SEMINÁRIO INTERNACIONAL: EVIDÊNCIAS CIENTÍFICAS PARA A TOMADA DE DECISÃO EM POLÍTICAS E PROGRAMAS DE SAÚDE

Oficina “Introdução ao desenvolvimento de guias de prática e guias para política informadas por evidências”

A. Composição de Grupo e Conflitos de interesse(Sessão de trabalho em grupo)

1. Você vai coordenar a elaboração de um guia sobre o uso de micronutrientes para a fortificação de alimentos consumidos por crianças de 6 a 23 anos a nível nacional no Brasil.

Identifique os grupos principais que participarão do desenvolvimento da guia e seus contextos, de acordo com o contexto do país.

2. Você foi convidado a tomar parte de um painel que formulará recomendações sobre o uso de micronutrientes para a fortificação de alimentos consumidos por crianças de 6 a 23 anos. O grupo que participou desta oficina é suficientemente representativo para compor o painel para formular as recomendações da guia? Quem faz falta?

3. Alguns dos participantes do painel declararam os seguintes conflitos de interesse. Classifique o conflito de interesse.

A: declarou envolvimento em trabalho acadêmico relacionado ao tema da reunião/guiaB: declarou qualquer interesse financeiro ou comercial relacionado com o tema da reunião/guia C: declarou qualquer interesse financeiro ou comercial, não diretamente relacionado com o tema da reunião/guiaD: declarou interesse não-comercial ou subsídios relacionados com o tema da reunião/guia

Devem ser excluídos do painel? Se forem incluídos podem ter opinião e/ou participar da formulação das recomendações? Como devem reportar na guia?

a. Dr XX declara ser o Presidente do Conselho Executivo do Instituto Danone no México (DIM), uma organização sem fins lucrativos para a promoção da pesquisa e disseminação do conhecimento científico em nutrição, e recebeu fundos como chair honorário do DIM. Algumas das atividades do DIM geralmente podem estar relacionados com a nutrição e são financiadas pela Danone México, um produtor de alimentos.b. Dr XX co-autoria a revisão sistemática sobre a utilização de múltiplos pós de micronutrientes em crianças menores de 2 anos de idade.c. Dr XX é o principal autor de um ensaio clínico com pós de micronutrientes. A pesquisa foi financiada por uma empresa que produz pós de micronutrientesd. Dr XX declara ser proprietária de um estoque em Victherra, um pool trigo para os agricultores que fabrica produtos relacionados ao presente guia.

B. Qualidade da Evidência(Sessão de trabalho de grupo)

1. Você foi convidado a tomar parte de um painel que formulará recomendações sobre o uso de micronutrientes para a fortificação de alimentos consumidos por crianças de 6 a 23 anos. Quais documentos espera receber por parte dos organizadores do painel?

2. Os especialistas em metodología desenvolveram uma revisão sistemática da literatura. Use a revisão sistemática Cochrane para avaliar a qualidade da evidência.

Avaliação da qualidade da evidência usando o sistema GRADE.

Item Avaliação ComentáriosECA

Estúdios observacionais

Risco de viés

Inconsistência (heterogeneidade)

Relevância da evidência (indireta/ aplicabilidade)

Imprecisão

Viés de publicação

Qualidade da evidência Alta: Moderada: Baixa: Muito Baixa:

Formulação de recomendações(Sessão de trabalho de grupo)

Pergunta PICO Avaliação ComentáriosQualidade da evidência Alta:

Moderada: Baixa: Muito Baixa:

Valores e preferências dos pacientes

Não há variabilidade significativa Variabilidade significativa

Magnitude do efeito (absoluta)

Grande efeito (RR>2 or RR<0.5) Pequeno efeito (0.5<RR<2)

Equilíbrio entre efeitos desejáveis e indesejáveis

Benefícios superam as desvantagens Vantagens e desvantagens são equilibradas. Desvantagens superam os benefícios

Recursos e custos Menos recursos intensivos Mais recursos intensivos

Viabilidade Sim, globalmente No, condicionalmente

Direção da recomendação

A favor da intervenção Em contra da intervenção

Forca da recomendação

Recomendação forte Recomendação fraca (ou condicionais)

C. Do Guia de prática para o Guia para política(Sessão de trabalho de grupo)

O programa de micronutrientes para população infantil no Peru encontrou que, após 2 anos de implementação, as taxas de prevalência da população com anemia foram díspares e que em algumas áreas os números permaneceram inalterados. No mesmo ano a OMS lança seu guia que mostra a eficácia e a segurança de micronutrientes em pó. Você também acaba de analisar essas evidências.

A equipe de Peru decide rever seu programa e implementar uma nova política. Durante a preparação do documento para política fizeram análise de barreiras (tabela1) para poder melhorar a implementação de qualquer ação e apresentou três opções para melhorar a distribuição e acesso aos micronutrientes.

As opções de políticas (intervenções) propostas foram: a) componente educativo e de comunicação (educação para pais e pessoal de saúde e campanhas de comunicação), b) monitoramento mais perto da intervenção c) participação comunitária através de trabalhadores comunitários e organizações comunitárias de base.

Tabela 1: Síntese das barreiras localizadas foram:

Nível Barreiras

Pessoas Em populações indígenas os homens não aceitam que suas mulheres sejam atendidas por profissionais do sexo masculino.A participação da comunidade está relacionada com a importância percebida dO problema, e por isso primeiramente deveria ser trabalhado a sensibilização sobre o impacto da anemia.Muitos povos indígenas falam quechua

Provedores A alta rotatividade de profissionais de saúde (médico e enfermeiras) não permitem o estabelecimento de uma relação sustentável com a comunidade. As diferenças culturais entre provedores de saúde e a comunidade são muitas vezes significativas.Nem todos os médicos sabem como indicar os micronutrientes.

Organização Há uma grande restrição para atividades fora dos muros por parte dos trabalhadores da comunidade, tais como incentivos.

Sistema Não só para o pó de polimicronutrientes, mas para a maioria das intervenções de saúde o papel dos trabalhadores de comunidade não é bem definido no sistema, bem como a remuneração a ser percebida e os mecanismos de sustentabilidade para sua participação de longo prazo.

O próximo trabalho é pensar como posso endereçar as barreiras já mencionadas para uma implementação eficaz das opções. Para esta etapa também são necessárias evidencias.

São apresentados em material anexo exemplos de estratégias de implementação para enfrentar várias barreiras e extratos de alguns resumos de estudos científicos relacionados direta ou indiretamente com as opções levantadas. Você não precisa recorrer aos textos completos. Este é apenas um exercício. Escolha um deles e tente completar a tabela 2 abaixo.

Tabela 2: Considerações para a implementação

Níveis Opção 1Componente educacional e comunicativo.

Opção 2Monitoramento mais perto da intervenção.

Opção 3Monitoramento mais perto da intervenção e das organizações comunitárias de base.

Pessoas

Provedores

Organização

Sistema

Extratos de alguns resumos de estudos científicos para abordagem sobre as barreiras

Guise JM, Palda V, Westhoff C, Chan BK, Helfand M, Lieu TA. The effectiveness of primary care-based interventions to promote breastfeeding: systematic evidence review and meta- analysis for the US Preventive Services Task Force. Annals of family medicine. 2003; 1(2): 70-8.

- Breastfeeding education increases breastfeeding initiation and short term continuation up to 3 months, but has little or no impact on long term duration up to 6 months. The impact of education was greatest in populations with baseline

- breastfeeding rate less than 50%.- Breastfeeding support increases short and long-term breastfeeding duration Combining

breastfeeding education and support increases initiation as well as short and long-term continuation of breastfeeding

- All the studies included in this summary were conducted in high income countries among vulnerable groups such as low-income, low educational level, and Black populations

Breastfeeding support with educational programmes. Four RCTs combined breastfeeding support with educational programmes and found that:

- Combining breastfeeding education and support increases initiation and (short and long-term) continuation of breastfeeding

- The increases in both initiation and continuation of breastfeeding are larger when support and education are combined than with support alone

- The increases in both initiation and short-tem continuation of breastfeeding when breastfeeding support and education are combined are not substantially different from those achieved with education alone.

Grilli R, Ramsay C, Minozzi S. Mass media interventions: effects on health services utilisation. Cochrane Database Syst Rev. 2002; (1): CD000389.

A B S T R A C TBackgroundThe mass media frequently cover health related topics, are the leading source of information about important health issues, and are targeted by those who aim to influence the behaviour of health professionals and patients.Objectives: To assess the effects of mass media on the utilisation of health services.Search methodsWe searched the Cochrane Effective Practice and Organisation of Care Group specialised register (1996 to 1999),MEDLINE, EMBASE, Eric, PsycLit (to 1999), and reference lists of articles. We hand searched the journals Communication Research (February 1987 to August 1996), European Journal of Communication (1986 to 1994), Journal of Communication (winter 1986 to summer 1996),Communication Theory (February 1991 to August 1996), Critical Studies in Mass Communication (March 1984 to March 1995) and Journalism Quarterly (1986 to summer 1996).Selection criteriaRandomised trials, controlled clinical trials, controlled before-and-after studies and interrupted time series analyses of mass media interventions. The participants were health care professionals, patients and the general public.Data collection and analysisTwo reviewers independently extracted data and assessed study quality.Main resultsTwenty studies were included. All used interrupted time series designs. Fifteen evaluated the impact of formal mass media campaigns, and five of media coverage of health-related issues. The overall methodological quality was variable. Six studies did not perform any statistical analysis, and nine used inappropriate statistical tests (ie not taking into account the effect of time trend). All of the studies apart from one concluded that mass media was effective. These positive findings were confirmed by our re-analysis in seven studies. The direction of effect was consistent across studies towards the expected change. Authors’ conclusionsDespite the limited information about key aspects of mass media interventions and the poor quality of the available primary research there is evidence that these channels of communication may have an important role in influencing the use of health care interventions. Although the findings of this review may be affected by publication bias, those engaged in promoting better uptake of research information in clinical practice should consider mass media as one of the tools that may encourage the use of effective services and discourage those of unproven effectiveness.Implications for practiceThis review supports the view that mass media campaigns may have a positive influence upon the manner in which health services are utilised. Agencies and organisations engaged in promoting a better uptake of research information in clinical practice should consider mass media as one of the tools that may encourage the use of effective services and discourage those of unproved effectiveness. In addition, these findings support the importance of efforts to ensure that reporting of health-related issues in the lay media correctly represents the best available knowledge on the effectiveness of health care interventions.

Gross U, Diaz MM, Valle C. Effectiveness of the communication program on compliance in a weekly multimicronutrient supplementation program in Chiclayo, Peru. Food Nutr Bull. 2006;27(4 Suppl Peru):S130-42. PubMed PMID: 17455399.

BACKGROUND:Compliance with daily micronutrient supplementation is usually poor and the question arises whether compliance with a weekly regimen would be better.

OBJECTIVES: The inputs (messages and channels), output (increase of knowledge), and outcome (behavior changes) of a communication campaign in a micronutrient supplementation program for women and adolescent girls 12 through 44 years of age and children under 5 years of age (primary audience) were analyzed.METHODS:

The communication program addressed not only the primary, but also the secondary (facilitators) and tertiary audiences. Formative research and descriptive statistics were used to analyze the communication campaign.

RESULTS:Nearly all women and adolescent girls (89%) and children (91%) took at least 75% of the supplements over the 3-month period. The incidence rates of reported negative side effects of supplementation in children and in women and adolescent girls were less than 10%. Knowledge of micronutrient nutrition among facilitators of all ages and education levels increased significantly (p <.001).

CONCLUSION:A thoroughly planned and implemented nutrition communication program can secure high compliance of the beneficiaries of micronutrient supplementation programs. The necessary supplies should be available at least 3 months before program implementation. With an adequate communication program,supplementation programs can be used to foster food-based approaches for the target audience.

Oyo-Ita A, Nwachukwu CE, Oringanje C, Meremikwu MM. Interventions for improving coverage of child immunization in low- and middle-income countries. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD008145. doi: 10.1002/14651858.CD008145.pub2. Review. PubMed PMID: 21735423.

BackgroundImmunization coverage remains low, particularly in low- and middle-income countries (LMIC), despite its proven effectiveness in reducing the burden of childhood infectious diseases. A Cochrane review has shown that patient reminder recall is effective in improving coverage of immunization but technologies to support this strategy are lacking in LMIC.ObjectivesTo evaluate the effectiveness of intervention strategies to boost and sustain high childhood immunization coverage in LMIC.Search methodsWe searched the following databases for primary studies: Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue1, part of The Cochrane Library. www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) ……… Reference lists of all papers and relevant reviews were identified and searched for additional studies.Selection criteria

Included studies were randomized controlled trials (RCTs), non-randomized controlled trials (NRCTs), and interrupted-time-series (ITS) studies. Study participants were children aged 0 to 4 years, caregivers, and health providers. Interventions included patient and community-oriented interventions, provider-oriented interventions, health system interventions, multi-faceted (any combination of the above categories of interventions), and any other single or multifaceted intervention intended to improve childhood immunisation coverage The primary outcome was the proportion of the target population fully immunized with recommended vaccines by age.Data collection and analysisTwo authors independently screened full articles of selected studies, extracted data, and assessed study quality.Main resultsSix studies were included in the review; four were at high risk of bias. There was low quality evidence that: facility based health education may improve the uptake of combined vaccine against diphtheria, pertussis, and tetanus (DPT3) coverage (risk ratio (RR) 1.18; 95% CI 1.05 to 1.33); and also that a combination of facility based health education and redesigned immunization cards may improve DPT3 coverage (RR 1.36; 95% CI 1.22 to 1.51). There was also moderate quality evidence that: evidence-based discussions probably improve DPT3 coverage (RR 2.17; 95% CI 1.80 to 2.61), and that information campaigns probably increase uptake of at least a dose of a vaccine (RR 1.43; 95% CI 1.01 to 2.02).Authors’ conclusionsHome visits and health education may improve immunization coverage but the quality of evidence is low.

DeWalt DA, Hink A. Health literacy and child health outcomes: a systematic review of the literature. Pediatrics. 2009; 124 Suppl 3: S265-74.

Resultados

Children with low literacy generally had worse health behaviors. Parents with low literacy had less health knowledge and had behaviors that were less advantageous for their children's health compared with parents with higher literacy. Children whose parents had low literacy often had worse health outcomes, but we found mixed results for the relationship of literacy to the use of health care services. Interventions found that improving written materials can increase health knowledge, and combining good written materials with brief counseling can improve behaviors including adherence. The average quality of the studies was fair to good.

Brown A, Malca R, Zumaran A, Miranda JJ. On the front line of primary health care: the profile of community health workers in rural Quechua communities in Peru. Hum Resour Health. 2006 May 17;4:11. PubMed PMID: 16707010; PubMed Central PMCID: PMC1481610.

OBJECTIVE:To describe the profile of community health workers--health promoters, traditional birth attendants and traditional healers--in rural Quechua communities from Ayacucho, Peru.

METHODS:Basic quantitative and qualitative information was gathered as part of a community health project implemented between 1997 and 2002 in 40 Andean communities with information from questionnaires, personal interviews and group discussions.

RESULTS:The majority of current community health workers are men with limited education who are primarily Quechua speakers undertaking their work on a voluntary basis. Health promoters are mostly young, male, high school graduates. There exists a high drop-out rate among these workers. In contrast, traditional healers and traditional birth attendants possess an almost diametrically opposite profile in terms of age, education and drop-out rates, though males still predominate. At the community level the health promoters are the most visible community health workers.

CONCLUSION:It is very important to consider and to be aware of the profile of community health workers in order to provide appropriate alternatives when working with these groups as well as with the indigenous population, particularly in terms of culture, language and gender issues.

Lechtig A, Gross R, Paulini J, de Romaã DL. Costs of the multimicronutrient supplementation program in Chiclayo, Peru. Food Nutr Bull. 2006;27(4 Suppl Peru):S151-9. PubMed PMID: 17455401.

BACKGROUND:There is little information on the cost parameters of weekly multimicronutrientsupplementation programs.

OBJECTIVE:To assess the cost parameters and cost-effectiveness of a weekly multimicronutrientsupplementation program in an urban population of Peru.

METHODS:Data from the Integrated Food Security Program (Programa Integrado de Seguridad Alimentaria [PISA]), which distributed capsules and foodlets to women and adolescent girls and to children under five, were extrapolated to a population of 100,000 inhabitants.

RESULTS:The annual cost per community member was US$1.51. The cost-effectiveness ratio was US$0.12 per 1% of prevented anemia per community member.

CONCLUSIONS:These costs are in the upper margin of iron supplementation alone. They will decrease notably when weekly multimicronutrient supplementation programs are integrated into health packages and participation by women increases. Focusing on micronutrient deficiencies would prevent these problems, and food-distribution programs would be effectively targeted to food-deficient populations.

Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. 2000;57 Suppl 1:181-217. Review. PubMed PMID: 11092163

This article develops a conceptual model of cultural competency’s potential to reduceracial and ethnic health disparities, using the cultural competency and disparities literature to lay the foundation for the model and inform assessments of its validity. Theauthors identify nine major cultural competency techniques: interpreter services,recruitment and retention policies, training, coordinating with traditional healers, use of community health workers, culturally competent health promotion, including family/

community members, immersion into another culture, and administrative and organizational accommodations. The conceptual model shows how these techniques could theoretically improve the ability of health systems and their clinicians to deliver appropriate services to diverse populations, thereby improving outcomes and reducing disparities.The authors conclude that while there is substantial research evidence to suggestthat cultural competency should in fact work, health systems have little evidence about which cultural competency techniques are effective and less evidence on when and how to implement them properly.

Harriet Nabudere, Delius Asiimwe, Rhona Mijumbi. An Evidence Brief for Policy. Task shifting to optimise the roles of health workers to improve the delivery of maternal and child healthcare.

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