Abstracts

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 ¹1. Pan American Health Organization . Strategy for universal access to health and universal health coverage. Proceedings of the 53rd Directing Council (CD53/5, Rev. 2) [Internet] Washington DC; October 2014. [Acessed 10 mai 2015]. Retrieved from: http://bit. ly/1DuHUIk
http://bit. ly/1DuHUIk... .

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 ²2. World Health Organization. Positioning Health in the Post-2015 Development Agenda. WHO discussion paper. 2012 [Internet]. [Acessed 14 may 2015]. Retrieved from: http://www.who.int/topics/millennium_ development_goals/post2015/WHOdiscussionpaper_October2012.pdf
http://www.who.int/topics/millennium_ de... ³3. Andrade LOM, Pellegrini Filho A, Solar O, Rígoli F, Salazar LM, Serrate PCF. Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries. Lancet. 2015;385:1343-51..

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 ⁴4. World Health Organization. Nursing and midwifery services: strategic directions 2011- 2015 [Internet]. Geneva: WHO; 2010. [Acessed 12 mar 2015]. Retrieved from: www.who.int/hrh/nursing_midwifery/en/
www.who.int/hrh/nursing_midwifery/en/... ⁵5. Cassiani SHB. Strategy for universal access to health and universal health coverageand the contribution of the International Nursing Networks. Rev. Latino-Am. Enfermagem. 2014; 22(6):891-2..

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 ⁶6. Yamin AE, Frisancho A. Human-rights-based approaches to health in Latin America.. Lancet 2015;385:e26-e29..

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 ⁵5. Cassiani SHB. Strategy for universal access to health and universal health coverageand the contribution of the International Nursing Networks. Rev. Latino-Am. Enfermagem. 2014; 22(6):891-2.; 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 ⁷7. Marziale MHP. Scientific production in Brazilian nursing: the search for international impact. Rev. LatinoAm. Enfermagem. 2005;13(3):287-8. ⁹9. Mendoza-Parra S, Paravic-Klijn T, Muñoz-Muñoz AM, Barriga OA, Jiménez-Contreras E. Visibility of Latin American nursing research (1959-2005). J Nurs Scholarsh. 2009;41(1): 54-63..

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 ¹¹11. Maceira D, Paraje G, Aramayo F, Duarte Masi S, Sánchez D. Financiamiento público de la investigación en salud en cinco países de América Latina.. Rev Panam Salud Publica 2010; 27(6):442-51..

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." ¹1. Pan American Health Organization . Strategy for universal access to health and universal health coverage. Proceedings of the 53rd Directing Council (CD53/5, Rev. 2) [Internet] Washington DC; October 2014. [Acessed 10 mai 2015]. Retrieved from: http://bit. ly/1DuHUIk
http://bit. ly/1DuHUIk...

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 ¹²12. Campbell SM, Cantrill JA. Consensus methods in prescribing research. J Clin Pharm Therapeut. 2001;26:5-14..

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

Stage 1: Systematic review of literature ¹³13. Bassalobre Garcia A, Cassiani SHB, Reveiz L. A systematic review of nursing research priorities on health system and services in the Americas.. Rev Panam Salud Publica 2015; 37(3):162-71.

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 ¹³13. Bassalobre Garcia A, Cassiani SHB, Reveiz L. A systematic review of nursing research priorities on health system and services in the Americas.. Rev Panam Salud Publica 2015; 37(3):162-71..

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 ¹³13. Bassalobre Garcia A, Cassiani SHB, Reveiz L. A systematic review of nursing research priorities on health system and services in the Americas.. Rev Panam Salud Publica 2015; 37(3):162-71.. 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.

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" ¹⁴14. World Health Organization. The World Health Report: research for universal health coverage.; Geneva: WHO 2013..

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 ¹⁵15. Frenk J. Leading the way towards universal health coverage: a call to action.. Lancet [Internet];2015 [Acessed 10 mai 2015];385:1352-8. Retrieved from: http://www.sciencedirect.com/science/article/pii/S0140673614614677.
http://www.sciencedirect.com/science/art... .

In Latin America, 11 countries face a severe shortage of health professionals (less than 25/10,000 inhabitants) ⁵5. Cassiani SHB. Strategy for universal access to health and universal health coverageand the contribution of the International Nursing Networks. Rev. Latino-Am. Enfermagem. 2014; 22(6):891-2., 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." ¹1. Pan American Health Organization . Strategy for universal access to health and universal health coverage. Proceedings of the 53rd Directing Council (CD53/5, Rev. 2) [Internet] Washington DC; October 2014. [Acessed 10 mai 2015]. Retrieved from: http://bit. ly/1DuHUIk
http://bit. ly/1DuHUIk...

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 ¹⁵15. Frenk J. Leading the way towards universal health coverage: a call to action.. Lancet [Internet];2015 [Acessed 10 mai 2015];385:1352-8. Retrieved from: http://www.sciencedirect.com/science/article/pii/S0140673614614677.
http://www.sciencedirect.com/science/art... . 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 ¹⁴14. World Health Organization. The World Health Report: research for universal health coverage.; Geneva: WHO 2013. ¹⁵15. Frenk J. Leading the way towards universal health coverage: a call to action.. Lancet [Internet];2015 [Acessed 10 mai 2015];385:1352-8. Retrieved from: http://www.sciencedirect.com/science/article/pii/S0140673614614677.
http://www.sciencedirect.com/science/art... .

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 ¹⁰10. Ranson K, Law TJ, Bennett S. Establishing health systems financing research priorities in developing countries using a participatory methodology. Socl Sci Med. 2010;70:1933-42..

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 ¹⁶16. Becerra-Posada F, Salgado de Snyder N, Cuervo LG, Montorzi G. Agendas de investigación priorizadas: un recurso estratégico para la salud en América latina.. Rev Panam Salud Publica 2014;36(6):361-7..

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 ¹⁷17. Caminal J, Starfield B, Sanchez E, Morales M. The role of primary care in preventing ambulatory care sensitive conditions. European J Public Health. 2004;14(3):246-25..

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 ¹⁸18. Etienne CF. Achieving universal health coverage is a moral imperative.. Lancet 2015;385: 1271-73..

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

Publication Dates