To determine the frequence and profile of congenital heart defects in Downsyndrome patients referred to a pediatric cardiologic center, considering the ageof referral, gender, type of heart disease diagnosed by transthoracicechocardiography and its association with pulmonary hypertension at the initialdiagnosis. Cross-sectional study with retrospective data collection of 138 patients with Downsyndrome from a total of 17,873 records. Descriptive analysis of the data wasperformed, using Epi-Info version 7. ostium secundum atrial septal defect, present in 51.8%,followed by atrioventricular septal defect, in 46.4%. Ventricular septal defectswere present in 27.7%, while tetralogy of Fallot represented 6.3% of the cases.Other cardiac malformations corresponded to 12.5%. Pulmonary hypertension wasassociated with 37.5% of the heart diseases. Only 35.5% of the patients werereferred before six months of age.  Among the 138 patients with Down syndrome, females prevailed (56.1%) and 112(81.2%) were diagnosed with congenital heart disease. The most common lesion was The low percentage of referral until six months of age highlights the need for abetter tracking of patients with Down syndrome in the context of congenital heartdisease, due to the high frequency and progression of pulmonary hypertension. This incidence may vary according to maternal age, affecting one in every30 live births in mothers with age higher than 45 years. The phenotype of DS includes muscular hypotonia, low height, dysmorphicfacial features, heart malformations, and cognitive deficits, with variable characteristics among carriers.Down Syndrome (DS) is characterized by a complete trisomy of chromosome 21 in 95% ofcases, occurring in approximately one in every 700 live births, especially in the first 2 years. On the other hand, symptoms or signs of these heart diseases may be absentin the fisrt days, what leads to a late diagnosis. This may be determining in thedevelopment of heart failure, penumonia, cardiac arrhythmias, or pulmonaryhypertension.Congenital heart diseases occurr in 40 to 60% of individuals with Down syndrome, beingone of the primary causes of morbimortality, especi 2 years,6. On. Heart diseases that have left-right shunt with increased pulmonary bloodflow  lead more easily tosituations of PH. Its symptoms are usually nonspecific . Thus, the early diagnosis of congenital heart diseaseis essential to prevent or treat PH in the early stages. In DS, the investigation ofsuch diseases is mandatory because of the high incidence of cardiac malformations andthe rapid progress of PH in this population. Pulmonary hypertension (PH) is characterized by a continuous increase in vascularpressure that progressively leads to a remodeling of the pulmonary vessels and to rightventricular failure. Heart ss of PH in thisTherefore, considering the importance of congenital heart disease for children with DS,this study sought to determine the prevalence and the profile of these diseases in thesepatients. We also verified the presence and severity of PH at diagnosis in a referralcenter for pediatric cardiology in the state of Pernambuco.We conducted a cross-sectional, descriptive and retrospective study of patients with DStreated in a pediatric cardiology referral center between 2005 and 2010. Patients werereferred by pediatricians in the municipality of Recife and surroundings, without apredetermined flow of referral of patients with chromosomal disorders. It is worthmentioning that, during the study period, 1,236 patients with DS were born in the stateof Pernambuco. Data were collected from the database of the service and sorted according to theconfirmation of the syndrome (evident phenotype or karyotype). Among a total of 17,873patients treated at the referral center, 138 had DS and were selected for the study. ostiumsecundum atrial septal defect from a patent foramen ovale, we used thedocumentation of a drop out in the atrial septum in the subcostal view  associated to thevisualization of the interatrial shunt by Doppler and presence of signs of volumeoverload.The respective medical charts were reviewed by collecting the following data: presenceor absence of congenital heart disease (diagnosed by transthoracic echocardiography),type of disease, gender, age at referral, presence or absence of pulmonary hypertensionat the first echocardiography performed in the service (pulmonary systolic pressureabove 25mmHg at rest on echocardiography), and reason for referral. According to thereferral reasons, patients were allocated into two groups: with and without suspicion ofcongenital heart disease. The records obtained were submitted to analysis of frequenciesusing the Epi-Info program, version 7. To differentiate the Subsequently, those who presented PH had their echocardiographic reports analyzed fordetermination of pulmonary artery pressure (PAP). This analysis referred to the firstechocardiogram at the service, always performed by pediatric cardiologists. Patientswhose echocardiogram was performed outside the service were excluded from the analysis.Then, the degree of PH was classified as mild (PAP between 25 and 40mmHg), moderate (PAPbetween 41 and 55mmHg) or severe (PAP higher than 55mmHg), based on the echocardiogram.The diagnosis of PH was established by estimating the peak systolic gradient of theshunt between the ventricles, through the Bernoulli equation, in patients withintracardiac defects . In caseswith patent ductus arteriosus, we used the shunt between the aorta and the pulmonaryartery. The analysis of the regurgitation jet of the right atrioventricular valve wasused only in cases where there was no possibility of shunt between the left ventricleand the right atrium. Among the 138 analyzed patients, 112 presented congenital heart disease (81.2%), whowere predominantly female (56.1%). Only 23.2% were referred without congenital signs ofheart disease, with 43.8% subsequently diagnosed with heart disease. ostiumsecundum atrial septal defect (ASD) with 51.78%, followed byatrioventricular septal defect (AVSD), with 45.5% - with its complete form representing22.3% -, and patent ductus arteriosus (PDA), with 34.8%. Tetralogy of Fallot representedonly 6.3% of cases. It is important to highlight that many patients presented more thanone structural heart defect concomitantly.As to the age at referral, patients were divided into before and after 6 months of age.Only a minority (35.5%) was referred before 6 months. The most common cardiovasculardefects in this group were ASD (59.2%), PDA (40.8%) and partial atrioventricular septaldefect (PAVSD - 30.6%).Pulmonary hypertension was found in 42 (37.5%) patients diagnosed with congenital heartdisease. Among these, around 1/3 of diagnostic echocardiograms were not performed in theservice, so they were excluded from the analysis of the degree of pulmonary hypertensionat diagnosis. In the remaining 2/3, we obtained: 21.4% of mild PH; 21.4% of moderate PHand 57.1% of severe PH. Among patients with PH, 11 were referred before 6 months of age,two with mild pulmonary arterial hypertension (PAH), 2 with moderate PAH, and 7 withsevere PAH. In the group with referral after 6 months, four presented mild PAH, fourmoderate PAH and nine presented severe PAH. In cases with mild PH, the most frequent diseases were the AVSD and ASD, affecting fromsix to five cases, respectively. All patients with moderate PAH had AVSD, associated toPDA is three cases. In patients with severe PAH, AVSD was the most frequent (10 cases),followed by VSD (eight cases). More details are found in . This finding is justified by the fact that the study site is a referencecenter, receiving patients who were already screened. Of those who were referred onlydue to DS , 43.8%suffered from some heart disease. This demonstrates that, often, the disease does notshow clear signs and symptoms, especially in the first days of life.Among the patients with DS referred to the center, 81.2% showed changes at theechocardiogram, which was a higher frequency than that reported in the literature,between 40 and 60%,,9. Th(6) more prevalent in some researches, while, in others, VSD is themost common. In this study, the ASD showed the highest prevalence (51.8%). Thisdifference may be due to the fact that this study used outpatients, that is, those inbetter clinical conditions. Therefore, we may have underestimated the amount of seriousdefects, such as the AVSD, in comparison to studies covering the entire population withDS. Nevertheless, the most common diseases found are consistent with the same group ofdiseases reported in the literature.The higher prevalence of AVSD, ASD, VSD, and PDA in individuals with DS is widelyreported in the literature. However, studies differ as to the frequency of each, beingAVSDt common. In thi(-). Only 35.5% of patients with DS were referred before six months of age for investigationof possible congenital heart disease. This is worrying, since early diagnosis coupledwith effective surgical treatment is mainly responsible for the decrease in morbidityand mortality in this population-13. . However, it should be highlighted that individuals with DS may have PH forvarious causes such as chronic airway obstruction, abnormal growth of the pulmonaryvasculature, alveolar hypoventilation, decreased number of alveoli, thinner pulmonaryarterioles, among others. In patients with pulmonary hypertension, the severe form was present in 57.1%, while themilder forms were equally divided among the rest. The majority of cases is explained bythe fact that the disease leads to an increased pulmonary blood flow and, consequently,to PH. Moreover, it has been reported that patients with DS demonstrate earlyprogression to PH when they present with left-to-right shunt lesions. Howeveg others. . Moreover, the incidence of PAH in neonates with DS is much larger (up to50 times more than those without the syndrome), which makes them more prone to progress to Eisenmenger syndrome than othergroups.However, only a minority of patients was referred to the service before 6 months of age,preventing early diagnosis. This fact may hinder the possibility of heart surgerybecause PH can evolve to a scenario in which surgery is contraindicated (PH byhyperesistance), further increasing mortality in these patients. Furthermore, mostpatients had severe PH, emphasizing even more the importance of the early diagnosis.This fact is described in some studies that justify the finding by the possibility ofendothelial dysfunction in such patients. Moreovyndrome), which rgroups.It is noteworthy that this study has limitations. The fact that this was a retrospectivestudy decreases quality in obtaining the necessary information, which was minimized bythe adoption of electronic medical records and the fact that only the echocardiogramsperformed by pediatric cardiologists within the service were analyzed. However, the useof the non-invasive assessment, rather than cardiac catheterization to establish thediagnosis of PH was also a limitation of the study. On the other hand, the study isvalid due to its considerable sample size and for the relative small number of studiesassociated to DS and PAH in Brazil. Therefore, the prevalence of congenital heart defects in individuals with DS was higherin the health service studied in comparison to other studies, which can be explained bythe fact that the service is a referral center. Still, the low percentage of referralsbefore the age of 6 months reinforces the need for better tracking of patients with DS.This approach becomes imperative when considering the high frequency and the evolutionto PH in these patients. . Essa incidência pode variar de acordo com a idade materna, atingindo uma cada 30 nascidos vivos em mães com idade superior a 45 anos. O fenótipo da SD inclui hipotonia muscular, baixa estatura,dismorfismos faciais, malformações cardíacas e déficits cognitivos, sendo essas características variáveis entre os portadores.A Síndrome de Down (SD) caracteriza-se pela trissomia completa do cromossomo 21 em95% dos casos, ocorrendo aproximadamente em um a cada 700 nascidos vivos, principalmente nos dois primeiros anos. Por outro lado, sintomas ou sinais dessas cardiopatias podem estarausentes nos primeiros dias de vida, o que acaba por levar ao diagnóstico tardio.Isso pode ser determinante no desenvolvimento de insuficiência cardíaca congestiva,pneumonia, arritmias cardíacas ou hipertensão pulmonar.As cardiopatias congênitas ocorrem em 40 a 60% dos portadores da síndrome,destacando-se na sua morbimortalidade. As cardiopatias que apresentam shunt esquerda-direitacom hiperfluxo pulmonar  levam maisfacilmente a quadros de HP. Seus sintomas geralmente são inespecíficos . Dessa forma, odiagnóstico precoce de cardiopatias congênitas é essencial para evitar ou tratar a HPem fases mais precoces. Na SD, a investigação de tais entidades é mandatória devido àalta incidência de malformações cardíacas e à evolução mais rápida da HP nessa população. A hipertensão pulmonar (HP) caracteriza-se pelo aumento contínuo da pressão vascularque, progressivamente, leva a uma remodelação dos vasos pulmonares e à falênciaventricular direitaLogo, considerando-se a importância das cardiopatias congênitas para a criança comSD, este trabalho buscou determinar a prevalência e perfil dessas cardiopatias nessespacientes. Verificou também a presença e a gravidade da HP no momento do diagnósticoem um serviço de referência em cardiologia pediátrica no estado de Pernambuco.Realizou-se um estudo de corte transversal, descritivo e retrospectivo, de pacientescom SD atendidos em serviço de referência em cardiologia pediátrica entre 2005 e2010. Os pacientes foram encaminhados por pediatras na cidade do Recife e cidadescircunvizinhas, sem haver um fluxo pré-estabelecido de encaminhamento de pacientescom cromossomopatia. Vale lembrar que, no período do estudo, nasceram 1.236 criançascom SD no estado de Pernambuco. Os dados foram colhidos do banco de dados do serviço e triados de acordo com aconfirmação da síndrome (fenótipo evidente ou cariótipo). De um total de 17.873pacientes atendidos no serviço de referência, 138 possuíam SD e foram selecionadospara o estudo. ostium secundum de um foramenoval patente, utilizou-se a documentação de solução de continuidade do septointeratrial no corte subcostal , associada à visualização doshunt interatrial pelo Doppler e presença de repercussõeshemodinâmicas do defeito.Os respectivos prontuários foram revisados, coletando-se os seguintes dados: presençaou não de cardiopatia congênita (diagnosticada por meio de ecocardiogramatranstorácico), tipo da cardiopatia, sexo, idade do encaminhamento ao serviço,presença ou não de hipertensão pulmonar ao primeiro ecocardiograma realizado noserviço (pressão sistólica pulmonar acima de 25mmHg em repouso no ecocardiograma) emotivo do encaminhamento. De acordo com os motivos de encaminhamento, alocaram-se ospacientes em dois grupos: com e sem suspeita clínica de cardiopatia congênita. Paradiferenciar a comunicação interatrial shunt entreos ventrículos, pela equação de Bernoulli, nos pacientes com defeitos intracardíacos. Nos casos com persistência do canal arterial, utilizou-se oshunt entre a artéria aorta e a pulmonar. A análise do jato daregurgitação da valva atrioventricular direita foi utilizada somente nos casos em quenão existia possibilidade de shunt entre o ventrículo esquerdo e oátrio direito.Logo depois, aqueles que apresentavam HP tiveram seus laudos ecocardiográficosanalisados para determinação da pressão na artéria pulmonar (PAP). Essa análisereferiu-se ao primeiro ecocardiograma do paciente realizado no serviço, sempre porcardiologistas pediátricos. Excluíram-se da análise os pacientes cujo ecocardiogramadiagnóstico foi realizado fora do serviço. Em seguida, o grau da HP foi classificadoem leve (PAP entre 25 e 40mmHg), moderada (PAP entre 41 e 55mmHg) ou grave (PAP maiordo que 55mmHg), com base no ecocardiograma. Estabeleceu-se o diagnóstico de HP pormeio da estimativa dos gradientes de pico sistólico do A análise estatística foi descritiva por meio do software Epi-Info, versão 7.Dos 138 pacientes analisados, 112 apresentaram cardiopatia congênita , compredomínio do sexo feminino . Apenas 23,2% foram encaminhados sem suspeitaclínica de cardiopatia, sendo 43,8% posteriormente diagnosticados como portadores decardiopatia congênita. ostium secundum (CIAOS) com 51,8%, seguida pelo defeitodo septo atrioventricular (DSAV), com 45,5% - com sua forma total representando 22,3%-, e pela persistência do canal arterial (PCA), com 34,8%. A tetralogia de Fallotrepresentou 6,3% dos casos. É importante salientar que boa parte dos pacientesapresentou mais de um defeito estrutural cardíaco concomitantemente.A Quanto à idade do encaminhamento, os pacientes foram divididos em antes e após osseis meses de idade. Uma minoria  foi encaminhada antes dos seis meses. Osdefeitos cardiovasculares mais frequentes nesse grupo foram a CIAOS , a PCA e o defeito do septo atrioventricular parcial .A hipertensão pulmonar foi encontrada em 42  pacientes diagnosticados comcardiopatia congênita. Nestes, cerca de 1/3 dos ecocardiogramas diagnósticos nãoforam realizados no serviço, tendo sido excluídos da análise do grau de hipertensãopulmonar ao diagnóstico. Nos 2/3 restantes, obteve-se: 21,4% de HP leve; 21,4% de HPmoderada e 57,1% de HP grave. Dos pacientes com HP, 11 foram ecaminhados antes dosseis meses de idade, sendo dois com hipertensão arterial pulmonar (HAP) leve, doiscom HAP moderada e sete com HAP grave. No grupo com encaminhamento acima dos seismeses, quatro apresentaram HAP leve, quatro HAP moderada e nove apresentaram HAPgrave. Nos casos com HP leve, as cardiopatias mais encontradas foram o DSAV e a CIAOS,acometendo seis e cinco casos, respectivamente. Nos casos de HAP moderada, o DSAV foiencontrado em todos, associado à PCA em três deles. Na HAP grave, o DSAV foi o maisfrequente (dez casos), seguido pela CIV (oito casos). Mais detalhes encontram-se no. Justifica-se tal achado pelo fato de o local do estudo ser um centro dereferência, recebendo pacientes já triados. Dos que foram encaminhados unicamentepela SD , 43,8% eramportadores de alguma cardiopatia. Isso demonstra que, muitas vezes, a cardiopatia nãoapresenta sinais e sintomas evidentes, principalmente nos primeiros dias de vida.Dos pacientes com SD encaminhados ao centro de referência, 81,2% mostraram alteraçõesao ecocardiograma, sendo tal frequência superior à relatada na literatura, entre 40 e60%(6) mais prevalente em algumas pesquisas, enquanto, emoutras, a CIV é a que mais ocorre. Neste trabalho, a CIAOS foi a que apresentou maior prevalência .Tal diferença pode se dever ao fato de este estudo contar com pacientesambulatoriais, ou seja, aqueles em melhores condições clínicas. Dessa forma, épossível que tenha ocorrido uma subestimação da quantidade de cardiopatias maisgraves, como o DSAV, em comparação com estudos que abrangeram toda a população comSD. Apesar disso, as cardiopatias mais frequentes encontradas condizem com o mesmogrupo relatado na literatura.A maior prevalência de DSAV, CIAOS, CIV e PCA em portadores de SD é amplamenterelatada na literatura. Entretanto, os estudos divergem quanto às frequências de cadaum, sendo o DSAV(-). Somente 35,5% dos pacientes com SD foram encaminhados antes dos seis meses de idadepara investigação de possível cardiopatia congênita. Isso é preocupante, já que odiagnóstico precoce aliado ao tratamento cirúrgico efetivo é o principal responsávelpela diminuição da morbimortalidade nessa população. Todavia, vale salientar que os portadores de SD podem apresentar HP pordiversas causas, como obstrução crônica da via aérea, crescimento anormal davascularização pulmonar, hipoventilação alveolar, número diminuído de alvéolos,arteríolas pulmonares mais finas, entre outras. Nos pacientes com HP, a forma grave estava presente em 57,1%, enquanto as formas maisleves apresentaram-se igualmente divididas entre os demais. A maioria dos casos éexplicada pela cardiopatia levar a um hiperfluxo pulmonar e, consequentemente, à HP.Ademais, já se descreveu que pacientes com SD demonstram evolução precoce para HPquando apresentam cardiopatia com hiperfluxo pulmonar. Além disso, a incidência de HAP em neonatos com SD é bem maior (até 50vezes mais do que aqueles sem a síndrome), sendo mais comum a evolução para síndrome de Eisenmenger do que emoutros grupos.Entretanto, somente a minoria dos pacientes foi encaminhada ao serviço antes dos seismeses de idade, impossibilitando o diagnóstico precoce. Esse fato pode inviabilizar acirurgia cardíaca, pois a HP pode evoluir para um quadro no qual a intervençãocirúrgica é contraindicada (HP por hiperresistência), elevando ainda mais amortalidade nesses pacientes. Além disso, a maior parcela dos pacientes tinha HPgrave, aumentando ainda mais a importância do diagnóstico precoce. Esse achado édescrito em alguns estudos que discutem a possibilidade de disfunção endotelial emtais pacientesVale ressaltar que o estudo possui limitações. O fato de ser retrospectivo diminui aqualidade da obtenção das informações necessárias, o que foi minimizado com a adoçãodo prontuário eletrônico e pelo fato de terem sido analisados apenas osecocardiogramas realizados por cardiologistas pediátricos do serviço, embora autilização do exame, em vez do cateterismo, para diagnóstico da HP seja também umalimitação do trabalho. Por outro lado, o estudo torna-se válido pela sua populaçãoamostral considerável e pela pouca quantidade de trabalhos que associam SD e HAP emnosso meio. Logo, a prevalência de cardiopatias congênitas em portadores de SD foi maior noserviço estudado em comparação a outros trabalhos, o que pode ser explicado peloserviço ser de referência. Ainda assim, o baixo percentual de encaminhamento até osseis meses reforça a necessidade de um melhor rastreamento dos portadores de SD. Essaconduta torna-se imperativa quando se considera a alta frequência e evolução para HPnesses pacientes.


To analyze the characteristics of health diagnosis according to the ecohealth approach in rural and urban communities in Mexico. Health diagnosis were conducted in La Nopalera, from December 2007 to October 2008, and in Atlihuayan, from December 2010 to October 2011. The research was based on three principles of the ecohealth approach: transdisciplinarity, community participation, gender and equity. To collect information, a joint methodology and several techniques were used to stimulate the participation of inhabitants. The diagnostic exercise was carried out in five phases that went from collecting information to prioritization of problems. The constitution of the transdisciplinary team, as well as the participation of the population and the principle of gender/equity were differentials between the communities. In the rural community, the active participation of inhabitants and authorities was achieved and the principles of transdisciplinarity and gender/equity were incorporated. With all the difficulties that entails the boost in participation, the incorporation of gender/equity and transdisciplinarity in health diagnosis allowed a holistic public health approach closer to the needs of the population. It allows the identification of the population’s needs and resources available to propose viable solutions to their problems. This diagnosis traditionally included three principles: (1) needs of the population, social and health-disease problems ; (2) social determinants; and (3) resources and services.Two perspectives exist to perform health diagnosis for the population: one is linked to health services; and the other integrates the participation of the population.26 mentions three types of health diagnosis of the population from the point of view of health services: administrative, focused on the analysis of the actions carried out by the institutions on the issue of health; strategic, focused on change, depending on the interests and conflicts that appear on social forces; and ideological, focused on the legitimation resulting from the link between the social forces structured around health with society as a whole. The Pan American Health Organization indicated in recent decades the need to perform health diagnosis with the participation of the population.25Testa16 analyze public health models throughout history: environmental-sanitarian: biomedical; social; techno-economic; and they also propose a fifth model, the ecological. The health of populations depends on the coexistence between humanity and the physical and social medium in this latest model. To this end, public health must integrate other approaches of thought, such as complex systems, holistic vision and interdisciplinary, in which several agents who consider the multiple dimensions of health converge.16 This model coincides with the ecohealth approach.17 Lebel17 defines the ecosystemic or ecohealth approach indicating that strong links between human beings exist, the biophysical environment and socioeconomic aspects reflected in the health of people.Lang and Rayner20 and also with vector-borne diseases.21 However, no reports around the population health diagnoses based on this approach exist. It promotes the active participation of the population to identify and understand the problems, to establish all the perspectives of the population, the authorities and the research team. Participation boost has a previous background in the Latin American context within proposals of participatory action research and popular education.13The ecohealth approach was used for problems linked with health and environment,17In this study, we considered the three principles presented by Lebel for the health diagnosis with the ecohealth approach: transdisciplinarity, gender and equity, and community participation.The aim of this study was to analyze the characteristics of health diagnosis according to the ecohealth approach in rural and urban communities in Mexico.Health diagnosis were carried out in the following locations in Mexico: La Nopalera, from December 2007 to October 2008, and Atlihuayan, from December 2010 to October 2011.The team that conducted the health diagnoses had educational purposes and was formed by teachers and students of both sexes, of the master’s program in public health from the Instituto Nacional de Salud Pública (INSP). The academic profile of the team members included the following areas: medicine, nursing, epidemiology, environmental engineering, anthropology, human nutrition, psychology, biochemistry, and education.a and also students and their families).Local authorities also participated , teachers of schools, religious representatives and popular groups , and the house do not have running water. A mobile unit of State health services visit the community once a week.Atlihuayan is an urban neighborhood of the outskirts of the city. In the past, in this place lands were planted with sugar cane, but in the early 1980s, the sale of land began, and the place turned into a settlement of houses, where families from other regions of the country established themselves. The main occupation was made by employees of offices and shops, construction workers and agricultural workers. The inhabitants receive medical attention at the health center, located ten minutes away by public transportation.The health diagnosis had five phases:Collecting information in secondary sources: Analysis of demographic, economic, historical, environmental and health damage information data in the municipality. We consulted databases of secondary sources of local history books and records of State and national health services.Approach: The team met with municipal and health authorities to reach an agreement on the health diagnosis of the population. A reconnaissance of the area was also performed. From these activities, it has become easier to contact with residents and local authorities, as well as to identify physical, environmental and social conditions in the region.Informational meetings were held about the health diagnosis with the various groups of the population . The team performed intentionally meetings with men and women in these sessions. The group was also present in the assemblies with countrymen; went to schools to talk to children and adolescents; and participated in meetings in the church and on health, with women. The educational material used intended to encourage collective reflection about health diagnosis. These activities stimulate the interest and participation of groups of the population, especially the rural community.3. Diagnosis (compilation of information): A mixed methodology was used .The quantitative component included:Formats to collect information from secondary sources: causes of mortality in the civil registry of the municipality ; demographic data ; causes of demand for consultation of national and state Health Services.A questionnaire with the sections: demographic data; characteristics of housing and public services; morbidity and mortality; access to and use of health services; needs, social and health problems. The questionnaire was applied in all households of the rural community and in a representative sample of the urban community, obtained by the calculation of sample size for global data for finite populations, resulting in 187 families (94% confidence level).The team applied the questionnaire to the head of the household by home visits in both localities.The qualitative component included:An ethnographic record of facts and events presented during the team’s participation in different assemblies or meetings.1 The questionnaire was carried out with children, adolescents and adults of both genders. Each group drew a map of the location and identified the places that hinder or promote the population’s health. In the end, a reflection was performed with each group about actions that could be undertaken to strengthen the population’s health.Social cartography: tool for the collective construction of knowledge and part of the premise that it is the locals who know better their own territory.Community assembly “festivity”. The entire population  was invited to identify needs and problems of the community. However, because residents appreciate being invited to a party, the format after the assembly was of “socializing” with custom invitations for each family. To inquire about their needs and problems, several techniques were used, taking age into account: with adult men and women, by group reflections; with adolescents, a board game was held and some participated in the graphic record (photos and videos); with children we used children’s games. The activities counted with the participation of local authorities.The team enabled the reflection on the bond of the social and health problems with the physical, social and economic environment to deepen their understanding.All the assistants and the team consumed food and beverages from the region during their stay.The residents of urban areas and local authorities did not attend the community meetings.4. Prioritization phase:Problem identification. A second community meeting  was convened in the rural community by means of invitations addressed to the people who participated in the previous meeting. Seven working groups were formed. Each selected two representatives to identify the top ten problems of the community. We used the method of prioritizing by Hanlon (adapted), with the criteria of magnitude, transcendence, feasibility and vulnerability (Table 1).Problem analysis and prioritization: Representatives of various groups, designated in the identification of problems in the rural community, were summoned. The participants analyzed the prioritized problems based on five components: social and environmental determinants; health effects; responsible for the solution of these problems ; responsibility of the population; solution viability. Reflections on the interaction between health problems and the social and environmental aspects of the region were encouraged. Authorities, population and research team elected five problems that can be addressed based on these elements.The prioritization exercise in the urban community was carried out with the local authority and six members of the community.4. Return of results: The results were presented in a meeting with the population, and local and municipal authorities of the rural community. From these results, collective decisions were taken to develop community initiatives to address some of the problems identified in the health diagnosis.The assistance of the population was scarce in the urban area and the diagnosis was delivered to local and municipal authorities.We performed descriptive analysis of sociodemographic characteristics of each community and of the characteristics of interest for methodological evaluation of the health diagnosis with an ecosystemic approach. Descriptive analyses were conducted using the statistical package Stata .® processor v. 2007, and subsequently converted them to the Ethnograph v.5 calculation program.We transcribed ethnographic registry notes, workshops, assemblies and social mapping in WordThe information was triangulated with quantitative and qualitative data.The health diagnosis protocol was approved by the colleges of education and Social Sciences of INSP on its eighth ordinary session of September, 2007. We requested the consent of all inhabitants of the community to carry out each activity.The rural community participated increasingly in each phase of the diagnosis in the same way that local authorities. However, difficulties to participate were detected in the urban community at all stages. It was difficult to establish contact with the population in the stage of approximation, and it was only possible to work with some members of community organizations. Urban authorities of the urban community showed little interest in the diagnosis .The sociodemographic characteristics were similar in the distribution by sex in both localities, with an average age of 28 years and a greater percentage of people with higher education levels in the urban community. We noticed a higher percentage of people dedicated to agricultural activities in the rural community . There wThe results of the prioritization, according to the method adapted from Hanlon, to the rural community were: disease  and social and environmental determinants . To the urban community, they were: social and environmental determinants  (Data not shown).The transdisciplinary approach held in both communities had different results. It was possible to integrate the vision of the population and the sociopolitical agents in the rural community; while it was not possible to incorporate local authorities or even the entirety of the inhabitants in the urban community.Men and women of the rural community attended all activities. Health problems seen as integral to the interaction with the physical and social environment has aroused similar interest in children, adolescents and adults of both genders. This fact made it possible to obtain the perspective of men and women in the various activities, in the social mapping and in the prioritization exercises.The participation of men in urban community was minimal, so the groups were mostly of adult women. A mixed group was achieved only in the cartography exercises with boys and girls. In this community, no groupings of men existed , one of the reasons that hindered their integration in the different stages of the diagnosis.The urban population lacked community belonging and had better conditions of basic consumption, compared to the countryside. These circumstances were translated into disinterest and lack of commitment of the inhabitants to improve their environment.The ecohealth approach has helped the population to visualize the relationship between the health, the physical environment and socioeconomic aspects, and to identify solutions. The participation of local authorities  favored strategies for finding solutions.In the countryside, the assemblies contributed to generate educational processes with the population, to advance the understanding of the health-disease phenomenon, that will not be visualized, but in the interaction with the sociocultural, economic and environmental aspects.c control of “flies” of porcine farm,d children and young people with gender perspective,e strengthening of community belonging for children and their familiesf and addiction prevention for children and adolescents.The generation of knowledge from the principles of the ecohealth approach allowed the development of proposals according to the themes prioritized by the population. Community initiatives in both localities focused on: solid waste management,20 This difference in participation in the diagnoses may be related to low community sense of belonging of the population in the urban area. Chavis et al8 gave solid support, showing the relationship between the sense of community and belonging, and community participation. Other authors confirm what Chavis et al18 reported, pointing out that, in so far as the community sense of belonging contributes to participation, these elements together strengthen the construction of citizenship.23Health diagnosis results, with respect to the participation of the population were different in both localities (with low participation in the urban community). However, in studies based on the ecohealth approach, in which specific problems were addressed, we obtained good results by boosting the participation of the population.15The participation of the population was favorable in the rural area, similar to what was reported in a study with older adults in Chile.3 We agree with these authors, who point out that political culture and context are factors that influence the way authorities act.In this investigation, we observed that local authority in the urban community participated and committed little, which is also found in another study of the ecosystemic approach conducted on Ecuador.19 However, participation at the local level is a process that can contribute to the construction of citizenship and to strengthen social agents so that they negotiate with the State,5 not denying the difficulties and conflicts of power that may arise during the process between the population and the State.The participation of the population in the health diagnosis lies at the local level and its importance is the identification of the involved of their own problems and respective solutions. Menéndez mentions that the sociopolitical and economic decisions that affect the lives of people are taken by political bodies, authorities, and institutions without the participation of the major social groups.26The population was able to identify, prioritize and engage with the solution of health problems in the countryside. The health diagnosis with the ecohealth approach establishes a substantial difference regarding diagnoses of traditional health , from health services, and are focused on goals, objectives and programming activities determined by experts, addressed to the people, but without its participation.9 observations, which state that the current approach of public health is benefited with the implementation of a holistic perspective that incorporates the complexity of health-disease process.The results rely on transdisciplinarity, participation, and equity/gender. The also agree with Dakubo’s10 points out that research based on communities is a model that drives the participation of the population, authorities and research team in the various phases of the project. For health diagnosis in this study, we considered elements of the research in the community, but it was not possible for the urban population to participate at all stages. A tool used to promote the participation of the population was social cartography. Its use has allowed promoting participation and improving the understanding of the local context by inhabitants, thus finding solutions to their problems.2Dakubo17 The vision of men and women has been integrated to rural community health diagnosis, and partly in the urban community.The ecohealth approach discusses equity and gender as a single principle. First, because it is not possible to speak of equity without addressing gender, and vice versa. Second, because to leave these themes aside is to partially understand the health status of the communities.20 believe that the gender is a category that shows in a differential manner the way by which men and women interact with the environment and with health, and the manner in which they participate in the projects. This coincides with the results of this research.Mertens et alThe challenges identified were: a) to integrate in the prioritization tool problems of environmental determinants to reflect together with the population on relations and social-ecological interactions that affect health, well-being and environmental sustainability; b) to draw strategies and mechanisms which enable the boosting of the participation of the population in several geographical areas  and in different social and cultural contexts; c) to raise awareness of those who make decisions of health services about the importance of conducting population health diagnosis with this approach; d) to promote the integration not only of local and municipal authorities, but also of national and state institutions for health diagnosis with the ecohealth approach, to influence public policy development.The health diagnosis of the population is the primary tool for health personnel and health authorities to make decisions, often limited by the obtaining of data . We went from the premise of health diagnosis, with an ecohealth approach, as a first step to seek an approximation with the populations and to generate knowledge that will lead to actions that are integrated and that responds to their needs.This study is a first approximation of a health diagnosis based on the ecohealth approach. It is necessary to continue conducting such diagnosis, setting the strategies according to the characteristics of the population and of the geographical areas, to deepen the concretion of the three principles of the approach presented in this paper. 24 La salud pública, además de enfocarse en riesgos y daños, debe incluir aspectos positivos, con lo cual surge otro eje que se puede incluir en el diagnóstico: (4) las fortalezas de la población.22El diagnóstico de salud poblacional es la herramienta fundamental de investigación en salud pública. Permite identificar las necesidades de la población y los recursos con que cuenta para proponer soluciones viables a sus problemáticas. Este diagnóstico, tradicionalmente, ha incluido tres ejes: (1) necesidades de la población, problemas sociales y de salud-enfermedad , (2) determinantes sociales y (3) recursos y servicios.Existen dos perspectivas para efectuar diagnóstico de salud poblacional: una se vincula con los servicios de salud; otra integra la participación poblacional.26 menciona tres tipos de diagnóstico de salud poblacional desde la óptica de los servicios de salud: administrativo, dirigido al análisis de las acciones que efectúan las instituciones frente a la problemática de salud; estratégico, enfocado en el cambio, en función de los intereses y conflictos que aparecen en las fuerzas sociales; e ideológico, dirigido a la legitimación resultante del vínculo entre las fuerzas sociales estructuradas en torno a la salud con el conjunto de la sociedad. La Organización Panamericana de la Salud señaló en décadas recientes la necesidad de efectuar diagnósticos de salud con la participación de la población.25Testa16 analizan los modelos de salud pública a lo largo de la historia: sanitarista-ambiental; biomédico; social; tecno-económico; y proponen un quinto modelo, el ecológico. La salud de las poblaciones depende de la coexistencia entre la humanidad y el ambiente físico y social en este último modelo. Para ello, la salud pública debe integrar otros abordajes de pensamiento, como sistemas complejos y visión holística e interdisciplinariedad en las que confluyan diversos actores que consideren las múltiples dimensiones de la salud.16 Este modelo posee coincidencias con el enfoque de ecosalud.17 Lebel17 define el enfoque ecosistémico o de ecosalud al indicar que existen fuertes vínculos entre los seres humanos, el ambiente biofísico y los aspectos socioeconómicos que se reflejan en la salud de las personas.Lang y Rayner20 y con enfermedades transmitidas por vector.21 Sin embargo, no existen reportes en torno a diagnósticos de salud poblacional con base en este enfoque. Este enfoque promueve la participación activa de la población en la identificación y comprensión de los problemas, al conjuntar las perspectivas de población, autoridades y equipo investigador. El impulso de la participación tiene antecedentes previos en el contexto latinoamericano dentro de las propuestas de investigación-acción-participativa y en educación popular.13El enfoque de ecosalud ha sido utilizado en problemáticas vinculadas con la salud y el ambiente,17Se consideraron los tres principios planteados por Lebel para el diagnóstico de salud con enfoque de ecosalud en este estudio: transdisciplina, género y equidad y participación comunitaria.El objetivo de este estudio fue analizar las características del diagnóstico de salud según el enfoque de ecosalud en comunidades rural y urbana en México.Los diagnósticos de salud se efectuaron en las localidades de México: La Nopalera, de diciembre 2007 a octubre 2008 y en Atlihuayan, de diciembre 2010 a octubre de 2011.El equipo que realizó los diagnósticos de salud tuvo finalidad pedagógica y se constituyó por profesoras y estudiantes de ambos sexos, pertenecientes a la maestría en salud pública del Instituto Nacional de Salud Pública (INSP). El perfil de los integrantes del equipo estaba enmarcado en las áreas de: medicina, enfermería, epidemiología, ingeniería ambiental, antropología, nutrición humana, psicología, bioquímica y educación.a agrupaciones religiosas de madres y padres de familia de las escuelas y estudiantes).Participaron también autoridades locales , docentes de escuelas, representantes religiosos y grupos poblacionales . El equipo realizó intencionalmente reuniones con hombres y mujeres en estas sesiones. Se acudió a las asambleas con los campesinos; se fue a las escuelas, con los niños y adolescentes; y a reuniones en la iglesia y de salud, con las mujeres. Se utilizó material educativo destinado a alentar la reflexión colectiva acerca del diagnóstico de salud. Estas actividades estimularon el interés y la participación de los grupos poblacionales, en especial en la comunidad rural.3. Diagnóstico (recolección de información): Se utilizó metodología mixta .El componente cuantitativo incluyó:Formatos para recabar información de fuentes secundarias: causas de mortalidad en el registro civil del municipio ; datos sociodemográficos ; causas de demanda de consulta, morbilidad, recursos  recabados de los Servicios de Salud estatales y nacionales.Cuestionario con las secciones: datos sociodemográficos; características de la vivienda y los servicios públicos; morbilidad y mortalidad; acceso y uso de servicios de salud; necesidades, problemas sociales y de salud y fortalezas. Se aplicó el cuestionario en todas las viviendas de la localidad rural, y en una muestra representativa de la urbana, obtenida mediante el cálculo de tamaño de muestra para datos globales para poblaciones finitas, resultando en 187 familias (nivel de confianza de 94%).El equipo aplicó el cuestionario al jefe o jefa de familia, mediante visitas domiciliarias en ambas localidades.El componente cualitativo consistió en:Registro etnográfico de los hechos y eventos que se presentaron durante la estancia del equipo y en las diferentes asambleas o reuniones en las que se participó.1 Se realizó con niños, adolescentes y adultos de ambos géneros. Cada grupo dibujo un mapa de la localidad e identificaron los sitios que dificultan o favorecen la salud de la población. Al final, se reflexionó con cada grupo sobre las acciones que se podrían hacer para fortalecer la salud poblacional.Cartografía social: herramienta para la construcción colectiva del conocimiento y parte de la premisa que son los propios habitantes quienes conocen mejor su territorio.Asamblea comunitaria “festividad”. Se convocó a toda la población  para identificar necesidades y problemas de la comunidad. Sin embargo, debido a que los pobladores valoran más ser invitados a una festividad, el formato que siguió la asamblea fue de “convivio” con invitaciones personalizadas por familia. Para indagar sus necesidades y problemáticas, se trabajó con diversas técnicas, teniendo en cuenta la edad: con hombres y mujeres adultos, en reflexiones grupales; con adolescentes, se realizó un juego de mesa y algunos participaron en el registro gráfico (fotografías y videos); con los niños hubo juegos infantiles. Se tuvo participación de autoridades locales.El equipo propició la reflexión sobre el vínculo de los problemas de salud y sociales con el ambiente físico, social y económico a fin de profundizar en su comprensión.Todos los asistentes y el equipo convivieron consumiendo alimentos y bebidas de la región.A las asambleas comunitarias no acudieron los habitantes de la zona urbana ni las autoridades locales.4. Fase de priorización:Identificación de problemas. Se convocó a una segunda asamblea comunitaria (“convivio”) en la zona rural a través de invitaciones dirigidas a personas que participaron en la reunión anterior. Se conformaron siete grupos de trabajo. Cada uno seleccionó dos representantes para identificar los diez principales problemas de la comunidad. Se utilizó el método de priorización de Hanlon (adaptado), con los criterios de magnitud, trascendencia, factibilidad y vulnerabilidad (Tabla 1).. Se convocó a los representantes de cada grupo, designados en la asamblea de identificación de problemas en la zona rural. Los participantes analizaron los problemas priorizados con base en cinco componentes: determinantes sociales y ambientales; efectos para la salud; responsables de la solución de esos problemas ; responsabilidad de la población; factibilidad de solución. Se alentó la reflexión acerca de la interacción entre los problemas de salud y los aspectos sociales y ambientales de la región. Autoridades, población y equipo investigador eligieron cinco problemas factibles de ser abordados con base en estos elementos.Análisis de problemas y priorizaciónEl ejercicio de priorización en la zona urbana se efectúo con la autoridad local y seis integrantes de la comunidad.5. Devolución de resultados. Fueron presentados los resultados en una asamblea con la población, autoridades locales y municipales de la zona rural. A partir de éstos, se tomaron decisiones colectivas para efectuar iniciativas comunitarias para enfrentar algunos problemas identificados en el diagnóstico de salud.La asistencia poblacional fue escasa en la zona urbana y se entregó el documento del diagnóstico a las autoridades locales y municipales.Se realizó análisis descriptivo de las características sociodemográficas de cada comunidad y de las características de interés para la evaluación metodológica del diagnóstico de salud con enfoque ecosistémico. Los análisis descriptivos se efectuaron utilizando el paquete estadístico Stata .® v. 2007 que, posteriormente, se transformaron al programa de computo Ethnopraph v.5.Se transcribieron notas de registro etnográfico, sesiones de trabajo, asambleas y cartografía social en el procesador de textos de WordSe trianguló la información con los datos cuantitativos y cualitativos.El protocolo del diagnóstico de salud fue aprobado por los colegios de educación y ciencias sociales del INSP en su octava sesión ordinaria del mes de septiembre del año 2007. A todos los habitantes de la comunidad se les pidió consentimiento informado para efectuar cada actividad.La comunidad rural participó de manera creciente en cada fase del diagnóstico, al igual que las autoridades locales. En contraste, se tuvo dificultad para la participación en la localidad urbana en todas las fases. Fue difícil establecer contacto con toda la población en la etapa de acercamiento y sólo se pudo trabajar con algunos integrantes de organizaciones comunitarias. Las autoridades locales de la zona urbana mostraron poco interés en el diagnóstico .Las características sociodemográficas fueron similares en la distribución por sexo en ambas localidades, con edad promedio de 28 años y mayor porcentaje de personas con más escolaridad en la comunidad urbana. Existió mayor porcentaje de personas dedicadas a las actividades agrícolas en la comunidad rural . Hubo diLos resultados de la priorización, según el método adaptado de Hanlon, para la comunidad rural fueron: enfermedades  y determinantes sociales y ambientales . Para la comunidad urbana, fueron: determinantes sociales y ambientales  (Datos no mostrados).El acercamiento transdisciplinario que se realizó en ambas comunidades tuvo resultados diferenciados. Se logró integrar la visión de la población y actores sociopolíticos en la comunidad rural; no fue posible incorporar ni a las autoridades locales ni a todos los habitantes en la localidad urbana.Hombres y mujeres asistieron a todas las actividades en la localidad rural. La problemática de la salud vista de forma integral en la interacción con el ambiente físico y social despertó interés similar en los niños, adolescentes y adultos de ambos géneros. Esto posibilitó obtener la perspectiva de hombres y mujeres en las distintas actividades, la cartografía social y los ejercicios de priorización.Fue mínima la participación de los hombres en la localidad urbana y los grupos fueron mayoritariamente de mujeres adultas. Sólo en el ejercicio de cartografía con los niños y niñas se consiguió un grupo mixto. En esta localidad, no existían agrupaciones de hombres , una de las razones que dificultó su integración a las distintas fases del diagnóstico.La población urbana carecía de pertenencia comunitaria y poseía mejores condiciones de satisfactores básicos, en comparación con la zona rural. Estas circunstancias se tradujeron en desinterés y falta de compromiso de los habitantes para mejorar su entorno.El enfoque de ecosalud contribuyó para que la población visualice la relación que existe entre los problemas de salud, el ambiente físico y los aspectos socioeconómicos, y para identificar soluciones. La participación de las autoridades locales  favoreció estrategias para encontrar soluciones.En la localidad rural, las asambleas (“convivios”) contribuyeron a generar procesos educativos con la población, para avanzar en la comprensión del fenómeno salud-enfermedad y que no se visualizará sólo desde el punto de vista biológico sino en la interacción con los aspectos socio-culturales, económicos y ambientales.d control de “moscas” de granja porcina,e niños y jóvenes con perspectiva de género,f fortalecimiento de pertenencia comunitaria en niños y sus familiasg y prevención de adicciones en niños y adolescentes.hLa generación del conocimiento a partir de los principios del enfoque de ecosalud permitió desarrollar propuestas acordes con los temas priorizados por la población. Las iniciativas comunitarias en ambas localidades se enfocaron en: manejo de residuos sólidos,20 Esta diferencia en la participación en los diagnósticos, puede relacionarse con la baja pertenencia comunitaria de la población en la zona urbana. Chavis et al8 han aportado sustento sólido, mostrando la relación que existe entre el sentido de comunidad o pertenencia comunitaria y la participación comunitaria. Otros autores confirman lo reportado por Chavis et al,18 señalando que, en la medida que la pertenencia comunitaria contribuye a la participación, estos elementos en conjunto fortalecen la construcción de ciudadanía.23Los resultados en los diagnósticos de salud, con relación a la participación poblacional fueron diferentes en ambas localidades (con baja participación en la zona urbana). Sin embargo, en estudios efectuados con base en el enfoque de ecosalud, en los cuales se abordan problemáticas específicas, se reportan buenos resultados impulsando la participación de la población.15La participación de la población fue favorable en el espacio rural, semejante a lo reportado en un estudio con adultos mayores en Chile.3 Coincidimos con estos autores, quienes señalan que la cultura política y el contexto son factores que influyen en la manera de proceder de las autoridades.En esta investigación, se encontró escasa participación y compromiso de la autoridad local en la zona urbana, que es también reportado en otro estudio con enfoque ecosistémico en Ecuador.19 Entretanto, la participación en el nivel local es un proceso que puede contribuir a la construcción de ciudadanía y al fortalecimiento de actores sociales para que negocien frente al Estado,5 sin negar las dificultades y conflictos de poder, que pueden surgir durante el proceso entre la población y el Estado.La participación de la población en el diagnóstico de salud se ubica a nivel local y tiene importancia debido a la identificación de los propios involucrados en sus problemáticas y soluciones. Menéndez menciona que las decisiones económicas y sociopolíticas que afectan la vida de las poblaciones son tomadas por organismos, autoridades e instancias políticas sin la participación de los grupos sociales mayoritarios.26La población fue capaz de identificar, priorizar y comprometerse en la solución de problemas de salud en la zona rural. El diagnóstico de salud con enfoque de ecosalud establece una diferencia sustancial con respecto a los diagnósticos de salud tradicionales , que parten de los servicios de salud y se enfocan en la programación de metas, objetivos y actividades dirigidas a la población por expertos, pero sin la participación de la población.9 que sostiene que el abordaje actual de la salud pública se beneficia cuando se implementa una perspectiva holística que incorpora la complejidad del proceso salud-enfermedad.Los resultados tienen sustento en la transdisciplina, participación, género/equidad, y concuerdan con los señalamientos de Dakubo,10 señala que la investigación basada en comunidad es un modelo que impulsa la participación de población, autoridades y equipo de investigación en las distintas fases del proyecto. En los diagnósticos de salud en este estudio se tomaron elementos de la investigación en comunidad, pero no se logró que la población urbana participara en todas las fases. Una herramienta utilizada para impulsar la participación de la población fue la cartografía social. Su uso obedeció para promover la participación y mejorar la comprensión del contexto local por los propios habitantes, y para encontrar soluciones a sus problemáticas.2Dakubo17 Se integró la visión de hombres y mujeres en los diagnósticos de salud de la comunidad rural y parcialmente en la urbana.El enfoque de ecosalud aborda la equidad y el género como un solo principio. Primero, porque no se puede hablar de equidad sin abordar el género, y viceversa; segundo, porque dejar de lado estos temas es comprender parcialmente la situación de salud de las comunidades.20 et al consideran que el género es una categoría que muestra de manera diferencial la forma en que hombres y mujeres interactúan con el medio ambiente y la salud, y la manera como participan en los proyectos. Esto coincide con los resultados de la presente investigación.MertensLos retos identificados fueron: a) integrar en el instrumento la priorización de los problemas de los determinantes ambientales, que permitan reflexionar con la población las relaciones e interacciones sociales-ecológicas que afectan la salud, el bienestar y la sostenibilidad ambiental. b) diseñar estrategias y mecanismos que permitan impulsar la participación de la población en diversas zonas geográficas  y en diferentes contextos socioculturales; c) sensibilizar a los tomadores de decisiones de los servicios de salud sobre la importancia de efectuar diagnósticos de salud poblacional con este enfoque; d) impulsar la integración no solo de las autoridades locales y municipales, sino también las estatales y nacionales en diagnósticos de salud con enfoque de ecosalud, con la finalidad de incidir en la formulación de políticas públicas.El diagnóstico de salud poblacional es la herramienta principal del personal de salud y autoridades sanitarias para tomar decisiones, muchas veces limitadas por la forma en que se obtienen los datos . Partimos de la premisa del diagnóstico de salud, con enfoque de ecosalud, como primer paso para procurar un acercamiento con las poblaciones y para generar conocimiento que conduzca a la acción de manera conjunta y que dé respuesta a sus necesidades.Este trabajo es una primera aproximación de un diagnóstico de salud con base en el enfoque de ecosalud. Es necesario continuar realizando diagnósticos de esta naturaleza, ajustando las estrategias de acuerdo a las características de la población y zonas geográficas, a fin de profundizar en la concreción de los tres principios del enfoque que presentamos en este artículo.


Apresenta propriedades antioxidantes e antiaterogênicas por hidrolisar o colesterol da LDL oxidado e produtos da peroxidação de fosfolipídios. Desta forma, confere proteção às membranas celulares e neutraliza os efeitos da oxidação lipídica, desempenhando importante papel cardioprotetivo. 8 e implicadas na patogenia da DAC conforme demonstrado em alguns estudos, 10 embora deva-se ressaltar a heterogeneidade de resultados na literatura conforme apontado em amplos estudos de metanálise, que concluíram pela associação fraca ou ausente para os principais polimorfismos estudados. 12 Dentre os quais, ressalta-se dois polimorfismos na região codificante do gene, com substituição na proteína de Glutamina (Q) por Arginina (R) na posição 192 (rs662 ou A192G) e Leucina por Metionina na posição 55 (rs854560 ou A55T) e o polimorfismo rs705379 (ou T[-107]C) na região promotora do gene, os quais tem sido relatados por influenciar a atividade ou a expressão da enzima.Polimorfismos das enzimas paraoxonases, particularmente a isoforma PON1, têm sido associadas com alterações lipídicas 13 que avaliaram a associação dos polimorfismos da PON1 mencionados  com DAC na população do Irã da região nordeste do país, pela comparação entre pacientes com DAC definida angiograficamente (grupo com angiografia positiva - obstrução com estenose coronariana >50% em pelo menos uma artéria coronária [N=266] e grupo com angiografia negativa - não obstrução com estenose < 30% nas artérias coronárias [N=335]). Os resultados obtidos indicaram uma significativa associação do alelo G (isoforma 192R da PON1) do polimorfismo rs662 com o aumento do risco a doença , apresentando consistência com resultados de outros estudos, 10 inclusive com outro estudo conduzido no oeste do Irã, 14 e com achados de metanálise. 12Neste contexto, deve-se destacar o trabalho de Soflaei et al., 15 sinalizando um aspecto importante a ser considerado nos estudos de atividade desta enzima, devido ao seu caráter multifuncional.O referido estudo também explorou a associação da atividade da PON1 (fenótipo) com DAC, não tendo verificado diferença entre os grupos estudados, porém confirmou o efeito dos polimorfismos avaliados sobre o nível de atividade dosada da PON1, tendo observado maior atividade da paraoxonases, que seria benéfico, nos portadores do perfil genotípico de risco . Este achado aparentemente paradoxal de avaliação de genótipo de risco e perfil de atividade da PON1 têm sido explicado, conforme discutido no estudo, pela diferença entre o que é medido como atividade da enzima no ensaio bioquímico de hidrólise do paraoxon (atividade paraoxonase) e sua atividade de proteção antioxidante em relação ao LDL-colesterol, que envolve outro sítio ativo na enzima, de forma que os portadores do alelo G (isoforma 192R) teriam, na verdade, uma atividade biológica reduzida da PON1 no que se refere a proteção antioxidante, como evidenciado no estudo de Aviram et al., De forma relevante na realidade atual, os estudos de associação genética têm permitido o desenvolvimento da medicina personalizada pela aplicação dos achados científicos obtidos na construção de painéis de testes genéticos por grupos de doenças, incluindo painéis específicos para as DCV, que já se encontram inclusive disponíveis à população em alguns laboratórios especializados. Os avanços no nível de conhecimento relacionados ao efeito de variantes genéticas em mecanismos moleculares subjacentes à fisiopatologia de doenças, como tem sido observado para os genes da paraoxonase na DAC, têm o potencial de propiciar o desenvolvimento de painéis genéticos mais acurados de forma a impactar decisões terapêuticas e abordagens no aconselhamento genético. 2 Therefore, scientific efforts have been made to identify new biochemical markers and in the elucidation of genotypic risk profiles for CAD and other CVDs in the field of disease-association medical genetics.3 In this sense, a gene that has been extensively studied is the paraoxanase (PON) gene, which has three gene cluster isoforms: PON1, PON2 and PON3, located on chromosome 7q21.3-22.1.4 PON1 is the most studied member of the paraoxanases family due to its prominent role in lipoprotein catabolism pathways, being even pointed out as a biochemical marker of the antioxidant capacity of HDL-cholesterol particles.6Cardiovascular Diseases (CVD), and more specifically Coronary Artery Disease (CAD), continue to be the most important causes of death from non-communicable diseases in Brazil and in the world.7PON1 is a multifunctional calcium-dependent ester hydrolase enzyme that is associated with HDL-cholesterol particles. It has antioxidant and antiatherogenic properties by hydrolyzing oxidized LDL cholesterol and phospholipid peroxidation products. In this way, it provides protection to cell membranes and neutralizes the effects of lipid oxidation, playing an important cardioprotective role.8 and have been implicated in the pathogenesis of CAD, as demonstrated in some studies,10 although the heterogeneity of results in the literature should be highlighted, as pointed out in extensive meta-analysis studies, who concluded that there was a weak or absent association for the main polymorphisms studied.12 Among which, two polymorphisms in the coding region of the gene stand out, with replacement of the Glutamine (Q) by Arginine (R) at protein position 192 (rs662 or A192G) and Leucine by Methionine at position 55 (rs854560 or A55T) and rs705379 polymorphism (or T[-107]C) in the promoter region of the gene, which have been reported to influence enzyme activity or expression.Polymorphisms of paraoxonase enzymes, particularly the PON1 isoform, have been associated with lipid alterations13 who evaluated the association of the mentioned PON1 polymorphisms  with CAD in the population of Iran in the northeast region of the country, by comparing patients with angiographically defined CAD (group with positive angiography - obstruction with stenosis coronary artery disease >50% in at least one coronary artery [N=266] and group with negative angiography - non-obstruction with stenosis < 30% in coronary arteries [N=335]). The results obtained indicated a significant association of the G allele (192R isoform of PON1) of the rs662 polymorphism with increased disease risk , which is consistent with results from other studies,10 including another study conducted in western Iran,14 and with meta-analysis findings.12In this context, it is worth highlighting the work of Soflaei et al.,15 indicating an important aspect to be considered in studies of the activity of this enzyme, due to its multifunctional character.The aforementioned study also explored the association of PON1 activity (phenotype) with CAD, not finding any difference between the groups studied, but it confirmed the effect of the polymorphisms evaluated on the level of measured activity of PON1, having observed greater activity of paraoxanase, which would be beneficial, in carriers of the genotypic risk profile . This apparently paradoxical finding of risk genotype assessment and PON1 activity profile has been explained, as discussed in the study, by the difference between what is measured as enzyme activity in the biochemical paraoxon hydrolysis assay (paraoxanase activity) and its activity of antioxidant protection in relation to LDL-cholesterol, which involves another active site in the enzyme, so that carriers of the G allele (192R isoform) would actually have a reduced biological activity of PON1 with regard to antioxidant protection, such as evidenced in the study by Aviram et al.,Currently, genetic association studies have allowed the development of personalized medicine through the application of scientific findings obtained in the construction of panels of genetic tests by groups of diseases, including specific panels for CVD, which are already available to the public in some specialized laboratories. Advances in the level of knowledge related to the effect of genetic variants on molecular mechanisms underlying the pathophysiology of diseases, as has been observed for the paraoxanase genes in CAD, have the potential to foster the development of more accurate genetic panels to impact therapeutic decisions and approaches in genetic counseling.


Background. Family caregivers are ever-present and crucial collaborators in the work of occupational therapists but are rarely the focus of their efforts. Purpose. This lecture will discuss the greater inclusion of family caregivers in occupational therapy and the exciting possibilities that emerge from this change. Key issues. Family caregivers are a unique client population. This position statement is supported by recent research on occupational therapists’ values and shifts towards an occupational participation approach in the profession. Working with this client population requires a nuanced understanding of their experience. Caregiving can be burdensome, but it can also create positive effects many of which can be identified and understood through a relational lens. Implications. Through a three-fold approach, occupational therapists can work with caregivers to locate and mitigate negative caregiving effects, discover, and build on positive effects, and further develop positive outcomes by encouraging and balancing caregiving and non-caregiving occupations. Throughout most of my research career, my passion has been two-fold: the first line of inquiry has been to analyze and measure different occupational phenomena to monitor and assess change over time. Working alongside many talented people I have tried to understand and create tools to measure different types of concepts important in occupational therapy (OT) and in rehabilitation. The second line of research that has dominated my career is gerontechnology, focusing on measuring the needs and impact of different assistive technologies on users and caregivers. In recent years, I have been honored to co-lead a work package with AGEWELL, which is Canada’s technology and aging network (https://agewell-nce.ca/). During my time in this role, ever-present and crucial collaborators in the work of occupational therapists (OTs) captured my imagination. Oftentimes, these collaborators are indispensable to our work but are rarely the focus of our efforts. These collaborators are family caregivers.A family caregiver is defined as a family member, friend, or another person who provides voluntarily or involuntarily physical or emotional care to a person experiencing mental or physical health issues or a person with disabilities . These cI will begin my lecture with a discussion of the central role that family caregivers play in our work, our society, and, likely, in our personal lives. Next, I propose considering caregivers as a unique client population and show how approaching them as clients fits with OT values and theory. I will then discuss how conceptualizing an approach to caregivers-as-clients can move beyond a caregiver burden perspective by considering an aspect of their experience that I believe deserves greater attention, that is the positive effects of caregiving. Finally, I conclude the lecture by introducing a caregiver-specific approach to working with them, both as care team partners and as clients.At its core, my lecture is a call to clinicians and researchers alike to deepen our understanding of, and interaction with, caregivers in OT practice, research, and theory. I invite all to see the caregiver not only as a key member of a care team who is instrumental in intervention efficacy but also as a client in their own rights who survives and thrives in all their occupations.I would like to begin by sharing an illustrative story from my personal life. It was one of many moments in recent years that highlighted for me the need for a new approach to caregivers-as-clients.A few years ago, my 88-year-old father-in-law, Hubert, started to deteriorate in terms of his health and participation. He had survived multiple coronary bypasses and was adapting to living with sarcopenia, memory loss, hearing loss, and musculoskeletal pain. Over time, he was less able to prepare meals, he started sleeping excessively, and he was losing interest in social activities. It was becoming clear that Hubert needed and wanted extra help with accomplishing some everyday tasks. My partner and I became family caregivers.For me, this was the first time that I had taken on this role for a person other than my own children. After several months, it became increasingly difficult to juggle providing care to Hubert and meeting the demands of our jobs. Thankfully, we were able to set up home care services for assistance during the week with tasks such as housekeeping, morning care, medication, and two meals a day. On the weekends, my partner and I would take over performing some of these tasks. Together, Hubert, my partner, the family, the care support, and myself, worked to achieve relative stability in our new routines.Throughout this caregiving episode, I felt a wide range of emotions. During the week, my partner and I found ourselves worrying about Hubert. Every unexpected phone call made us jump: was it bad news? If we called and he didn’t answer, we worried about his welfare: did something happen? Did he fall? Was he okay? We felt frustration and sometimes a sense of guilt for not being able to be more present. On weekends, I sometimes found myself emotionally and physically exhausted by some caregiving tasks and distressed by Hubert’s continued decline. Yet, I felt grateful and rewarded by a deepening relationship with Hubert and with my partner too. At the end of his life, Hubert was still able to say how important we were to him. I was deeply saddened, and somewhat relieved, when he eventually passed away last summer at the beginning of the COVID pandemic. Having had the chance to care for him and hear him express how important our years of caregiving were to him, still means so much to me.As I share this personal story, I am very aware of its apparent ordinariness. My personal experience of family caregiving was not necessarily unique, nor was it long or particularly challenging, but that is the point. I share my experience of family caregiving to highlight the idea that caring for a family member or friend is almost a universal role that most of us, if we have not already, will take on in our lives, and quite possibly multiple times. The ubiquitous nature of family caregiving is the fundamental reason why OT should continue to deepen its understanding of and interactions with caregivers.The profile and contribution of family caregivers to Canadian society are dynamic and profound. In the 2018 census, one in four Canadians aged 15 or older reported providing care to a family member or friend with a long-term health condition, disability, or age-related need . Of the As you might expect, the economic and social contribution of family caregivers’ labor is significant in Canadian society, especially in our healthcare systems. In fact, our healthcare systems across the country have historically relied heavily on family caregivers  and thisThe economic contribution and savings to healthcare systems that caregivers provide are truly invaluable. Some, however, have tried to quantify this. For example, in Quebec, it is estimated that 1.9 million family caregivers contribute 743 million hours of unpaid labor per year. This, in turn, saves Santé Québec approximately 9.3 billion dollars per year . And thiCaregivers can struggle to find a balance between the different occupations in their lives—such as paid employment, other commitments to family, friends, or community, or finding time for leisure activities and relaxation. Without them, however, many of the positive outcomes that the care recipient achieves could be compromised, and in some cases, not possible at all.As OTs, we are acutely aware of the integral and challenging role that family caregivers play in the lives of people with long-term health conditions, disabilities, or age-related needs. From the early days of our training, we are taught to understand the complexities of family dynamics that surround the patient and their care . The carI am certain that these models resonate with the experiences of many OT clinicians and researchers. We can likely all attest that caregivers are an important environmental factor or influence in our work. Caregivers play a vital role in implementing recommendations that improve the lives of care recipients. Indeed, researchers have noted that gains made during rehabilitation can be more effectively maintained when the family members are supportive and involved .Thus, it could be said that OTs need caregivers to assist with a wide variety of tasks that are central to our action plan with the care recipient. These tasks can include managing medications, helping with mobility and transfers, advocating for the healthcare needs of the care recipient, and the list goes on and on. Without caregivers, the work of OTs would likely be less impactful.Likewise, as OTs need caregivers, many caregivers would likely agree that there is a need for OTs in their lives as well. While caregivers help accomplish the aims of our care recipient-centered interventions, many of our interventions improve and facilitate the care they provide. For example, we educate and train caregivers regarding how to perform caregiving tasks, provide opportunities to practice new care-related skills, and give feedback and coaching . We can www.movitplus.com/). The team is currently working with stakeholders to produce caregiver training and resources in relation to mobility devices. These resources come in a variety of formats, including written material, videos, and websites. They are delivered through an internet-based monitoring and support system intended to increase their access and availability.There is also research work conducted in OT to support caregivers. One such example is from a team of researchers and clinicians in Quebec, led by Claudine Auger . In this study, the top three values identified by participants were: first, “autonomy”, which was defined as functional autonomy and the autonomy to freely make existential and life project decisions; second, human dignity, which the authors characterized as respecting and honoring the “clients’ subjectivity” and working with clients to help them realize “significant and signifying life projects”; and third, occupational participation, which was described as enabling individuals and communities to achieve important and meaningful occupations.The aforementioned values strengthen and justify a case for including the caregiver within our client population. From the perspective of autonomy, it could be argued that the autonomy of the care recipient should not come at the expense of or fully infringe upon that of the caregiver. The second value, human dignity, supports the notion that OTs can work with the caregiver to assess their needs, desires, and life goals in relation to their caregiving duties and their other occupations. Finally, the third value, occupational participation, further strengthens the idea that a caregiver can, and should be, a client. Like Karen Whalley Hammell noted during her Muriel Driver lecture in 2017, OTs must “advance the right of all people to engage in occupations that contribute positively to their own well-being and the well-being of their communities” , p. 216.Promoting occupational participation: Collaborative, relationship-focused OT, the ‘sequel’ to Enabling Occupation . What activities or practices sustain caregiving, and what are the parts of caregiving that are enjoyable, if any? Mary revealed that she drew strength from seeing Francois comfortable and enjoyed making him nutritious meals. She also noted that she used gardening to help release the stresses associated with caregiving. Finally, she also noted that she took pride in her ability to overcome care-related challenges and enjoyed sharing her lived experience with others.After having gained further knowledge about the challenges and positive aspects of caregiving, the last step could be to explore some of the caregivers’ needs, goals, and desires beyond caregiving. For Mary, she wanted to make time for her volunteer activities and hoped to draw on her skills as a teacher to help others learn from her caregiving experience. Taking all these aspects of Mary’s experience into consideration, an OT could potentially help Mary strategize ways to achieve these goals. With the insight that Mary feels a sense of pride for overcoming care-related challenges, and knowing that she wants to share her story, encouraging her to seek out formal or informal opportunities to discuss her caregiving journey could support her sense of occupational satisfaction. Seeking out and engaging in such activities could strengthen the positive aspects of caregiving, further sustaining her caregiving efforts, as well as provide Mary with increased social activities.Thus, by considering both the positive and the negative aspects of caregiving, as well as the occupational needs, goals, and desires of caregivers in relation to all domains of their lives, we get a multidimensional perspective of the caregiver. With this knowledge, we can work with caregivers-as-clients to enhance their autonomy and social participation as their life circumstances change. This novel approach, with its three steps, is presented in To summarize this lecture, I began by acknowledging the massive contribution caregivers make to the Canadian healthcare system and to our work as OTs. I then shifted to discussing how both OTs and caregivers need each other to ensure that the combined efforts lead to positive outcomes for the care recipients. Next, I argued that OTs must consider caregivers as a unique client population. The logic of this reasoning is supported by recent research on OT values and shifts toward an occupational participation approach when working with clients. Yet, in order to work with caregivers-as-clients, I encourage all to incorporate a more nuanced understanding of the caregiving experience. That is one that recognizes that caregiving can be burdensome, but also one that can create positive effects for the caregiver, many of which can be identified and understood through a relational lens. In addition to the positive effects of caregiving, I also urge to consider caregiver occupation writ large across all life domains. Through a three-fold approach, we can work with caregivers to locate and mitigate negative caregiving effects, discover, and build on positive effects, and further develop positive outcomes by encouraging and balancing caregiving and non-caregiving occupations.That said, I want to make clear that I am not arguing for a doubling of workload. Rather, a more holistic approach to caregivers that explicitly considers their needs and occupations. In time, however, OTs could, and possibly should, lobby governments for a systems-change to clearly identify who is and is not considered a client.I strongly believe a holistic understanding of the caregiver experience embedded within an occupational participation approach used to explore the multitude of caregiver and care recipient occupations could produce a “double well-being.” That is, improved quality of life for caregivers and care recipients. As OTs, we are well-equipped for the challenge of incorporating caregivers into our practice as clients, bringing to light this potential client population who deserves our attention to guide and assist them to achieve their greatest level of occupational success.While my preoccupation with this message pertains primarily to caregivers of older adults, it is one that resonates and can be applied to all caregivers of care recipients of all ages. I encourage us all to consider caregivers in a new light moving forward both in practice and research. https://agewell-nce.ca/). Des collaboratrices et collaborateurs toujours présents et qui jouent un rôle crucial dans le travail des ergothérapeutes ont alors retenu mon attention. Ces personnes sont souvent indispensables à notre travail, mais elles sont rarement l’objet même de nos efforts. Il s’agit des proches aidants.Au cours de ma carrière en recherche, je me suis passionnée pour deux choses, dont, premièrement, l’analyse et la mesure de différents phénomènes occupationnels pour suivre et évaluer les changements au fil du temps. Auprès de nombreuses personnes de talent, j’ai essayé de créer des outils pour mesurer différents types de concepts importants dans les domaines de l’ergothérapie et de la réadaptation. Le second domaine de recherche ayant dominé ma carrière est celui de la gérontechnologie, particulièrement la mesure des besoins relatifs aux différentes technologies d’assistance et des répercussions de celles-ci sur les utilisateurs et les personnes aidantes. Ces dernières années, j’ai eu l’honneur de codiriger un ensemble de projets avec AGEWELL, le réseau canadien axé sur les technologies et le vieillissement . L’équipe travaille actuellement avec les parties prenantes pour produire une formation et des ressources en lien avec les dispositifs d’aide à la mobilité. Ces ressources se présentent sous diverses formes, y compris des documents écrits, des vidéos et des sites Web. Elles sont offertes par l’intermédiaire d’un système de suivi et de soutien sur Internet, qui vise à en accroître l’accessibilité.Des recherches sont également effectuées dans le domaine de l’ergothérapie pour soutenir les personnes aidantes. Un exemple est celui d’une équipe de chercheurs et de cliniciens québécois dirigée par Claudine Auger , aucun ensemble de valeurs de l’ergothérapie reconnu à l’échelle nationale. Lorsque je parle des valeurs de l’ergothérapie, je fais donc référence à une étude de 2015 de Drolet et Désormeaux-Moreau se penchant sur les valeurs de l’ergothérapie au Québec. Dans cette étude, les trois principales valeurs désignées par les participants étaient, dans l’ordre, l’autonomie, comprise comme l’autonomie fonctionnelle et le fait de pouvoir prendre librement des décisions existentielles et liées aux projets de vie; la dignité humaine, caractérisée comme le respect de la subjectivité et le fait de travailler avec les clients pour les aider à réaliser des projets de vie significatifs; et enfin la participation occupationnelle, décrite comme le fait de permettre aux individus et aux collectivités de réaliser des occupations importantes et significatives.Les valeurs susmentionnées renforcent et justifient l’inclusion de la personne aidante parmi notre clientèle. Pour ce qui est de l’autonomie, on pourrait faire valoir que l’atteinte de l’autonomie de la personne bénéficiaire des soins ne devrait pas nuire à celle de l’aidant ou empiéter entièrement sur celle-ci. La deuxième valeur, celle de la dignité humaine, soutient l’idée selon laquelle les ergothérapeutes peuvent travailler avec la personne aidante pour évaluer ses besoins, ses désirs et ses objectifs de vie en lien avec ses tâches d’aidance et ses autres activités. Enfin, la troisième valeur, celle de la participation occupationnelle, renforce encore davantage l’idée selon laquelle les personnes aidantes peuvent, et doivent, être incluses dans notre clientèle. Comme l’a noté Karen Whalley Hammell dans son Discours commémoratif Muriel Driver en 2017, les ergothérapeutes doivent faire valoir « le droit de toute personne à s’engager dans des occupations signifiantes qui contribuent positivement à leur bien-être personnel et au bien-être de leurs communautés » , p. 216.Promoting occupational participation : Collaborative, relationship-focused OT, la « suite » d’Habiliter à l’occupation . Quelles sont les activités ou les pratiques qui soutiennent les soins, et quels sont les aspects de l’aidance qui lui sont plaisants, le cas échéant? Marie a révélé qu’elle puisait des forces dans le fait de voir François à l’aise, et qu’elle aimait lui préparer des repas nutritifs. Elle a également mentionné se servir du jardinage comme moyen de réduire le stress associé à l’aidance. Enfin, elle a dit tirer de la fierté du fait de pouvoir relever des défis liés aux soins et aimer pouvoir témoigner de son expérience avec d’autres.Après en avoir appris davantage sur les défis et les aspects positifs de l’aidance, la dernière étape pourrait être d’explorer certains des besoins, des objectifs et des désirs des personnes aidantes, au-delà de l’aidance. Marie, pour sa part, voulait trouver du temps pour ses activités bénévoles, et espérait pouvoir mettre à profit ses compétences en enseignement pour aider les autres à apprendre de son expérience d’aidance. En prenant en compte tous ces aspects de l’expérience de Marie, un ergothérapeute pourrait l’aider à élaborer des stratégies pour atteindre ces objectifs. En sachant que Marie tire de la fierté du fait de relever des défis liés aux soins et qu’elle veut faire part de son histoire aux autres, le fait de l’encourager à rechercher des occasions officielles ou non officielles de discuter de son parcours pourrait contribuer à soutenir son sentiment de satisfaction occupationnelle. La recherche de telles activités et l’engagement dans celles-ci pourraient renforcer les aspects positifs de l’aidance et soutenir davantage les efforts de Marie dans ce sens, en plus de lui donner accès à plus d’activités sociales.Ainsi, en considérant les aspects tant positifs que négatifs de l’aidance, de même que les désirs, les objectifs et les besoins occupationnels des aidants en lien avec toutes les sphères de leur vie, nous obtenons une perspective multidimensionnelle de la personne aidante. Avec ce savoir, nous pouvons travailler avec la clientèle des aidants pour augmenter leur autonomie et leur participation sociale en fonction de l’évolution de leurs circonstances de vie. Cette nouvelle approche en trois étapes est présentée au tableau 2.Pour résumer, j’ai commencé cette conférence en reconnaissant l’immense contribution des proches aidants au système de santé canadien et à notre travail comme ergothérapeutes. J’ai ensuite abordé le fait que tant les ergothérapeutes que les personnes aidantes avaient besoin les uns des autres pour veiller à ce que leurs efforts combinés entraînent des effets positifs pour les bénéficiaires de soins, puis j’ai soutenu que les ergothérapeutes devaient considérer les aidants comme une clientèle unique. La logique derrière ce raisonnement est soutenue par les dernières recherches sur les valeurs de l’ergothérapie, et le tournant vers une approche axée sur la participation occupationnelle lors du travail avec la clientèle. Néanmoins, pour travailler avec la clientèle des aidants, je nous encourage tous et toutes à intégrer une compréhension plus nuancée de l’expérience de l’aidance. C’est-à-dire une approche qui reconnaît que l’aidance peut être un fardeau, mais qu’elle peut aussi avoir des effets positifs pour les aidants, notamment dans une perspective relationnelle. En plus des effets positifs de l’aidance, je nous invite fortement à considérer l’occupation d’aidant ou d’aidante dans toutes les sphères de la vie. Par une approche triple, nous pouvons travailler avec les proches aidants pour déterminer et atténuer les effets négatifs de l’aidance, découvrir les effets positifs et construire sur leur base, puis encourager et équilibrer les activités liées à l’aidance et les autres activités afin d’en renforcer les effets positifs.Cela étant dit, je veux qu’il soit clair que je ne souhaite pas doubler ainsi notre charge de travail. Je fais plutôt la promotion d’une approche plus holistique abordant explicitement les besoins et les occupations des personnes aidantes. Avec le temps, néanmoins, les ergothérapeutes pourraient, et devraient sans doute, faire pression après des gouvernements pour changer le système de manière à identifier clairement qui est un client et qui ne l’est pas.Je crois fortement qu’une compréhension globale de l’expérience de la personne aidante, ancrée dans une approche de participation occupationnelle et visant à explorer la multitude d’occupations des aidants et des bénéficiaires de soins, pourrait produire un « double bien-être ». Autrement dit, une meilleure qualité de vie pour les aidants et pour les bénéficiaires de soins. Comme ergothérapeutes, nous sommes bien équipés pour relever le défi de travailler auprès des personnes aidantes, mettant en lumière cette clientèle potentielle qui mérite notre attention de manière à la guider et à l’aider à s’épanouir sur le plan occupationnel.Si, en livrant ce message, je pense d’abord aux aidants de personnes âgées, celui-ci peut trouver un écho ailleurs et s’appliquer aux aidants qui œuvrent auprès de personnes de tous âges. Je nous encourage tous et toutes à considérer les aidants sous un nouveau jour, tant dans l’exercice de notre profession que dans la recherche.