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Revista Latino-Americana de Enfermagem

Print version ISSN 0104-1169On-line version ISSN 1518-8345

Rev. Latino-Am. Enfermagem vol.23 no.6 Ribeirão Preto Nov./Dec. 2015  Epub Oct 20, 2015

https://doi.org/10.1590/0104-1169.1075.2667 

Original Articles

Universal Access to Health and Universal Health Coverage: identification of nursing research priorities in Latin America

Silvia Helena De Bortoli Cassiani1 

Alessandra Bassalobre-Garcia2 

Ludovic Reveiz3 

1PhD, RN, Advisor on Nursing and Allied Health Personnel, Health Systems and Services Department, Pan American Health Organization, Washington, DC, USA

2BSN, MSc, Intern (2014), Health Systems and Services Department, Pan American Health Organization, Washington, DC, USA

3Advisor, Knowledge Management, Bioethics and Research Department, Pan American Health Organization, Washington, DC, USA


ABSTRACT

Objective:

To estabilish a regional list for nursing research priorities in health systems and services in the Region of the Americas based on the concepts of Universal Access to Health and Universal Health Coverage.

Method:

five-stage consensus process: systematic review of literature; appraisal of resulting questions and topics; ranking of the items by graduate program coordinators; discussion and ranking amongst a forum of researchers and public health leaders; and consultation with the Ministries of Health of the Pan American Health Organization's member states.

Results:

the resulting list of nursing research priorities consists of 276 study questions/ topics, which are sorted into 14 subcategories distributed into six major categories: 1. Policies and education of nursing human resources; 2. Structure, organization and dynamics of health systems and services; 3. Science, technology, innovation, and information systems in public health; 4. Financing of health systems and services; 5. Health policies, governance, and social control; and 6. Social studies in the health field.

Conclusion:

the list of nursing research priorities is expected to serve as guidance and support for nursing research on health systems and services across Latin America. Not only researchers, but also Ministries of Health, leaders in public health, and research funding agencies are encouraged to use the results of this list to help inform research-funding decisions.

Descriptors: Nursing; Research; Nursing Research; Health Services Research; Consensus; Americas

RESUMO

Objetivo:

estabelecer uma lista regional para prioridades de pesquisa em enfermagem dos sistemas e serviços de saúde de investigação na Região das Américas com base nos conceitos do Acesso Universal à Saúde e Cobertura Universal de Saúde.

Método:

processo de consenso de cinco estágios: revisão sistemática da literatura; apreciação de questões e tópicos resultantes; classificação dos itens por coordenadores de programas de pós-graduação; discussão e classificação entre um fórum de pesquisadores e líderes de saúde pública; e consulta com os Ministérios da Saúde dos países membros da Organização Pan-Americana da Saúde.

Resultados:

a lista resultante de prioridades de pesquisa em enfermagem consiste em 276 questões/tópicos de estudo, que são classificados em 14 subcategorias distribuídos em seis categorias principais: 1. Políticas e formação de recursos humanos de enfermagem; 2. Estrutura, organização e dinâmica dos sistemas e serviços de saúde; 3. Ciência, tecnologia, inovação e sistemas de informação em saúde pública; 4. Financiamento de sistemas e serviços de saúde; 5. As políticas de saúde, governança e controle social; e 6. Estudos Sociais no campo da saúde.

Conclusão:

espera-se que a lista de prioridades de pesquisa em enfermagem sirva como orientação e apoio para pesquisa de enfermagem em sistemas e serviços de saúde em toda a América Latina. Não apenas pesquisadores, mas também os líderes dos Ministérios da Saúde, a saúde pública e as agências de fomento à pesquisa são incentivados a utilizar os resultados desta lista para ajudar a informar as decisões de financiamento da investigação.

Descritores: Enfermagem; Pesquisa; Pesquisa em Enfermagem; Pesquisa sobre Serviços de Saúde; Consenso; Américas.

RESUMEN

Objetivo:

establecer una lista regional de las prioridades de la investigación en enfermería en los sistemas y los servicios de salud en la Región de las Américas sobre la base de los conceptos de Acceso Universal a la salud y Cobertura Universal de Salud.

Método:

proceso consensual de cincoetapas: revisión sistemática de la literatura; evaluación de cuestiones por tópicos; clasificación de los elementos por los coordinadores del programa de posgrado; discusión y clasificación en un foro de investigadores y líderes de la salud pública; y consulta con los Ministerios de Salud de los Estados miembros de la Organización Panamericana de la Salud.

Resultados:

el resultado de la lista de prioridades para la investigación en enfermería consta de 276 preguntas para los estudios/temas, que se clasifican en 14 subcategorías distribuidas en seis categorías principales: 1. Las políticas y la educación para el recurso humano en enfermería; 2. Estructura, organización y dinámica de los sistemas de salud ; 3. La ciencia, la tecnología, la innovación y los sistemas de información en salud pública; 4. Financiación de los sistemas de salud ; 5.Las políticas de salud, la gestión pública y control social; y 6. Estudios Sociales en el campo de la salud.

Conclusión:

se espera que la lista de las prioridades de investigación en enfermería sirva de orientación y apoyo para la investigación de enfermería en los sistemas y servicios de salud en América Latina. No sólo los investigadores, sino también a Ministerios de Salud, líderes de la salud pública y a los organismos de financiación de la investigación se les incentiva a que utilicen los resultados de esta lista para ayudar a tomar decisiones en la financiación para investigación.

Descriptors: Enfermería; Investigación; Investigación en Enfermería; Investigación sobre Servicios de Salud; Consenso; Américas

Introduction

In October 2014, the Pan American Health Organization/World Health Organization (PAHO/WHO) and its Member States adopted the Resolution CD53/5, Rev. 2 - Strategy for Universal Access to Health and Universal Health Coverage (Universal Health), which first defines this as the absence of sociocultural, organizational, economic, geographical, and genderrelated barriers to healthcare, and second, as the capacity of health systems to meet the needs of populations at any level of care, providing infrastructure, adequate human resource capacity, and health technologies without causing financial harm 1.

These two concepts of Universal Health hold paramount importance for the improvement of health outcomes and to reach other significant health system objectives. These are based on the basic human right to be able to enjoy a healthy life. The Universal Health strategy also represents an inclusive umbrella for other issues and stakeholders affected by the health field 2 3.

Additionally, Universal Health requires solid health systems supported by motivated health personnel who are equitably distributed and have acquired an appropriate combination of skills, thus resulting in the provision of quality health services based on the population's needs. Nurses play an important role in the context of Universal Health because of their close contact with people and a greater understanding of their needs. Their education should therefore qualify them to produce and apply scientific evidence within their practice, while also fostering critical and reflexive thinking in order to deliver a better quality and community-centered care 4 5.

Beyond technical and scientific qualifications, the ethical and political competencies of nursing are additional dimensions that must be taken into consideration by toward in health systems that are designed to effectively implement health as a basic human right for the achivement of Universal Health 6.

The commitment, collaborative work, exchange of knowledge and experience performed by the 25 international nursing networks in Latin America can be a clear example of the contributions for UAH and UHC 5; however, there is still a need to set priorities for the collaborative research.

Nursing sciences continues to increase its scientific output. Differences among nurses remain based on their training, ability to lead research, and implement evidence-based professional practice. Despite this recognized increase in nursing literature, little has been carried out within the context of health systems and services, or conducted by nursing that work in research settings 7 9.

On the other hand, the field of health systems and services research has continued to gain worldwide attention in the last decade (10). This field of research, along with research in social, economic and cultural determinants of health, has been poorly explored in some Latin American countries 11.

For the reasons mentioned above, there is a need to discuss nursing research priorities in order for there to be synergy in addressing health issues, healthcare practices, and major global health challenges, particularly those related to current debates involving health policies.

Furthermore, "developing an adequately financed research agenda, and a better knowledge management are essential elements to address social determinants of health, ensure access to quality services, incorporate technology, and evaluate the effectiveness of implemented actions and programs." 1

In this context, the objective of this study was to set a list for nursing research priorities on health systems and services in the Americas based on the concepts of Universal Access to Health and Universal Health Coverage.

Method

This study was carried out through a group consensus method. A group consensus combines a variety of perspectives and information on a specific area in a systematic and organized way. This method involves participation by experts and its objective is to synthesize accumulated expert opinions and knowledge about the area of interest. It also enhances the decisionmaking and policy development process, as well as the identification and measurement of areas where there is uncertainty, controversy or incomplete evidence 12.

In order to reach group consensus, a five-stage process was undertaken ( figure 1).

Figure 1 Group consensus stages to establish the list of nursing research priorities 

Stage 1: Systematic review of literature 13

The first stage consisted of a systematic review of literature, which was conducted from March to June 2014, and guided by the following study question: "Are there priority nursing research agendas focused on health systems and services or public health?" The databases used for the initial literature search were Web of Science, PubMed, LILACS, and Google (for grey literature). Advanced search strategies were based on Medical Subject Headings (MeSH) and inclusion criteria were documents published between 2008 to 2014 in either English, Spanish, or Portuguese.

Throughout the selection process, three criteria were applied: 1) to address nursing research priorities focused on primary health care systems and services or public health; 2) to explicitly formulate research priorities on nursing and/or health systems and services; 3) to relate to the Region of the Americas, or on a global scale that includes the Region. The study questions and topics were compiled and a thematic analysis was conducted to sort them into categories and subcategories.

A previous publication provides details of this systematic review, its search strategies, and assessment of the documents selected 13.

Stage 2: Assessment by WHO Collaborating Centers and PAHO/WHO advisors

The second stage consisted of an assessment of the questions and topics identified in the review mentioned above. This appraisal was completed by coordinators and professors of the WHO Collaborating Centre for Nursing Research Development at the Ribeirao Preto School of Nursing - University of São Paulo, Brazil, and from the Escuela Nacional de Enfermería y Obstetrícia de la Universidad Autonoma de México; their appraisal was then revised by two PAHO/WHO advisors. This first screening allowed changes to the document and the removal of items deemed as irrelevant.

Stage 3: Classification by coordinators of nursing graduate and research programs

At the third stage, the topics and questions of the study were submitted to be reviewed and classified by nursing graduate and research program coordinators from across Latin America. In order to retrieve their contacts, a list from Latin American Association of Nursing Schools and Colleges (ALADEFE) was requested; all 81 schools of nursing from ALADEFE's list were requesting the coordinator's contact information.

Next, each coordinator was then requested to complete an evaluation of the document. All items were classified by the coordinators according to a 3-point Likert scale: "high relevance", "relevant", or "low relevance". This classification was based on the criteria: 1) Magnitude and impact - to what extent would the answer of the study question contribute to social welfare and facilitate attaining the objective of Universal Access to Health and Universal Health Coverage; 2) Feasibility - to what extent can the study question be answered in a manner that is based on the concepts of ethical behavior, equity, and sustainable research, while also considering the political, cultural, legal, social, economic, and technological contexts where the research is taking place.

The experts were also encouraged to suggest revisions, remove or propose new research questions/ topics, and make general observations about the agenda. The data was entered into a Microsoft Excel spreadsheet and analyzed by descriptive statistics. The topics and questions with the highest percentage of "low relevance" ratings were removed from the draft agenda.

Stage 4: Ranking and discussion by nursing research and public health experts

The fourth stage consisted of discussion on the classification of the identified research priorities. This discussion took place during a 2-day meeting held at the XV Pan American Nursing Research Colloquium in September 2014 in Cartagena de Indias, Colombia. Coordinators from graduate programs, research programs, deans of nursing schools as well as nurses employed by the ministries of health of 14 Latin American countries were invited to take part in the meeting.

During the first day of the meeting, the motivations that led to the development of the agenda were presented to the attendees, followed by the study methods undertaken, and the state of research in Brazil, Chile and Colombia. Participants were assigned to five groups and were instructed to review and discuss each research topic/question, and classify them as "high relevance", "relevant", or "low relevance" according to the same criteria adopted in stage 3. During the second day of the meeting, participants were asked to finalize their group work and present findings from their small groups, in addition to returning a copy of the agenda containing their ranking and suggested revisions.

Most of the suggestions/modifications were incorporated in the final document, and questions/ topics ranked as "low relevance" were removed from the agenda.

Stage 5: Consultation with Ministries of Health

The fifth and final stage was a consultation with national authorities in charge of the Human Resources for Health or Nursing units at the Ministries of Health in Latin American and Caribbean countries (PAHO/WHO Member States). Formal solicitations were submitted to the Ministries of Health of 28 countries through each country's PAHO/WHO representative office, requesting assessment of the research priorities list, which included changing, adding or removing items according to their expertise of the country's public health, and addressing the concepts of Universal Health. Their suggestions were analyzed and incorporated into the final research list.

Results

A total of 23 documents were retrieved from the systematic review, and the thematic analysis resulted in a document with 444 research topics/questions distributed into five categories and 16 subcategories 13. This document with compiled topics/questions was the basis for the stages that followed.

In stage 2, all items were assessed and reviewed, and a total of 21 questions/topics were removed from the document.

In stage 3, of the 81 emails sent to the Schools of Nursing, 31 were answered providing contact information for a total of 92 contacts of nursing graduate and research program coordinators, representing 12 Latin American countries. Nonetheless, only 24 coordinators responded with thorough evaluations and classification of the study topics/questions. As a result, only one question, belonging to the "Policies and education of nursing human resources" category, was removed from the list since it was ranked as being of "low relevance" by 41.7% of the experts. Additionally, they modified 50 questions/topics, providing suggestions for the inclusion of 16 additional research questions, and 10 general comments on the draft list of priorities. The experts' suggestions were thoroughly reviewed, most of which were accepted.

Stage 4, the 2 day meeting in Colombia was attended by 122 participants representing 12 countries: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, El Salvador, Mexico, Panama, Peru, Portugal and Uruguay. These attendants included nursing researchers, faculty, practitioners, deans, representatives of professional associations, regulatory bodies, Ministries of Health, public health leaders, nursing journal and nursing network coordinators. Their combined work resulted in the removal or modification of 87 topics/questions, an addition of 32 topics, and the inclusion of a sixth category: Social studies in the health field.

During stage 5, formal replies were obtained from the Ministry of Health of eight countries: Belize, Brazil, Colombia, Guatemala, Mexico, Peru, St. Vincent & the Grenadines, and Uruguay. They suggested adding 30 questions/topics, removing two, and modifying/ rewriting several items within the entire document. All suggestions were reviewed, compared to each other, and added as appropriate.

The entire group consensus process yielded 276 priority research topics/questions sorted into 14 subcategories, which were distributed into six major categories: 1. Policies and education of nursing human resources; 2. Structure, organization and dynamics of health systems and services; 3. Science, technology, innovation, and information systems in public health; 4. Financing of health systems and services; 5. Health policies, governance, and social control; and 6. Social studies in the health field (see Figures 2- 7). All topics/ questions hold equal priority.

Figure 2 Research topics/questions into subcategories of the category Policies and Education of Nursing Human Resources 

Figure 3 Research topics/questions into subcategories of the category Structure, Organization, and Dynamics of Health Systems and Services 

Figure 4 Research topics/questions of the category Science, Technology, Innovation, and Information Systems in Public Health 

Figure 5 Research topics/questions of the category Financing of Health Systems and Services  

Figure 6 Research topics/questions of the category Health Policies, Governance, and Social Control 

Figure 7 Research topics/questions into subcategories of the category Social Studies in the Health Field 

Discussion

The 2013 World Health Report "Research for universal health coverage", proposed that research for universal health coverage be tailored to the broader context of development research. "Research will play a role not only in meeting the Millennium Development Goals (MDGs) but also in supporting the post-2015 development agenda. [...] Because many more questions can be asked than answered, it is vital to set priorities for investigation" 14.

Human Resources for Health are one of the major barriers for Universal Health expansion in developing countries where they are often insufficient in numbers and in ditribution. In order to expand effective and equitable health coverage and guarantee access, the countries in the Latin American region should improve human resource capacity, skill mix, availability and distribution 15.

In Latin America, 11 countries face a severe shortage of health professionals (less than 25/10,000 inhabitants) 5, which has proven to be a major challenge in the region and can be illustrated by the great number of study topics/questions that arose during the consensus process. From the final research list, 30% (83) of the total research topics/questions are related to category 1: Policies and education of nursing human resources.

Furthermore, the Resolution previously mentioned urges PAHO's Member States to "improve human resource capacity at the first level of care, increasing employment opportunities with attractive labor conditions and incentives, particularly in underserved areas; consolidate collaborative multidisciplinary health teams; ensure that these teams have access to health information and telehealth services (including telemedicine); and introduce new professional and technical profiles and strengthen existing ones, coherent with the model of care to be implemented to achieve universal access." 1

Another major issue is the structure, organization and dynamics of health systems and services in Latin America. Since Universal Health demands an expansion of health services where quality should be imperative, this requires mechanisms that can effectively monitor quality and safety of care, both technically and in the interpersonal dimension 15. The category relating to this area represented 34% of the total research topics/ questions, demonstrating some concern by the experts in regards to health systems' organization and structure.

The forth category, related to financing issues - another controversial aspect, has only nine research questions/topics, a number that decreased significantly throughout the consensus process. This demonstrates that nurses are still not involved enough in the development of health policies, even though efficient financing mechanisms are crucial to ensure Universal Health 14 15.

Moreover, while health systems financing is deemed as important for achieving the Millennium Development Goals, funding for this research field is often not aligned with national priorities 10.

Regarding methodological aspects, one of the strengths of this study was the broad range of participants involved, including representation by nursing researchers, faculty and practitioners, deans, representatives of professional entities, regulatory bodies and ministries of health, public health leaders, nursing journal and nursing network coordinators from across Latin America. Another study on research priorities setting in Latin America highlights the importance of the participation of diverse key actors in order to avoid bias and to balance research interests 16.

Although some of the documents selected during the systematic review stage were related to the United States context, the participation of experts solely from Latin America, and the criteria established for ranking or modifying the questions shaped the priority setting process to the Latin American region with a focus on the concepts of Universal Health.

Participants used a 3-point Likert scale over a 5-point scale because other studies have shown that allowing experts multiple options limited the identification of priority interventions 17.

Lastly, in spite of the great number of topics and questions for a priority list, items were identified and agreed upon consensus of at least 159 people representing 14 countries; moreover, one should consider that, using this document as a basis, each country may select the items deemed as priority within its own contextual needs. The autonomy of each country concerning ways to achieve UAH and UHC needs to be ratified due to each member state's unique historical, cultural, political and economic characteristics 18.

The identification of nursing research priorities should be a dynamic and fluid process, which will require regular updates, reviews, and consultations involving a variety of actors: governments, academic and research institutions, research support agencies, researchers, professionals, and practitioners.

Conclusion

It is possible to achieve consensus through a highly participative method, including a broad range of participants' diverse contexts, although to be effective this process may demand considerable time and commitment from its stakeholders.

Moreover, for the reasons mentioned above, this list will be suitable for any country in the region, allowing them to set their own research priorities adapted to their contextual needs, while aiming to advance Universal Access to Health and Universal Health Coverage.

The findings of this study are expected to serve as guidance and support for the of nursing research on health systems and services across the region. Additionally, not only are researchers encouraged to consult this list of priorities, leaders of ministries of health, public health and research funding agencies can also use this list to help inform research-funding decision-making.

Disclaimer

The opinions expressed herein are those of the authors and do not necessarily reflect the views of the Pan American Health Organization.

Acknowledgments

Our special gratitude to all nursing faculty, experts and practitioners, public health leaders, ministry of health officials, and PAHO's staff who took part in the consultations undertaken for the development of this list of nursing research priorities.

The authors want to express their gratitude to all professionals from the many countries involved in the revision of the research topics.

References

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Corresponding Author: Silvia Helena De Bortoli Cassiani Pan American Health Organization. Health Systems and Services Department 525 Twenty Third Street NW 20037 Washington DC, USA E-mail: cassianis@paho.org

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