento de los familiares de los casos y 3,1 por ciento de los de las controles; con diabetes mellitus hubo 5,6 por ciento de los parientes de las mujeres con síndrome de ovario poliquístico y 1,5 por ciento de los de las sanas. En el 47,2 por ciento de los familiares de mujeres con síndrome de ovario poliquístico y el 21,5 por ciento de los de las sanas se detectó hipertrigliceridemia. Conclusiones: la frecuencia de los componentes del síndrome metabólico en familiares de mujeres con síndrome de ovario poliquístico, es mayor al compararlo con el de los familiares de mujeres que no lo presentan(AU)

Introduction: it is known that women with polycystic ovary syndrome have a higher risk of developing cardiometabolic complications, but there is also evidence that their relatives are more prone to those too. Objective: to identify the frequency of components of the metabolic syndrome in relatives of women with polycystic ovary syndrome. Methods: a cross-sectional, descriptive study was conducted in the National Institute of Endocrinology from 2012 to 2014, which included 25 women with polycystic ovary syndrome and 36 of their relatives (cases); and 50 women without polycystic ovary syndrome and 65 of their relatives (controls). The relatives were inquired about a history of hypertension, diabetes mellitus, dyslipidemia; and blood pressure, weight and height were measured. An oral glucose tolerance test was carried out for measuring glycaemia and insulinaemia (excepting those suffering from diabetes mellitus), and cholesterol and triglycerides. Frequencies were determined and chi2 was used for comparisons. Results: 76.0 percent of women with polycystic ovary syndrome reported a relative with diabetes mellitus, 80.0 percent a relative with arterial hypertension, and 20.0 percent a relative with a lipid disorder. In healthy women, 28.0 percent of them had a family member with diabetes mellitus, 36.0 percent a relative with arterial hypertension, and 12.0 percent a relative with dyslipidemia. According to the oral glucose tolerance´s test, impaired glucose in fasting was diagnosed in 16.7 percent of the relatives of women with polycystic ovary syndrome, and in 12.3 percent of the relatives of healthy women. There were 19.4 percent of the relatives of the cases with impaired glucose tolerance, and 3.1 percent of the controls. There were 5.6 percent of the relatives of the women with polycystic ovary syndrome with diabetes mellitus and 1.5 percent of those of the healthy ones. In 47.2 percent of the relatives of women with polycystic ovary syndrome and 21.5 percent of those of healthy women, hypertriglyceridemia was detected. Conclusions: the frequency of metabolic syndrome components in family members of women with polycystic ovary syndrome is higher when compared to the relatives of women who do not have it(AU)

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This study seeks to understand the difficulties experienced by family physicians (FP) in the management of mental disorders (MD) and their proposals to improve the quality of care. It is qualitative study with semi-structured interviews with ten family physicians. These were recorded, transcribed and their content analyzed. Eight thematic categories were identified: perceived working conditions and available resources; perceived level of training in mental health; therapies used for treatment of MD; mental health instruments used in consultation; MD addressed in Primary Health Care (PHC) and referral to hospitals; patient's reaction to referral; articulation of PHC with hospitals; proposals to improve mental health care in PHC. Articulation with the Mental Health Services suffers from lack of accessibility, one-way communication and delayed response. The FP propose creation of consultancies; multidisciplinary teams in the community; creating a two-way communication platform; continuous learning through discussion of cases. The FP have responsibilities in providing MHC. This requires working in a multidisciplinary team. Services should be organized to function as a learning system that allows the progressive improvement of the professionals and the improvement of the interfaces between them.

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Introducción: las necesidades de aprendizaje resultan de contrastar un desempeño ideal o propuesto con el real, bien sea para un individuo o un grupo determinado. Constituyen el punto de partida para la búsqueda de una solución pedagógica, a fin de contribuir a la transformación cualitativa de los servicios de salud, y su oportuna identificación una trascendental herramienta de la educación permanente. Objetivo : identificar las necesidades de aprendizaje de los médicos que laboran en los Equipos de Atención Primaria de Salud, del municipio Playa, sobre la conducta violenta. Métodos: como método empírico se aplicó un cuestionario con carácter anónimo, en forma de examen escrito, a 22 especialistas de Medicina General Integral, seleccionados al azar, que laboran en tres policlínicas del extremo Este, del municipio Playa. Resultados: se puntualizaron las deficiencias e insuficiencias de los conocimientos y habilidades profesionales sobre el fenómeno de la violencia, fundamental, en lo que respecta a su dimensión cognitiva y su manifestación en niños, mujeres y ancianos. Conclusiones: a pesar de que el fenómeno de la violencia constituye, en el primer nivel de atención, uno de los Programas priorizados, en lo que a Salud Mental se refiere, la mayoría de los especialistas no lo identifican como es debido, por lo que persiste como un comportamiento infradiagnosticado, cuyo riesgo es, en lo habitual, poco explorado y su evaluación adolece, en ocasiones, de elementos de obligatoria indagación y conocimiento, lo que afecta su calidad y su adecuado seguimiento(AU)

Introduction: The learning needs result from contrasting an ideal or proposed performance with the real, either for an individual or a particular group. They constitute the starting point for seeking a pedagogical solution, in order to contribute to the qualitative transformation of health services, and their timely identification constitutes a transcendental tool of lifelong education. Objective: To identify the needs of learning on violent behavior of the physicians who work in the primary health care teams of Playa Municipality. Methods: As an empirical method, a questionnaire was conducted, with an anonymously character and as a written examination, on 22 family medicine specialists randomly chosen and who work in three polyclinics of the East end of Playa municipality. Results: The deficiencies and inadequacies of professional knowledge and skills on the phenomenon of violence were pointed out, fundamentally with regard to their cognitive dimension and their manifestation in children, women and the elderly. Conclusions: Although the phenomenon of violence constitutes, in primary health care, one of the priority programs, as far as it is about mental health, most specialists do not identify it correctly. It persists as an underdiagnosed behavior, whose risk is sometimes scarcely explored and its evaluation often suffers from elements of obligatory inquiry and knowledge, which affects its quality and its adequate update(AU)

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Resumo Pretende-se conhecer as dificuldades sentidas pelos médicos de família (MF) na abordagem dos doentes com transtornos mentais (TM) e conhecer as suas propostas para melhorar os cuidados os cuidados de saúde mental (CSM). Estudo qualitativo. Realizaram-se entrevistas semiestruturadas e audio-gravadas a 10 MF. Com análise de conteúdo identificaram-se oito categorias temáticas: condições de trabalho percecionadas; formação em saúde; terapêuticas usadas para tratamento dos TM; instrumentos de saúde mental usados na consulta; TM abordados na atenção primária (AP) e referenciadas a cuidados hospitalares; reação do doente à referenciação; articulação da atenção primária com a psiquiatria; propostas para melhorar os CSM na AP. A articulação com os serviços de saúde mental é deficiente pela falta de acessibilidade, comunicação unidirecional e atraso na resposta. Para melhorar os MF propõem criação de consultorias; equipes multidisciplinares; plataformas que permitam a comunicação bidirecional; aprendizagem contínua com a discussão de casos. O MF presta CSM, o que exige trabalho em equipe, com elementos da comunidade e dos hospitais. Os serviços devem organizar-se como sistemas aprendentes que permitam a progressiva melhoria dos profissionais e o aperfeiçoamento das interfaces entre os mesmos.

Abstract This study seeks to understand the difficulties experienced by family physicians (FP) in the management of mental disorders (MD) and their proposals to improve the quality of care. It is qualitative study with semi-structured interviews with ten family physicians. These were recorded, transcribed and their content analyzed. Eight thematic categories were identified: perceived working conditions and available resources; perceived level of training in mental health; therapies used for treatment of MD; mental health instruments used in consultation; MD addressed in Primary Health Care (PHC) and referral to hospitals; patient's reaction to referral; articulation of PHC with hospitals; proposals to improve mental health care in PHC. Articulation with the Mental Health Services suffers from lack of accessibility, one-way communication and delayed response. The FP propose creation of consultancies; multidisciplinary teams in the community; creating a two-way communication platform; continuous learning through discussion of cases. The FP have responsibilities in providing MHC. This requires working in a multidisciplinary team. Services should be organized to function as a learning system that allows the progressive improvement of the professionals and the improvement of the interfaces between them.

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Although it is known that the social determinants of health have a larger influence on health outcomes than health care, there currently is no structured way for primary care providers to identify and address nonmedical social needs experienced by patients seen in a clinic setting. We developed and piloted WellRx, an 11-question instrument used to screen 3048 patients for social determinants in 3 family medicine clinics over a 90-day period. Results showed that 46% of patients screened positive for at least 1 area of social need, and 63% of those had multiple needs. Most of these needs were previously unknown to the clinicians. Medical assistants and community health workers then offered to connect patients with appropriate services and resources to address the identified needs. The WellRx pilot demonstrated that it is feasible for a clinic to implement such an assessment system, that the assessment can reveal important information, and that having information about patients' social needs improves provider ease of practice. Demonstrated feasibility and favorable outcomes led to institutionalization of the WellRx process at a university teaching hospital and influenced the state department of health to require managed care organizations to have community health workers available to care for Medicaid patients.

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Cervical cancer is a health population problem that affects all the world. It remains globally the second leading cause of death in women according to the reports of the International Agency for Cancer Research. In 2008 it was reported an incidence of 8.8 %, which represents a total of 530 232 new cases worldwide and a mortality rate of 8.2 %, meaning a total of 275 008 deaths from this pathology that year. If we bear in mind that the affected group is composed by women in reproductive age, we can size the sociodemographic and family consequences that this pathology brings. So the integral level approach with emphasis on the preventive area is the key to the reduction of morbidity from this disease. This premise suggests the need to offer a broad outlook about the role played by health personnel with care in Family Medicine.

El cáncer cervicouterino es un problema de salud poblacional que afecta a todo el mundo y continúa siendo la segunda causa de muerte en mujeres a nivel global. En el 2008 la Agencia Internacional de Investigación para el Cáncer reportó una incidencia del 8.8 %, lo cual representa un total de 530 232 nuevos casos a nivel mundial y una tasa de mortalidad de 8.2 %, que significaron un total de 275 008 defunciones por esta patología. Si tomamos en cuenta que el grupo con mayor afectación son mujeres en edad reproductiva, podemos dimensionar las secuelas sociodemográficas y familiares que esta patología trae como consecuencia, por lo cual el abordaje de manera integral con énfasis en el área preventiva es la clave para lograr la reducción de la morbimortalidad por esta enfermedad. De esta premisa se desprende la necesidad de brindar un panorama amplio del rol que juega el personal de salud con atención en Medicina Familiar.

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INTRODUCTION: Globally, older adults are a population group that often suffers abuse by their caregivers. Along with women and children, they are among those most often reported as victims of abuse of any kind in Cuba. OBJECTIVE: Characterize presence of domestic abuse of older adults in family doctor-and-nurse office No. 28 of the Carlos Manuel Portuondo University Polyclinic in Havana, Cuba, determining the main manifestations of abuse and help-seeking behavior by the older adults identified as victims. METHOD: This was a descriptive cross-sectional study of adults aged ≥ 60 years; all those not diagnosed with dementia and who agreed to participate were interviewed. In a universe of 268 older adults, 29 were living outside the area, 24 declined to participate, and 18 had a diagnosis of dementia, leaving a study population of 197 individuals. Variables included: personal experience of abuse, type of abuse, perpetrator, help sought, and reasons for not seeking help. Statistical analysis was based on percentages. RESULTS: Of 197 older adults interviewed, 88 (44.7%) reported that they were victims of domestic abuse; 50 of these were women. The most common types of abuse were psychological abuse and disrespect for personal space, reported by 69 (78.4%) and 54 (61.4%) individuals, respectively. Sons- and daughters-in-law were identified as the abusers by 68 participants and grandchildren by 65. Of the 88 victims, 67 (76.1%) stated that they did not seek help. CONCLUSIONS: The finding that substantial numbers of older adults are victims of domestic abuse brings to light a hitherto insufficiently addressed issue in the community studied. More research is needed to deepen understanding of the scope and causes of the problem to inform prevention and management strategies, not only at the level of the polyclinic catchment area, but in the health system in general.

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OBJECTIVE: To evaluate the implementability of the "2008 Mexican Clinical Practice Guideline for the management of hip and knee osteoarthritis at the primary level of care" within primary healthcare of three Mexican regions using the Guideline Implementability Appraisal methodology version 2 (GLIA.v2). METHODS: Six family physicians, representing the South, North, and Central Mexico, and one Mexican physiatrist evaluated the 45 recommendations stated by the Mexican guideline. The GLIA.v2 methodology includes the execution of qualitative and semi-quantitative techniques. RESULTS: Reviewers' agreement was between moderate to near complete in most cases. Sixty-nine percent of the recommendations were considered difficult to implement within clinical practice. Eight recommendations did not have an appropriate format. Only 6 recommendations were judged as able to be consistently applied to clinical practice. Barriers related to the context of one or more institutions/regions were identified in 25 recommendations. These barriers are related to health providers/patients' beliefs, processes of care within each institution, and availability of some treatments recommended by the guideline. CONCLUSIONS: The guideline presented problems of conciseness and clarity that negatively affect its application within the Mexican primary healthcare context. We identified individual, organizational and system characteristics, which are common to the 3 institutions/regions studied and constitute barriers for implementing the guideline to clinical practice. It is recommended that the 2008-Mexican-CPG-OA be thoroughly revised and restructured to improve the clarity of the actions implied by each recommendation. We propose some strategies to accomplish this and to overcome some of the identified regional/institutional barriers.

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