Identify barriers and facilitators to implementing the Group Prenatal Care model in Mexico (GPC) from the health care personnel's perspective.We carried out a qualitative descriptive study in four clinics of the Ministry of Health in two states of Mexico  from June 2016 to August 2018. We conducted 11 semi-structured interviews with health care service providers, and we examined their perceptions and experiences during the implementation of the GPC model. We identified the barriers and facilitators for its adoption in two dimensions: a) structural  and b) attitudinal .The most relevant barriers reported at the structural level were the availability of physical space in health units and the work overload of health personnel. We identified the difficulty in adopting a less hierarchical relationship during the pregnant women's care at the attitudinal level. The main facilitator at the attitudinal level was the acceptability that providers had of the model. One specific finding for Mexico's implementation context was the resistance to change the doctor-patient relationship; it is difficult to abandon the prevailing hierarchical model and change to a more horizontal relationship with pregnant women.Analyzing the GPC model's implementation in Mexico, from the health care personnel's perspective, has revealed barriers and facilitators similar to the experiences in other contexts. Future efforts to adopt the model should focus on timely attention to identified barriers, especially those identified in the attitudinal dimension that can be modified by regular health care personnel training. The mainly affected populations have a greater structural and social vulnerability, lower health service coverage and less probability of receiving adequate prenatal care The World Health Organization has issued recommendations on prenatal care for a positive experience during pregnancy. The recommendations refer to health system interventions that improve the utilization and quality of prenatal care ,-Prenatal care is provided by various health care providers who assume a facilitating role in this model. Groups of between eight and twelve women of similar gestational age (12–20 weeks) are organized into small cohorts that meet eight to ten times during pregnancy in sessions of about two hours, incorporating all the components mentioned in a circuit of four phases The different phases of the cycle of care in each of the group sessions of group prenatal care, based on the CenteringPregnancy model include: (1) registration and self-care: participants start the session and check their vital signs; (2) socializing or building social networks: they sit in a circle and spend time talking freely with their peers; (3) medical check-up: in parallel with the second phase, each woman has an individual consultation with the doctor or midwife, who performs individual physical exams, in the same place where the group meets; and (4) health education: once the round of physical examinations is completed, women and facilitators come together into the same circle, where information about pregnancy is shared between them in a participatory, non-hierarchical approach   .The process of implementing innovative interventions such as GPC faces significant barriers that impact the stages of adoption and escalation, as well as the results that are achieved -Studies have explored the barriers and facilitators of GPC implementation, based on the perceptions of health personnel who took on the facilitator's role. In general, facilitators have positive perceptions and consider that the model has advantages over the individual care model. Such as more time for medical staff to interact with the pregnant woman, better relationships and communication with women, and the attention is much more satisfying and effective in improving health promotion ,,,Among the challenges for the successful implementation of the model are the health system's support and leadership ,In Mexico, since 2016, we began a study to adapt the CenteringPregnancy model to the Mexican context and measure the feasibility and acceptability for women and health personnel during its initial implementation The objective of this study was, from the perspective of health personnel, to identify barriers and facilitators to the implementation of GPC model in Mexico.We conducted a qualitative descriptive study in four health centers of the Ministry of Health in the states of Morelos and Hidalgo, Mexico. We used semi-structured interviews to explore health personnel's perceptions and identify barriers and facilitators of implementing the GPC model. The theoretical framework used as a guide for this research was the one suggested by Novick et al. We selected the participating health centers (HC) according to the patient volume, physical space availability to implement the model, and health personnel availability. Informants played the role of facilitators during the implementation of the model. The interviews lasted an average of 50 minutes and were conducted when the facilitator had completed the implementation of at least one GPC. Four of the 15 providers contacted did not agree to participate in the interview, arguing that they did not have enough time to conduct the interview.We used a semi-structured interview guide that explored: a) sociodemographic data, b) perception about the model, c) barriers and facilitators for the development of the model, d) experience being a facilitator, and e) suggestions for improving the model. The guide was conducted with subjects close to the target population to achieve the instrument's internal validity.We conducted 11 interviews with facilitators in the selected health centers. Most participants were women (8/11). Five interviews were with medical personnel, five with nurses and one with social work personnel. Five interviewees had 20-29 years of experience working in health services, four had 10-19 years of experience, and two had one to nine years.We transcribed the interviews and then used a response matrix. We classified the information into the previously defined thematic components, corresponding to the proposed conceptual framework, to examine and describe their content, according to the conceptual framework's dimensions.We carried out a thematic analysis identifying recurrences and coincidences in discourses, opinions and reported behaviors. Subsequently, we carried out the process of data interpretation. We checked the information's consistency and validity by identifying the testimonies offered iteratively by the participants. We carried out an exercise of interpretative triangulation Participants signed an informed consent form authorizing recordings of the interviews. The study was approved by the Ethics and Research Committees of the National Institute of Public Health of Mexico (No. 1756).The testimonies (T) that supported the findings identify the cited person by an interview number   . We begOne of the main challenges was the need for a physical space, allowing around 15 people for the group sessions.Physical space availability is fundamental, and not all the health centers had space with the ideal characteristics to carry out the group sessions. The space was a critical element during the implementation of the model in Mexico. Specific adaptations were required according to each place  (TE01 and TE02). However, this required additional staff efforts to move necessary materials and supplies, waiting time if the room was being occupied for other activities; and the need to prepare the room before the beginning of the sessions.We did not identify any characteristics that would facilitate the implementation of the model in this dimension.The support received by the research team, providing materials and inputs necessary for the group sessions' implementation, favored the development of the model.The providers highlighted the importance of having the necessary resources for the adequate implementation of the model. However, they said that some health centers did not have enough material and equipment. For example, the units had only one fetal monitoring team (Doppler), which was insufficient to carry out the GPC model activities and, at the same time, the usual activities of the staff who stayed in the health center (TE04).During our experience implementing the model, the research team provided some of the material (TE11). Since it was not always possible to have resources and equipment assigned exclusively to this type of consultation in the health units, providing the material needed to implement the model is something to consider in future efforts to implement it.Uncertainty in the facilitator staff's employment contracts threatened their permanence in the units and the continuity in the implementation of the GPC model. On occasion, implementing the model generated work overload for health personnel and the need to reorganize activities during the working day to comply with the recording of medical and nursing notes and update medical records.At least two trained team members in each clinic were able to take on the facilitator's role per session at all places. In some cases, the staff's employment contract with the institution was temporary, creating uncertainty about their stay in the units. Ensuring the continuity of the employment's contracts should be considered in future efforts to avoid, as much as possible, the uncertainty surrounding this limitation.Health care providers expressed readiness to conduct the sessions. Several strategies were implemented to affect the daily dynamics of the health centers as little as possible, such as organizing the GPC in the morning, coordinated teamwork with specific tasks for each member, and scheduling their activities on the consultation day exclusively for the GPC session, without attending to other tasks in the unit (TE08 and TE10).However, the GPC sessions were generating excess workload for the facilitator staff. They had to reorganize activities during the workday to facilitate the filling out of medical and nursing records. Also, sometimes it was not possible to spend the day exclusively on the GPC session and they had other health unit activities scheduled before or after the sessions (TE04).GPC is perceived as a model that favors networking, group cohesion and peer learning. Still, some facilitators perceive that it can also put at risk the daily individual productivity of health personnel.Bringing together eight to 12 women of similar gestational age to receive prenatal control in the same space was seen as advantageous (TE04). However, some of the facilitator staff perceived that the number of people they care for when they did the GPC was lower compared to standard individual care, reducing the volume of pregnant women they usually serve. This perception is an element that affects the model's acceptance, because of the concern about low individual productivity (TE01).For the community category, no testimonies were identified that refer to facilitators or barriers to implementing the GPC model.The GPC model is perceived as a model that motivates the updating the knowledge regarding topics shared in the sessions. Likewise, they identify the lack of stimuli or incentives to the health care personnel who implemented the GPC model.The testimonies will express the favorable opinion that health personnel have about the educational component of the GPC, which motivates them to prepare themselves better before the session (TE09). However, part of the interviewees considered that, in order to be more motivated, it would be desirable to offer incentives to those who participate in the intervention. The health personnel who worked as facilitators performed additional functions to those, they would typically perform. It would be important to receive some incentive for those additional efforts associated with this model's practice (TE08).Leadership strategies were created; however, entrenched clinical practice, where health personnel spend a great deal of time on the clinical examination of pregnant women, created some barriers for facilitators to adhere to the model's demands.The GPC model's implementation requires leadership strategies around the organization, team coordination, monitoring and follow-up of the GPC. Some facilitators reported difficulties in coordinating all session activities during the GPC (TE01).Operational strategies were implemented for frequent contact with participating pregnant women for follow-up. To this end, health personnel created mechanisms to have greater control over the care of pregnant women. These activities facilitated the leadership of the facilitators. For example, communication mechanisms were created, such as phone calls, messages by WhatsApp, etc. Facilitators offered session scheduling reminders or explored reasons for not attending. They simplified interaction and the creation of an atmosphere of trust between facilitators and pregnant women (TE02).Difficulties were also identified for health personnel in adjusting to the times during the clinical review. These difficulties generated uncertainty and leadership conflicts during the development of the GPC model or adoption of practices that were far from the essential elements (TE01).The GPC model is perceived as a model that favors women's active participation in the care of their pregnancy and prepares them for childbirth and puerperium.Health personnel found the model acceptable because it facilitated women empowerment and the acquisition of new knowledge to deal with their pregnancy, childbirth, and postpartum periods. Women acquire self-care skills during pregnancy, while at the same time, it is easier to perceive the achievement of a closer and more trusting relationship with health personnel (TE08).An exceptional testimony considered that some elements of the model decrease the level of quality of care, making explicit the tendency towards the traditional individual consultation style (TE01).The implementation of the GPC model, at times, generated discomfort because of the time required for the sessions. However, providers implemented alternatives to make up for the time spent implementing the model.Almost in general, the time dedicated to the sessions was not enough for them to carry out all the activities proposed by the attention model (TE01). However, some solution initiatives were identified, as dedicating the day exclusively to the GPC session without attending to other tasks in the unit to complete the medical notes in the files immediately after the sessions (TE08).The activities of the model, at times, generated discomfort in the health personnel who were not linked to its implementation in the participating units, who expressed negative comments about the activities and the time allocated to them by the model's facilitators.At times, there were negative attitudes among some colleagues at the health center towards those implementing the model (TE02). These types of attitudes can generate a feeling of rejection among health center staff not involved in the GPC model. The support of health center managers to facilitate GPC activities is an enabler element of the model. No elements of the work atmosphere were identified to facilitate the implementation of the model.Having a document that justifies leaving the health center to carry out GPC model's activities when it is carried out in another place is useful for the providers. However, it also requires the sensitization of health center directors and senior management.y TE06).Having an official communication of the activities to be carried out was useful so that personnel not involved in implementing the model are aware (TE03 Having the authorization to implement the model was not enough. Immediate and superior managers must be convinced of the model's benefits to facilitate its implementation (TE03).,The physical space required to develop the group consultation sessions is one of the main challenges in the Mexican experience. Similar results were identified by Novick et al. ,The implementation of the GPC requires basic inputs and equipment that should be available to the facilitators. It is worth noting the importance of the availability of educational materials according to the characteristics of the women attending the consultation. The provision of supplies and equipment may be a common need in the context of health units in low and middle-income countries, where shortages of these resources are frequently experienced The perception of work overload is another barrier that the model imposes on health workers since they also have to respond to patient demand for regular consultation GPC is perceived as a model that favors networking, group cohesion and peer learning. However, in the present study, we identified testimonials that expressed the concern of health personnel related to the fact that with GPC, their daily productivity is put at risk. Supplier productivity is not affected ,The model's implementation favored continuous communication between facilitators and pregnant participants in each group through strategies such as cell phone messages to remember the sessions, ask questions, and report the reason for not attending a session. These activities were a clear expression of the leadership of the facilitators. Our results are similar to those found by Nair et al. ,-,,,,,,,-,The facilitators' good acceptability of the model was evidenced, mainly by recognizing that the model improves their knowledge about patients and the self-efficacy and empowerment of pregnant women. Previous studies have reported similar results; the model allows them to know their patients better Some limitations should be considered regarding our study. We conducted the interviews at different times during the implementation of the model and only one interview per informant. These two elements suggest that the participants' experience concerning implementing the GPC model was not homogeneous at the time of the interview. However, we did not identify differential elements associated with this temporality in the testimonies of the participants.On the other hand, personnel who agreed to participate in the interviews may have a more favorable attitude toward the GPC than those who did not agree to participate. Additionally, we had more representation from physicians. Despite this, we consider relevant that during the adaptation and implementation of the model in Mexico, we were able to document the experiences of this type of health personnel, which allowed us to identify particular challenges in their participation, of extraordinary importance for future efforts of expansion within the health system.The participating health centers were intended to care for people without social security, limiting their scope and not explain the phenomenon studied for other population groups and environments. The small number of participating units did not allow us to examine differences related to institutional factors at the site level. Future and more comprehensive studies should explore these factors.Other researchers found similar limitations to those found in our study. Novick et al. The most relevant barriers for the implementation of GPC are focused on the low availability of adequate physical space in the units, the overload of work and the difficulty of adopting a more horizontal relationship with the pregnant women during the group sessions. Concerning the facilitators, they are mainly related to the acceptability that health personnel have of the model for promoting greater participation of pregnant women and greater knowledge of aspects of their self-care. We recommend that future efforts to implement the model focus timely on identified barriers. -,Persisten grandes retos en salud materna en términos de acceso y calidad de la atención en México y en muchos países de la región de América Latina. Las poblaciones principalmente afectadas cuentan con mayor vulnerabilidad estructural y social, con menores coberturas de servicios de salud y menores probabilidades de recibir atención prenatal de calidad La Organización Mundial de la Salud ha emitido recomendaciones sobre la atención prenatal para una experiencia positiva durante el embarazo. Las recomendaciones hacen referencia a intervenciones en los sistemas de salud que mejoran la utilización y la calidad de la atención prenatal CenteringPregnancy , el modelo grupal más difundido y estudiado, han sido implementados a nivel mundial, tanto en países industrializados como en países de medianos y bajos ingresos, y en poblaciones específicas ,-La atención prenatal es otorgada por diversos prestadores de servicios de salud que asumen un rol de facilitador en este modelo. Se organizan grupos de entre ocho y 12 mujeres, con edad gestacional similar (12–20 semanas), conformados en pequeñas cohortes que se reúnen de ocho a 10 veces durante el embarazo, en sesiones de alrededor de dos horas de duración, incorporando todos los componentes mencionados en un circuito de cuatro fases CenteringPregnancy incluyen: (1) registro y autocuidado: las participantes inician sesión y verifican sus propios signos vitales; (2) socialización o construcción de redes sociales: se sientan en círculo y pasan tiempo conversando libremente con sus compañeras; (3) chequeo médico: en paralelo con la segunda fase, cada mujer tiene una consulta individual con el médico o la partera, que realiza exámenes físicos individuales, en el mismo espacio que el grupo; y (4) educación para la salud: una vez completada la ronda de controles, las mujeres y los facilitadores se integran en un mismo círculo y se les comparte información sobre el embarazo por un enfoque participativo y no jerárquico  participantes fueron seleccionados según el volumen de pacientes, disponibilidad del espacio físico para implementar el modelo y disponibilidad del personal de salud. Los informantes desempeñaron el rol de facilitadores durante la implementación del modelo. Las entrevistas duraron en promedio 50 minutos y se realizaron cuando el facilitador hubiera concluido la implementación de, al menos, un grupo de APG. Cuatro de los 15 prestadores contactados no aceptaron participar en la entrevista, argumentando no disponer del tiempo suficiente para la realización de ésta.Utilizamos una guía de entrevista semiestructurada que exploró: a) datos sociodemográficos, b) percepción sobre el modelo, c) barreras y facilitadores para el desarrollo del modelo, d) experiencia como facilitador, y e) sugerencias para mejorar el modelo. La guía fue piloteada con sujetos cercanos a la población objetivo con la intención de lograr la validez interna del instrumento.Realizamos 11 entrevistas a facilitadores en los centros de salud seleccionados. La mayoría fue realizada a mujeres (8/11). Cinco entrevistas correspondían a personal del área médica, cinco a personal de enfermería y una a personal de trabajo social. Cinco tenían entre 20-29 años de experiencia trabajando en los servicios de salud, cuatro de 10-19 años, y dos entre uno y nueve años.Las entrevistas fueron transcritas y vertidas en una matriz de respuestas. Clasificamos la información en los componentes temáticos definidos previamente, en correspondencia con el marco conceptual propuesto, para examinar y describir su contenido, según las dimensiones definidas en el marco conceptual.Realizamos un análisis temático identificando las recurrencias y coincidencias en cuanto a discursos, opiniones y comportamientos reportados. Posteriormente, realizamos el proceso de interpretación de los datos. La comprobación de la consistencia y validez de la información la realizamos por medio de la identificación de los testimonios ofrecidos de manera reiterativa por los participantes. Realizamos un ejercicio de triangulación interpretativa Los participantes firmaron un consentimiento informado escrito autorizando las grabaciones de las entrevistas. El estudio contó con las aprobaciones de los Comités de Ética e Investigación del Instituto Nacional de Salud Pública de México (No. 1756).Los testimonios (T) que sustentaron los hallazgos identifican al actor citado por medio del número de entrevista   . IniciaUno de los principales retos fue la necesidad de un espacio físico que permita la presencia de alrededor de 15 personas para las sesiones grupales.La disponibilidad de espacio físico es fundamental, y no todos los centros de salud contaban con un lugar con las características ideales para realizar las sesiones grupales. Esto fue un elemento crítico durante la implementación del modelo en México. Se requirieron adecuaciones especificas según cada sitio  (TE01 y TE02). Sin embargo, esto demandó esfuerzos adicionales del personal para el traslado de materiales e insumos necesarios, tiempo de espera en caso de que el local estuviera ocupado para otras actividades, y necesidad de acondicionarlo antes de iniciar las sesiones.No identificamos alguna característica que facilitara la implementación del modelo en esta dimensión.El apoyo recibido por parte del equipo de investigación, facilitando materiales e insumos necesarios para la implementación de las sesiones grupales, favoreció el desarrollo del modelo.doopler ), el cual resultaba insuficiente para realizar las actividades del modelo de APG y, al mismo tiempo, las actividades habituales del personal que se quedaba en el centro de salud (TE04).Los prestadores resaltaron la importancia de contar con los recursos necesarios para la adecuada implementación del modelo. Sin embargo, manifestaron que algunos centros de salud no contaban con suficiente material y equipo. Por ejemplo, en las unidades sólo había un equipo para el monitoreo fetal . Eso es algo a considerar en futuros esfuerzos para implementar este modelo, dado que no siempre fue posible disponer de insumos y equipos asignados exclusivamente a esta consulta, en las unidades de salud.La incertidumbre en las contrataciones laborales del personal facilitador amenazó su permanencia en las unidades y la continuidad en la implementación de la APG. En ocasiones, la implementación del modelo generó sobrecarga de trabajo en el personal de salud, y la necesidad de reorganizar las actividades durante la jornada laboral para poder cumplir con el registro de las notas médicas y de enfermería, así como actualizar los expedientes clínicos.Se logró que al menos dos miembros del equipo capacitado en cada clínica adoptasen el rol de facilitadores por sesión en todos los sitios. En algunos casos, el contrato laboral del personal con la institución era de forma eventual, lo que generó incertidumbre sobre su permanencia en las unidades. Esto debe considerarse en futuros esfuerzos para evitar, en lo posible, la incertidumbre que rodea a esta limitante.Los prestadores de servicios de salud expresaron buena disposición para la realización de las sesiones. Se realizaron varias estrategias para afectar lo menos posible la dinámica diaria de los centros de salud, como organizar la APG en horario matutino, trabajo coordinado en equipo, con tareas específicas para cada integrante, y la programación de sus actividades el día de consulta de manera exclusiva a la sesión de APG, sin atender otras tareas dentro de la unidad (TE08 y TE10).Sin embargo, las sesiones de APG generaban sobrecarga de trabajo al personal facilitador. Tenían que reorganizar las actividades durante la jornada laboral para facilitar el llenado de notas médicas y de enfermería. Igualmente, en ocasiones se imposibilitaba la opción de destinar el día de manera exclusiva a la sesión de APG programando otras actividades de las unidades de salud antes o después de las sesiones (TE04).La APG se percibe como un modelo que favorece la formación de redes, cohesión de grupo y aprendizaje entre pares, pero algunos facilitadores perciben que también puede poner en riesgo la productividad diaria individual del personal de salud.Reunir en un mismo espacio ocho a 12 mujeres con edad gestacional similar para recibir el control prenatal fue percibido como algo ventajoso (TE04). Sin embargo, parte del personal facilitador percibió que el número de personas atendidas cuando hacían la APG era menor, en comparación con la atención individual estándar, reduciéndose el volumen de gestantes que ellos atienden habitualmente. Eso es un elemento que afecta la aceptación del modelo, por la preocupación de una baja productividad individual (TE01).Para la categoría comunidad no se identificaron testimonios que hagan referencia a facilitadores o barreras de la implementación del modelo de APG.El modelo de APG se percibe como un modelo que los motiva para actualizarse en los temas que se imparten en las sesiones. Así mismo, identifican la falta de estímulos o incentivos al personal participante por los esfuerzos realizados en la implementación del modelo de APG.Los testimonios expresaran la opinión favorable que tiene el personal de salud sobre el componente educativo de la APG, que los motiva a prepararse mejor previamente a la sesión (TE09). Sin embargo, parte de los entrevistados consideraba que, para estar más motivados, sería deseable ofrecer incentivos a quienes participan en la intervención. El personal de salud que fungió como facilitador realizaba funciones adicionales a las que ordinariamente realizaría, y sería importante recibir algún incentivo por esos esfuerzos adicionales asociados a la práctica de este modelo(TE08).Se crearon estrategias de liderazgo; sin embargo, la práctica clínica arraigada, en la que el personal de salud emplea amplio margen de tiempo para la exploración clínica de las embarazadas, generó algunas barreras para que los facilitadores se apegaran a las exigencias del modelo.La implementación del modelo de APG requiere de estrategias de liderazgo en torno a la organización, coordinación del equipo, monitoreo y seguimiento de la APG. Algunos facilitadores refirieron dificultades para coordinar todas las actividades de las sesiones durante la APG (TE01).Se implementaron estrategias operativas para el contacto frecuente con las gestantes participantes para el seguimiento. Para ello, el personal de salud creó mecanismos para tener mayor control sobre la asistencia de las gestantes. Estas actividades facilitaron el liderazgo de los facilitadores. Por ejemplo, se crearon mecanismos de comunicación como llamadas telefónicas, mensajes por WhatsApp, etc. Los facilitadores ofrecían recordatorios de programación de las sesiones o exploraban las razones de no asistencia. Eso facilitó la interacción y la creación de un ambiente de confianza entre facilitadores y gestantes (TE02).Así mismo, se identificó dificultad para que el personal de salud se ajustara a los tiempos durante la revisión clínica. Eso generó, en ocasiones, incertidumbre y conflictos de liderazgo durante el desarrollo de éstas o adopción de prácticas ajenas a los elementos esenciales (TE01).El modelo de APG es percibido como un modelo que favorece la participación activa de las mujeres en el cuidado de su embarazo, y las prepara para el parto y puerperio.El personal de salud consideraba aceptable al modelo porque facilitaba el empoderamiento y la adquisición de nuevos conocimientos para enfrentar su embarazo, parto y puerperio. Las mujeres adquieren habilidades para realizar su autocuidado durante el embarazo, a la vez que facilita que se perciba el logro de un trato más cercano y de confianza con el personal de salud (TE08).Un testimonio de excepción consideraba que algunos elementos del modelo bajan el nivel de calidad de la atención, haciendo explicita su preferencia hacia el estilo de consulta tradicional individual (TE01).La implementación del modelo de APG, en ocasiones, generó molestias por el tiempo que hay que dedicar a las sesiones. Sin embargo, los prestadores implementaron alternativas para subsanar el tiempo que dedicaban a la implementación del modelo.De forma casi generalizada, el tiempo dedicado a las sesiones no les era suficiente para realizar todas las actividades que propone el modelo de atención (TE01). Sin embargo, se identificaron algunas iniciativas de solución, por ejemplo, destinar el día exclusivamente a la sesión de APG sin atender otras tareas dentro de la unidad, para que pudieran completar las anotaciones médicas en los expedientes, inmediatamente posterior al término de las sesiones (TE08).Las actividades del modelo, en ocasiones, generaron molestias en el personal de salud que no estaba vinculado con su implementación en las unidades participantes, quienes se manifestaban con comentarios negativos sobre las actividades y el tiempo destinado a ellas, por parte del personal facilitador del modelo.En ocasiones, había actitudes negativas por parte de algunas compañeras o compañeros en el centro de salud hacia quien participaba en la implementación del modelo (TE02).Este tipo de actitudes pode generar un clima de rechazo entre el personal del centro de salud no involucrado en la APG. El apoyo de los directivos de los centros de salud para facilitar las actividades de APG es un elemento facilitador del modelo. No se identificaron elementos del clima laboral que faciliten la implementación del modelo.Contar con un documento que justifique la salida del centro de salud para realizar las actividades del modelo de APG, cuando se lleva a cabo en otro sitio, es de utilidad para los prestadores. Sin embargo, también se requiere la sensibilización de directivos de los centros de salud y mandos superiores.y TE06).Contar con una comunicación oficial de las actividades a desempeñar fue de utilidad para que el personal que no participa en la implementación del modelo esté enterado .La ,El espacio físico que se requiere para desarrollar las sesiones de consulta grupales es uno de los principales retos en la experiencia mexicana. Similares resultados fueron identificados por Novick et al. ,La implementación de la APG requiere de insumos y equipos básicos de los que deben disponer los facilitadores. Se destaca la disponibilidad de materiales educativos acorde a las características de las mujeres que asisten a la consulta. La aportación de insumos y equipos puede ser una necesidad común en el contexto de las unidades de salud de países de medianos y bajos ingresos, donde la escasez de estos recursos se experimenta frecuentemente La percepción de sobrecarga de trabajo es otra de las barreras que el modelo impone a los trabajadores de salud, ya que además tienen que responder a la demanda de los pacientes de la consulta regular La APG se percibe como un modelo que favorece la formación de redes, cohesión de grupo y aprendizaje entre pares. Sin embargo, en el presente estudio identificamos testimonios que expresaban la preocupación del personal de salud relacionada con el hecho de que con la APG se pone en riesgo su productividad diaria individual. La productividad de los proveedores no se ve afectada ,La implementación del modelo favoreció la comunicación continua entre facilitadores y gestantes participantes en cada grupo, a través de estrategias como mensajes en el celular para recordar sobre las sesiones, reportar el motivo de no acudir a alguna sesión o preguntar dudas. Estas actividades fueron una clara expresión del liderazgo realizado por los facilitadores. Nuestros resultados son similares a los encontrados por Nair et al. ,-,,,,,,,-,Se evidenció buena aceptabilidad al modelo por los facilitadores, fundamentalmente al reconocer que el modelo mejora su conocimiento sobre sus pacientes y la autoeficacia y empoderamiento de las gestantes. Resultados similares han sido reportados por estudios previos, en los que se reporta que el modelo les permite conocer mejor a sus pacientes, Limitaciones deben ser consideradas en el presente estudio. Las entrevistas las realizamos en diferentes momentos de la implementación del modelo y aplicamos solamente una entrevista por informante. Estos dos elementos sugieren que la experiencia que el personal de salud participante tenía al momento de la entrevista, con relación a la implementación del modelo de APG, no era homogénea entre todos los participantes. Sin embargo, no identificamos elementos diferenciales asociados a esta temporalidad en los testimonios de los participantes.Por otra parte, el personal que accedió a participar en las entrevistas podría tener una actitud más favorable hacia la APG que quienes no aceptaron participar. Adicionalmente, tuvimos mayor representación de médicos. A pesar de ello, consideramos que es relevante que durante la adaptación e implementación del modelo en México pudiéramos documentar las experiencias de este tipo de personal de salud, lo que permitió identificar retos muy puntuales de su participación, de extraordinaria importancia para futuros esfuerzos de escalamiento dentro del sistema de salud.Los centros de salud participantes estuvieron destinados a la atención de personas sin seguridad social, lo que limita su alcance y no permite explicar el fenómeno estudiado para otros grupos poblacionales y entornos. El pequeño número de unidades participantes no hizo posible que examináramos las diferencias entre los sitios, relacionadas con factores institucionales a nivel de sitio. Futuros estudios de mayor alcance deberán explorar estos factores.Otras investigaciones encontraron limitaciones parecidas a las encontradas en nuestro estudio. Novick et al. Las barreras más relevantes para la implementación de la APG se focalizan en la poca disponibilidad de espacio físico adecuado en las unidades, la sobrecarga de trabajo y la dificultad de adoptar una relación más horizontal con las gestantes durante las sesiones grupales. Con relación a los facilitadores, principalmente se relacionan con la aceptabilidad que el personal de salud tiene del modelo por propiciar una mayor participación de las gestantes y un mayor conocimiento de aspectos de su autocuidado. Se recomienda que futuros esfuerzos de implementación del modelo se enfoquen en la atención oportuna de las barreras identificadas.


To validate an instrument measuring the cultural competence in health care workers from Chile.Using Sue & Sue’s theoretical model of cultural competence, we designed a scale, which was assessed by health care workers and experts. Subsequently, the scale was applied to a sample of 483 different health care workers, during 2018 in Santiago de Chile. The analysis included: exploratory and confirmatory factor analysis, estimation of reliability, and analysis of measurement bias. Finally, the level of cultural competence was calculated for every professional who participated in this study.The final scale include 14 items that are grouped into three dimensions concordant with the theoretical model: sensitivity to own prejudices, cultural knowledge, and skills to work in culturally diverse environments. This scale showed good fit in factor models, adequate reliability and lack of evidence of measurement bias. Regarding the performance of health care workers, sensitivity showed a lower level compared with the other dimensions evaluated.The scale for measuring the level of cultural competence in health care workers (EMCC-14) is a reliable instrument, with initial support for its validity, which can be used in the Chilean context. Additionally, the results of this study could guide some possible interventions in the health sector to strengthen the level of cultural competence. In health care, Chile is committed to providing patient-centred health care 3 . It means, among other things, addressing the particular needs of different population groups and providing treatment free of discrimination. To achieve this, it is important to consider the role of cultural aspects in people’s relationship with the processes of health and disease 3 .Chile has progressively become a more diverse country as 4.4% of its population is composed of foreign immigrants 4 . When cultural aspects are not considered in health care, interactions between patients and professionals are less patient-centred, shorter, and less positive 5 . Cultural competence (CC) in health refers to the permanent reflection and questioning by the health care worker about how culture – of the professional and of the patient – impacts on the interaction with the users of the health system 6 . CC, includes a commitment to delivering services which take into account the patient’s beliefs and actions.Culture corresponds to a system of shared conceptual frameworks and schemes used by the members of a group (or subgroup) to interpret reality and relate to the world around them, including their health 8 . Sue & Sue 8 propose a conceptual framework for CC that includes these two aspects, and four levels of cultural competence are considered: individual , professional , organizational , and social . At each of these levels, the following should be considered: sensitivity to prejudices, knowledge of cultural aspects, and the ability to integrate these aspects into care.Although there are different definitions of CC, it is a multidimensional concept  and multilevel  9 . However, its measurement remains a challenge, which makes it difficult to evaluate the effectiveness of interventions in this field 9 . There are several scales for measuring CC, but aspects associated with their validity 11 have been questioned. On the other hand, several instruments usually highlight the relevance of ethnic and racial aspects over other cultural encounters, which could make its use difficult in other contexts where these factors do not predominantly explain cultural diversity 12 .One of the relevant characteristics of CC is that it can be trained This study aimed to validate a measurement instrument for CC in Chile.13 : (i) item development, (ii) content validity study; (iii) internal structure validity analysis; (iii) reliability estimation and; (iv) bias analysis. The data collection took place in the city of Santiago de Chile during 2018.The development of the Measurement Scale of CC in health care workers in Chile (EMCC-14) considered 8 , we reviewed the literature concerning CC and measurement instruments previously published. The first version of the EMCC-14 had 31 items divided into three theoretical dimensions  9 . The final version of the EMCC-14 has 14 items  participated in it. Each one evaluated the relevance of the 31 initial items using a 3-point Likert-type scale . With this information, the content validity coefficient (CVI) proposed by Lawshe was calculated. It was considered that an item should be retained when the CVI value was ≥ 0.62 Four focus groups were organized with health care workers to find out their perceptions about the ownership and understanding of the items. Of the 31 items initially developed, nine were eliminated. The preliminary version consisted of 22 items and a 5-point Likert answer scale .13 . For this purpose, exploratory (EFA) and confirmatory (CFA) factor analyses were performed.The analysis of the internal structure provides empirical evidence of the way in which the different items are grouped according to the theoretical dimensions proposed 19 , which showed that both were adequate to achieve a power of 0.80 and type error 1 < 0.05.A sample of 483 health care workers was collected. The inclusion criteria was the direct contact with users. The total sample was randomized into two subsamples   . In one20 . EFA were calculated using Weight Least Squeare Mean and Variance Adjusted estimator and Varimax rotation. The number of factors was determined considering 20 : (i) Kaiser’s criterion ; (ii) Scree plot; (iii) theoretical sense of the factor solution. A factor load ≥ 0.3 was considered appropriate and those items with loads ≥ 0.4 on two or more factors were eliminated 20 .The KMO and Bartlett of sphericity test was performed to assess whether the data were susceptible to exploratory factor analysis (EFA) 19 was accepted as a good fit. For the RMSEA, a value close to 0.06 19 was considered and for the WRMR, < 1.0 21 . Since the Chi-square index is susceptible to sample size, the ratio between the model’s chi-square and its degrees of freedom was used. Values < 3.0 suggest an acceptable fit 22 .For confirmatory factor analysis (CFA), the factor structure obtained by EFA was considered. The model fit was evaluated according to different goodness-of-fit indexes: Root mean square error approximation (RMSEA), Standardized root mean square residuals (SRMR), Tucker Lewis index (TLI) and Comparative fit index (CFI). A value of ≥ 0.90 for the CFI and TLI Reliability was determined using Cronbach’s alpha coefficient and calculated for the total scale, for each of its dimensions, and the variations of the coefficient when eliminating items were analyzed. An alpha coefficient value of 0.7 was considered.Given the potential subjectivity of self-report scales, it is relevant to assess whether different groups of respondents understand in the same way both the questions and the response scales, as this can be a cause of measurement bias. Given the differences in the sample size of the different groups of professionals, only the presence of bias was examined among the largest groups: physicians (n = 116) and nurses (n = 217), using Differential Item Functioning Analysis (DIF), and Factor Invariance Analysis (FIA).23 . The dependent variable was the response to each of the items and the independent variables were the membership group and the total score obtained in the instrument . It was stated that there was a bias if: (i) the difference in the fit statistic (chi-square) between models 1 and 3 was significant (p < 0.01) and (ii) the explained percentage variance variation was > 13.0% between the same models.The presence of DIF was determined using a hierarchical ordinal regression model 24 . A new level of invariance was accepted if the difference in CFI in the different comparisons was < 0.01 25 . A scalar level of invariance is expected to affirm that the factor structure is equivalent.The FIA allows determining if the factor structure of the questionnaire is equivalent among the stakeholders (examples: physicians and nurses). To determine the presence of invariance, four successive factor models were estimated  and compared sequentially with each other  using the CFI To facilitate interpretation, the scores of each of the three subscales and the total instrument were scaled to a metric between 0 and 100. Descriptive analyses of the scores obtained were performed. Mann-Whitney U and ANOVA were used for subgroup analysis. Estimates were made in Mplus 8 and SPSS v21.This study is part of the FONIS SA16I0182 project, approved by the Ethics Committee of the South East Metropolitan Health Service in Santiago, Chile, by resolution in July 2017.Data were adequate for factor analysis . The EFA showed that the initial 22 items were grouped into the three proposed theoretical dimensions. When analyzing the reliability for each of the dimensions, two items were identified as negatively affecting the reliability, which, after evaluating their content, were eliminated. The same situation was applied to another item that presented a load > 0.4 on two factors. A new factor analysis with 19 items successfully reproduced three dimensions, explaining 50.8% of the variance   .19 . The model with 14 items and three dimensions showed a good fit . The correlation between sensitivity to own prejudices and the ability to incorporate cultural aspects of users into care was not significant. The other correlations between factors were moderate . Six items were eliminated using the modification rates oderate   .The alpha coefficient for the overall scale was 0.7. For the dimensions of sensitivity, knowledge and skills, it was 0.65, 0.81 and 0.68 respectively.In the DIF analysis, two items were identified that could be interpreted as biased (items 9 and 10). However, the difference in percentage variance explained between models was < 13.0% in both cases. Therefore, none of these items met sufficient statistical criteria to claim that they were biased.In the FIA, the EMCC-14 presented configural, metric and scalar invariance   . The scThe descriptive analysis of the items of the EMCC-14 is found in This study reports on the development and validation of an instrument to measure cultural competence in health care workers in Chile (EMCC-14). The analyses support the validity, reliability and high comparability between the groups with greater participation in the sample (physicians and nurses) of the EMCC-14.11 . The EMCC-14 provides both aspects, in addition to having questions that are representative of the three dimensions of CC . These analyses suggest that both the questions and the response scales of the EMCC-14 can be interpreted in an equivalent manner in both groups and, therefore, their results are comparable.Most CC instruments have been validated in a single group of health care providers 28 . Our prejudices as well as stereotypes towards certain cultural groups are closely related to the way we relate to these groups 11 .A relevant result is the low score achieved by all professionals in the sensitivity dimension. Sensitivity implies being aware of our own prejudices and preconceived notions 29 showed that a training program for health professionals focused on this area, in addition to favoring the development of sensitivity, could positively affect knowledge and skills and favorably impact user satisfaction 29 . This is consistent with our other findings suggesting that increased sensitivity may facilitate knowledge acquisition. In turn, greater knowledge would precede greater skills in delivering culturally competent health care.Improving the sensitivity of professionals is key to achieving CC. Majumdar, Browne, Roberts and Carpio This is the first instrument to measure CC developed in Chile and represents an advance in this issue in the country. One of the strengths of this study is the inclusion of a diverse sample of health providers, from different levels of health care.In addition, this study provides a benchmark of the level of health care worker’s CC, which is a good starting point for intervention, either by developing CC training or adapting programs that have been shown to be effective, which can address the areas of greatest deficit. In addition, the EMCC-14 could be used in the field of research on this topic, thus contributing to addressing health inequalities.Chile has a mixed health system made up of public and private providers. This study only considered a sample of public sector workers of areas of high social vulnerability. Despite this, CC is a new issue in Chile, and it is possible that there are other variables more relevant than administrative dependence that may influence its development. Examples of this are the level of contact of professionals with different populations or individual variables .13 such as user satisfaction or trust in health care providers could also be explored. This could provide evidence for the predictive validity of EMCC. The limitations noted do not affect the validity of the results of this study.In addition to the evidence of the validity and reliability of the EMCC-14 provided in this study, the relationship of the scores of this instrument with other variables EMCC is an instrument that has shown favorable evidence about its validity and reliability to measure the level of CC in different health care workers in Chile. Its availability is transformed into a contribution to the health care, academic training and research fields. 1 , un 12,8% declara pertenecer a algún pueblo indígena1 y el 3,1% de los hombres y 2,3% de las mujeres se identifican con un género distinto a su sexo de nacimiento2 . En el ámbito sanitario, Chile ha comprometido la entrega de cuidados de salud centrados en los pacientes3 . Esto significa, entre otras cosas, atender necesidades particulares de diferentes grupos de la población y brindar un trato libre de discriminación. Para lograr esto, es importante considerar el rol de los aspectos culturales en la relación de las personas con los procesos de salud y enfermedad3 .Chile se ha transformado progresivamente en un país más diverso. El 4,4% de la población es migrante internacional4 . Cuando los aspectos culturales no son considerados en la atención de salud, las interacciones entre pacientes y profesionales son menos centradas en el paciente, más breves, y menos positivas5 . La competencia cultural (CC) en salud se refiere a la reflexión y cuestionamiento permanentes por parte del trabajador de la salud en torno a cómo la cultura -propia y del paciente- impacta en la interacción con los usuarios del sistema de salud6 . CC incluye el compromiso de brindar atención de salud que tenga en cuenta las creencias y comportamientos del paciente.La cultura corresponde a un sistema de marcos conceptuales y esquemas compartidos, utilizados por los miembros de un grupo (o subgrupo) para interpretar la realidad y relacionarse con el mundo que los rodea, incluida su salud8 . Sue y Sue8 proponen un marco conceptual para CC que recoge estos dos aspectos, donde se plantean cuatro niveles de competencia cultural: individual , profesional , organizacional  y social . En cada uno de estos niveles, se debe considerar: la sensibilidad a los prejuicios, el conocimiento de los aspectos culturales y la habilidad para integrar tales aspectos en la atención.Pese a que existen diferentes definiciones de CC, hay consenso en que es un constructo multidimensional  y multinivel 9 . Sin embargo, su medición sigue siendo un desafío, lo cual dificulta evaluar la efectividad de las intervenciones en esta línea9 . Existen varias escalas de medición de CC, sin embargo se han cuestionado aspectos asociados a su validez11 . Por otra parte, varios instrumentos habitualmente remarcan la relevancia de aspectos étnicos y raciales por sobre otros encuentros culturales, lo cual podría dificultar su utilización en otros contextos donde dichos factores no explican de forma predominante la diversidad cultural12 .Una de las características relevantes de la CC es que puede ser entrenadaEl presente estudio tuvo por objetivo validar un instrumento de medición de CC en Chile.13 : (i) desarrollo de ítems, (ii) estudio de validez de contenido; (iii) análisis de validez de estructura interna; (iii) estimación de confiabilidad y; (iv) análisis de sesgo. La recolección de datos tuvo lugar en la ciudad de Santiago de Chile durante 2018.El desarrollo de la Escala de Medición de CC en trabajadores de salud en Chile (EMCC-14) consideró8 , se revisó la literatura en el área de CC e instrumentos de medición publicados previamente. La primera versión del EMCC-14 contó con 31 ítems divididos en tres dimensiones teóricas 9 . La versión final del EMCC-14 cuenta con 14 ítems . Cada uno evaluó la pertinencia de los 31 ítems iniciales mediante una escala tipo Likert de 3 puntos . Con esta información, se estimó el coeficiente de validez de contenido (CVI) propuesto por Lawshe. Se consideró que un ítem debía ser retenido cuando el valor del CVI fuese ≥ 0,62Se realizaron cuatro grupos focales con trabajadores de salud para conocer sus percepciones sobre la pertenencia y comprensión de los ítems. Las características de los participantes están en la De los 31 ítems inicialmente desarrollados, nueve fueron eliminados. La versión preliminar quedó conformada por 22 ítems y una escala de respuesta tipo Likert de 5 puntos .13 . Para esto, se realizó análisis factorial exploratorio (AFE) y confirmatorio (AFC).El análisis de la estructura interna aporta evidencia empírica de la forma en que se agrupan los diferentes ítems de acuerdo a las dimensiones teóricas propuestas19 , la cual mostró que ambas eran adecuadas para alcanzar un poder de 0,80 y error tipo 1 < 0,05.Se recolectó una muestra a conveniencia de 483 trabajadores de salud. El criterio de inclusión fue que estos tuviesen contacto directo con usuarios. La muestra total fue aleatorizada en dos submuestras   . En una20 . Se estimó EFA utilizando Mínimos Cuadrados Ponderados por Media y Varianza y rotación Varimax. El número de factores fue determinado considerando20 : (i) criterio de Kaiser : (ii) análisis del grafico de sedimentación; (iii) sentido teórico de la solución factorial. Se consideró como apropiado una carga factorial ≥ 0,3 y se eliminaron aquellos ítems con cargas ≥ 0,4 en dos o más factores20 .Se realizó la prueba de esfericidad de Bartlett y KMO para evaluar si los datos eran susceptibles de ser sometidos a análisis factorial exploratorio (EFA)( AFC) se consideró la estructura factorial obtenida mediante EFA. El ajuste del modelo se evaluó de acuerdo a diferentes índices de bondad de ajuste: Root mean square error aproximation (RMSEA), Standarized root mean square residuals (SRMR), Tucker Lewis index (TLI) y Comparative fit index (CFI). Se aceptó como buen ajuste un valor ≥ 0,90 para el CFI y TLI19 . Para el RMSEA, se consideró un valor cercano a 0,0619 y para el WRMR, < 1,021 . Dado que el índice de Chi cuadrado es sensible al tamaño muestral, se utilizó la razón entre el chi cuadrado del modelo y sus grados de libertad. Valores < 3,0 sugieren un ajuste aceptable22 .Para el análisis factorial confirmatorio La confiabilidad fue determinada utilizando coeficiente alpha de Cronbach. Se estimó la confiabilidad para la escala total, para cada una de sus dimensiones y se analizaron las variaciones del coeficiente al eliminar ítems. Se consideró como referencia un valor de coeficiente alpha de 0,7.Dada la potencial subjetividad de escalas de autorreporte, es relevante evaluar si los diferentes grupos de examinados comprenden de la misma forma tanto las preguntas como las escalas de respuesta, ya que esto puede ser una fuente de sesgo de medición. Atendiendo a las diferencias en el tamaño muestral de los diferentes grupos de profesionales, solo se examinó la presencia de sesgo entre los grupos de mayor tamaño: médicos (n = 116) y enfermeras (n = 217), utilizando Análisis de Funcionamiento Diferencial de ítems (DIF) y Análisis de Invarianza Factorial (AIF).23 . La variable dependiente fue la respuesta a cada uno de los ítems y las variables independientes fueron el grupo de pertenencia y el puntaje total obtenido en el instrumento . Se afirmó que existía sesgo si: (i) la diferencia en el estadístico de ajuste (chi cuadrado) entre los modelos 1 y 3 era significativa  y (ii) la variación del porcentaje de varianza explicada era > 13,0% entre los mismos modelos.La presencia de DIF se determinó utilizando un modelo jerárquico de regresión ordinal24 . Se aceptó un nuevo nivel de invarianza si la diferencia de CFI en las distintas comparaciones era < 0,0125 . se espera un nivel de invarianza escalar para afirmar que la estructura es equivalente.El AIF permite determinar si la estructura factorial de cuestionario es equivalente entre los grupos de interés (ejemplos médicos y enfermeras). Para determinar la presencia de invarianza, se estimaron cuatro modelos factoriales sucesivos  y se compararon secuencialmente entre sí  utilizando el CFIPara facilitar la interpretación, se escalaron los puntajes de cada una de las tres subescalas y del instrumento total a una métrica entre 0 y 100. Se realizaron análisis descriptivos de los puntajes obtenidos. Se utilizó U de Mann-Whitney y ANOVA para el análisis de subgrupos. Las estimaciones se realizaron en Mplus 8 y SPSS v21.Este trabajo es parte del proyecto FONIS SA16I0182, el cual fue aprobado por el Comité de ética del Servicio de Salud Metropolitano Sur Oriente en Santiago de Chile, mediante resolución de Julio de 2017.Los datos resultaron adecuados para realizar análisis factorial . El AFE mostró que los 22 ítems iniciales se agruparon en las tres dimensiones teóricas propuestas. Al analizar la confiabilidad para cada una de las dimensiones, se identificaron dos ítems que afectaban negativamente la confiabilidad, los cuales, tras evaluar su contenido, fueron eliminados. La misma situación se aplicó a otro ítem que presentó una carga > 0,4 en dos factores. Un nuevo análisis factorial con 19 ítems, reprodujo exitosamente tres dimensiones, explicando el 50,8% de la varianza   .19 , se eliminaron seis ítems. El modelo con 14 ítems y tres dimensiones mostró un buen ajuste . La correlación entre los factores no fue significativa para la relación entre sensibilidad a los propios prejuicios y las habilidades para incorporar aspectos culturales de los usuarios en la atención. Las otras correlaciones entre factores fueron moderadas . Utilizando los índices de modificaciónderadas   .El coeficiente alpha para la escala global fue de 0,7. Para las dimensiones de sensibilidad, conocimiento y habilidades fue 0,65, 0,81 y 0,68 respectivamente.En el análisis de DIF, se identificaron dos ítems susceptibles de ser interpretados como sesgados (ítems 9 y 10). Sin embargo, la diferencia en el porcentaje de varianza explicada entre modelos fue < 13,0% en ambos casos. Por lo tanto, ninguno de estos ítems reunió criterios estadísticos suficientes para afirmar que se encontraban sesgado.En el AIF la EMCC-14 presentó invarianza configural, métrica y escalar   . Es decEl análisis descriptivo de los ítems del EMCC-14 se encuentra en la El presente estudio da cuenta del desarrollo y validación de un instrumento para medir competencia cultural en trabajadores de salud en Chile (EMCC-14). Los análisis apoyan la validez, confiabilidad y alta comparabilidad entre los grupos con mayor participación en la muestra (médicos y enfermeras) del EMCC-14.11 . El EMCC-14 da cuenta de ambos aspectos, sumado a contar con preguntas representativas de las tres dimensiones de la CC 8 .La mayoría de los cuestionarios existentes para medir CC entregan alguna evidencia de validez de contenido. Sin embargo, muchos de ellos no poseen análisis psicométricos apropiados26 . Sumado a lo anterior, la distinción empírica alcanzada de los constructos de sensibilidad, conocimiento y habilidades distingue a este estudio de otros previamente publicados27 , donde se presenta un número mayor de dimensiones y los constructos que estas representan tienden a superponerse.Por otra parte, mediante el AFC, se aportó evidencia de validez discriminante. Las tres dimensiones medidas constituyen constructos distintos pero complementarios entre sí, lo cual se ve reflejado en que la correlación entre los diferentes factores es adecuada y en que cada uno de los ítems se relaciona exclusivamente con una dimensión teórica. En el análisis de correlación entre factores, se encontró asociación entre sensibilidad y conocimiento, y entre conocimiento y habilidades. Eso podría sugerir que trabajar sobre la sensibilidad a los propios prejuicios sería un buen precursor de CC, tal como ha sido propuesto en la literatura27 .El EMCC-14 muestra una adecuada consistencia interna. Sin embargo, dos de las subescalas obtuvieron una confiabilidad ligeramente baja 0,7, lo cual podría ser explicado por el reducido número de ítems en cada una de ellas. Pese a esto, los índices obtenidos son comparables con los de otros instrumentos en esta área28 . Este trabajo, además de incluir una muestra diversa de profesionales, evaluó la presencia estadística de sesgo entre los grupos con mayor representación en nuestra muestra (médicos y enfermeras). Estos análisis sugieren que tanto las preguntas, como las escalas de repuesta del EMCC-14 pueden ser interpretadas de forma equivalente en ambos grupos y, por lo tanto, sus resultados son comparables.La mayoría de los instrumentos de CC han sido validados en un único grupo de proveedores de salud28 . Nuestros prejuicios así como los estereotipos hacia ciertos grupos culturales se relacionan estrechamente con la forma en que nos relacionamos con dichos grupos11 .Un resultado relevante es el bajo puntaje alcanzado por todos los profesionales en la dimensión de sensibilidad. La sensibilidad implica ser conscientes de nuestros propios prejuicios y nociones preconcebidas29 mostraron que un programa de entrenamiento para profesionales de salud enfocado en esta área, además de favorecer el desarrollo de sensibilidad, puede afectar positivamente el conocimiento y habilidades e impactar favorablemente la satisfacción de los usuarios29 . Esto es concordante con otros de nuestros hallazgos que sugieren que una mayor sensibilidad podría facilitar la adquisición de conocimiento. A su vez, un mayor conocimiento precedería a mayores habilidades para entregar una atención de salud culturalmente competente.Mejorar la sensibilidad de los profesionales es clave para lograr CC. Majumdar, Browne, Roberts y CarpioEste es el primer instrumento para medir CC desarrollado en Chile y representa un avance en esta temática en el país. Una de las fortalezas de este estudio es la inclusión de una muestra diversa de proveedores de salud, de diferentes niveles de atención en salud.Además, este trabajo entrega una referencia del nivel de CC de trabajadores de salud, lo que constituye un buen punto de partida para intervenir, ya sea desarrollando entrenamiento en CC o adaptando programas que han demostrado ser efectivos, que puedan abordar las áreas más deficitarias. Además, el EMCC-14 podría ser utilizado en el campo de la investigación en este tema, aportando así en el abordaje de las desigualdades en salud.Chile posee un sistema mixto de salud conformado por prestadores públicos y privados. Este estudio solo consideró una muestra de trabajadores del sector público que se desempeñan en áreas de alta vulnerabilidad social. Pese a esto, la CC es un tema nuevo en Chile y es posible que existan otras variables más relevantes que la dependencia administrativa que puedan influir en su desarrollo. Ejemplos de esto son el nivel de contacto de los profesionales con diferentes poblaciones o variables individuales .13 como satisfacción usuaria o confianza en los prestadores de salud. Esto podría entregar evidencia sobre la validez predictiva del EMCC. Las limitaciones señaladas no afectan la validez de los resultados de este estudio.Además de las evidencias de la validez y confiabilidad del EMCC-14 entregadas en este estudio, también podría ser explorada la relación de los puntajes de este instrumento con otras variablesLa EMCC es un instrumento que ha mostrado poseer evidencia favorable acerca de su validez y confiabilidad para medir el nivel de CC en diferentes trabajadores de salud en Chile. Su disponibilidad se transforma en una contribución en el área asistencial, formación académica e investigación.


To apply the THOR 2 multi-criteria support system to select the Brazilian navy's most suitable hospital care vessel (NAsH) to support the fight against the covid-19 pandemic.We used the first three stages of the Soft Systems Methodology for structuring and modeling of the problem. For the evaluation and ordering of alternatives, we used the Thor 2 multi-criteria support system, comparing four classes of NAsH in the light of their operational and hospital criteria: “Dr. Montenegro,” “Soares Meirelles,” “Oswaldo Cruz” and “Tenente Maximiano.” The chosen ship would support the amazon hospital system, which has an increasing number of cases of covid-19.After the application of the methods, we analyzed three distinct scenarios of ordering the alternatives, which allowed a robust sensitivity analysis, conferring greater transparency and reliability to the decision-making process. The NAsH “Oswaldo Cruz” was selected to be used in the fight against the pandemic.This study brings valuable contribution to academia and society, since it represents the application of a multi-criteria decision-aid method in the state of the art to contribute to the solution of a real problem that affects millions of people in Brazil and worldwide. The new coronavirus disease pandemic (covid-19) apparently represents the biggest and fastest challenge for public health systems in decades. As the virus and its impact spread, health systems around the world respond with large-scale protection measures and resource reallocation to contain its advanceThe international dissemination of cases of covid-19 was rapid and intense due to the facilities of displacement between countries in modern life. This has led these countries authorities to adopt non-pharmaceutical control measures to avoid transmission, such as social isolationAccording to Ozamiz-Etxebarria et al.To reduce the damage associated with covid-19, urgent measures to control infection and public health are necessary to limit the global spread of the virusStudies and recommendations from experts have identified strategies to increase hospital capacity and manage the flow of patients, among which the naval service care stands out. The United States, for example, has used the USNS Comfort, a hospital ship with a capacity of 1,200 bedsAccording to the Brazilian Medical AssociationA NAsH is a ship operated by the Brazilian Navy that can be specially designed, built or eventually adapted to the functions of floating hospital, with periodic passage through the special health centers. These centers are strategic places dedicated for the performance of the NAsH, ensuring medical and dental care, sanitary and health guidance, as well as epidemiological surveillance and fighting the endemic diseases of riverside populationsOur article analyzes four classes of the Brazilian Navy's NAsH; three of which operate in the Amazon Flotilla Command, subordinated to the Command of the 9th Naval District: “Oswaldo Cruz,” composed of two ships – “Oswaldo Cruz” (U18) and “Carlos Chagas” (U19) –; “Dr. Montenegro” (U16); and “Soares Meirelles” (U21). The fourth class – NAsH “Tenente Maximiano” – operates in the Command of the Flotilla of Mato Grosso, subordinated to the 6th Naval District Command (Ladário-MS). We analyze their operational and hospital capacities in the fight against covid-19 to employ them as hospital ships.Given the limited number of beds in specialized units, it is not uncommon to consider early discharge or transfer to less complex units to provide vacancies for more severe casesThe installation of a hospital on board of a NAsH would support the health systems of several municipalities of Amazonas, from the capital Manaus to riverside regions, and even other states. We emphasize the possibility of using aircraft to support the operation of the ship, providing flexibility and speed in the transport of patients.Production engineering becomes a fundamental mechanism in advising managers In the process of making the right decisionOne of the stages of the decision-making process includes problem structuring methods (PSM), which seek to organize themes and issues for which decision proposals are initially drawn up,Among the most commonly used methods, we chose the Soft Systems Methodology (SSM) for our study. Developed by ChecklandIn the third stage, after analysis of the rich picture, four relevant systems were identified: number of infected by the new coronavirus increasing on daily basis without signs of attenuation; collapse of the Amazon health system; possibility of assistance from the Brazilian Navy by the NAsH in the fight against the pandemic; and doubt about which NAsH would be more appropriate as floating hospital, considering that the use of all NAsH in the fight against the pandemic would hinder the provision of basic medical care in several riverside regions, since they often depends exclusively on the Navy hospital ships.After applying the first three stages of SSM, we obtained the criteria that compose the problem. To fulfill the floating hospital mission, the ship must be able to provide assistance to the cities of Amazonas, from the capital Manaus to the riverside regions, that is, it must have great range of action, travel speed and autonomy so that it can provide unrestricted support, in the shortest time possible, to the regions far from its port headquarters, whose access can be difficult, also requiring good maneuverability of the vessel.Regarding hospital capacity, the ship needs to be able to attend to non-contagious diseases, aiming to reduce the demand of the Amazon health system, which would focus only on fighting covid-19. The ship should have as few crew members as possible to have more space available to receive patients and accommodate them in beds that would compose a floating hospital. Moreover, the NAsH must have good capacity to evacuate patients to ground hospital units, either by speedboats or aircraft, providing speed and dynamism in patient care.Based on the parameters presented in the analysis of the rich picture and after consulting Brazilian navy officers with more than 20 years of experience in the area, the following criteria were established:maximum speed: speed corresponding to the maximum power regime of the machines. The maximum speed of a warship is rarely used in peacetime, as it implies increased fuel consumption and unnecessary machine effort;radius of action: maximum distance, in nautical miles, that the ship can reach when leaving its base and returning to it without refuel;crew: set of hierarchically organized persons that ensure ship operation. A larger crew decreases the comfort and autonomy of the vessel when considering the supplies. In our study, we considered that larger crews are more disadvantageous;maneuverability: composition between the length and the ability of the ship to move, notably, in this case, when entering and docking in ports of smaller cities, with low depth and narrow space for maneuver, in addition to smaller piers;patient evacuation capacity: capacity of transferring patients, for medical reasons, to a health organization, or from the organization to the ship, either by smaller vessels (organic boats) or in aeromedical evacuation activities, extremely important for the efficient performance of a hospital ship, since they provide flexibility and speed in the transportation and care of patients; andhospital capacity: considers the types of medical care available, such as operating rooms and intensive care units (ICU), and the capacity of increasing the number of beds by installing a floating hospital.Autonomy would be an extremely important criterion for the proposed analysis; however, since all ships evaluated have very similar values (in days), this criterion will not compose the problem.The THOR method is based on three axiomatic concepts/theories for simultaneous use: preference modeling (approaching the French school – non-compensatory model), multi-attribute utility theory (bringing it closer to the American school – compensatory model) and theories that deal with inaccurate information. The combination of these theories allows quantifying the attractiveness of each alternative by creating a non-transitive aggregation functionAccording to Gomesa hybrid algorithm that encompasses concepts of the rough set theory (RST), fuzzy set theory (FST), utility theory and preference modeling;classification of discrete alternatives in transitive or non-transitive decision-making processes;elimination of redundant criteria, considering the possibility of duality in information using RST and inaccuracy in the decision-making process using FST.quantification of inaccuracy, using it in the multi-criteria decision-aid method;simultaneous entry of data from different decision makers, enabling them to express their value judgment(s) on a scale of reasons, intervals or ordinal;the possibility of decision-makers to work without assigning weights to such criteria if they are not able to, since they can use a resource that assigns weights to the criteria on an ordinal scale, which allows classifying THOR, therefore, as cardinal and partially ordinal method;elimination of the need to assign a value, usually arbitrary for agreement, according to some algorithms that have preference modeling as the basis.To apply the methodology, the decision-maker must weigh the relative importance between the criteria, establish a limit of preference (p) and indifference (q) for each criterion (j), establish the disagreement and pertinence of the values of the weights attributed to each criterion, as well as the pertinence of the classification of the alternative in criterionGiven the inaccuracy and the lack of security in the judgment of the values used in the multi-criteria decision-aid methods, we think it is necessary to quantify the inaccuracy for each weight and each classification of alternatives. Decision-makers must express the levels of certainty through index of pertinence, associating a real number of the range with an element of the universe . A pertinence index equal to 1 corresponds to absolute certainty, that is, the decision-maker is certain of the weight attributed to the criterion, whereas a pertinence index equal to 0 indicates absolute uncertainty. Two pertinence indices are used to reflect the degree of uncertainty of decision-makers, one referring to the weights of the criteria and the other to the classification of alternatives in each criterion1, S2 e S3. When using the S1 algorithm, the alternatives only have their attractiveness punctuated when aPjb occurs. Index j represents each criterion analyzed. Thus, comparing the alternative “a” with the “b,” we identify the criteria in which aPjb occurs, considering the preference limits , indifference (I designates indifference) and disagreement, verifying if the imposed condition is met. If satisfied, it is known that “a” dominates “b.” The ratios P, I and Q are expressed in Given two alternatives, “a” and “b,” three situations should be considered when using THOR: SThe notation “g(a)” represents the performance  of the alternative “a” in a given criterion.2 algorithm, the alternatives only have their attractiveness punctuated when both aPjb and aQjb occurs. Using the S3 algorithm, the alternatives only have their attractiveness punctuated when aPjb, aQjb and aIjb occurs. In the algorithms S2 and S3, we see a more flexible scenario, in which a smaller difference between the alternatives allows classifying an alternative as better than the otherUsing the S1 and S2,THOR is recommended preferably in situations of pseudocriteria and quasi-criterion since the method can be used at its full capacity. The use of THOR in situations of true criterion, when the values of p and q assume a value equal to zero, leads to the equality of the orders corresponding to SAmong its main contributions, we emphasize the application of the THOR multi-criteria system in waste recycling in Braziljb situation, deteriorating the gain only in this case. THOR 2 is an evolution of the original THOR method, which also includes punctuation depreciation in situations of strong preference and indifference. Thus, THOR 2 represents a significant contribution since it quantifies all the uncertainty present in the attribution of the classifications of alternatives and weights.THOR only considers the multiplication by the index in the aQ–To support our study, we conducted a literature research to obtain the operational and hospital data of each vessel. Many data are confidential, since NAsH are military ships; therefore, we used only the parameters available in official sources of the Brazilian Navy–Data were also collected in academic articles that address the performance of NAsH in civic-social actionsThe values of weights, preference limits (p), limits of indifference (q) and disagreement for each criterion were attributed by joint analysis with specialists in the area.Using the data from 1, the four ships obtained exactly the same score. Therefore, we could not conclude which ship would be the best to the mission.In situation S2, which considers the overclassification ratios aPjb and aQjb to dominance, the NAsH “Oswaldo Cruz” had a slightly higher sum than “Soares Meirelles,” being mathematically the best ship in the proposed analysis. However, in practice, the two can be considered technically even due to the extremely small relative difference between them (0.167). Also in scenario S2, it is observed that the NAsH “Tenente Maximiano” and “Dr. Montenegro” presented the lowest scores, with higher relative differences when compared with the two best classified ships and can be discarded from the selection process.In algorithm S3 algorithm, the most flexible situation, the NAsH “Oswaldo Cruz” obtained again the highest score, but with a more considerable relative difference to the second place, which confirms its choice as the most appropriate ship to be used in the fight against the pandemic.Regarding STherefore, we obtained the following final classification: first, NAsH “Oswaldo Cruz; second, NAsH “Soares Meirelles”; third, NAsH “Tenente Maximiano”; and fourth, NAsH “Dr. Montenegro.”Evaluating the reasons that led to the final classification of the alternatives, we observe that “Oswaldo Cruz” and “Soares Meirelles” obtained the two best results due to the highest evacuation and hospital capacities, respectively – the two criteria with greater weight (4) assigned by the specialists in the proposed analysis. The “Soares Meirelles” obtained the highest score in three of the six criteria evaluated; however, it did not obtain good grades in the other criteria. The “Oswaldo Cruz,” in turn, obtains the highest score only in the evacuation capacity, maintaining regularity in the other criteria, thus becoming the most indicated ship. The capacity of operating with aircraft may have been the differential factor for choosing the NAsH “Oswaldo Cruz,” making it obtain the highest note of evacuation capacity and with greater relative distance.Therefore, we have clearly achieved our objective by pointing out the NAsH “Oswaldo Cruz” as the most appropriate ship for fighting the pandemic in the Amazon. THOR 2 method can notably be used to solve real problems of the most varied types – tactical, operational and strategic – thus being a very useful method for decision making.Moreover, the ease, flexibility, reliability and speed of application of the method can greatly facilitate the often complicated calculations that involve multi-criteria decision aid.Finally, we suggest this model of ordering alternatives using THOR 2 to be further applied in the health area. A nova pandemia de doença do coronavírus (covid-19) aparentemente representa o maior e mais rápido desafio para os sistemas de saúde pública em décadas. À medida que o vírus e seu impacto se espalham, os sistemas de saúde em todo o mundo respondem com medidas de proteção em grande escala e realocação de recursos para tentar conter seu avançoDevido às facilidades de deslocamento entre países na vida moderna, a disseminação internacional de casos de covid-19 foi rápida e intensa. Isso tem levado as autoridades a adotar medidas de controle não medicamentoso de transmissão, como isolamento socialDe acordo com Ozamiz-Etxebarria et al.Para diminuir os danos associados à covid-19 são necessárias medidas urgentes de controle de infecção e saúde pública para limitar a propagação global do vírusPesquisas e recomendações de especialistas identificaram estratégias para aumentar a capacidade hospitalar e gestão do fluxo de pacientes, dentre as quais se destaca o atendimento naval de pacientes. Os Estados Unidos, por exemplo, têm usado o USNS Comfort, navio-hospital com capacidade para 1.200 leitosDe acordo com a Associação Médica BrasileiraUm NAsH é um tipo de navio operado pela Marinha brasileira que pode ser especialmente projetado, construído ou eventualmente adaptado para as funções de hospital flutuante, com passagem periódica pelos denominados polos de saúde. Estes polos são locais estratégicos para a atuação dos NAsH, assegurando assistência médica e odontológica e orientação sanitária e de saúde, além de vigilância epidemiológica e combate às endemias das populações ribeirinhasNeste artigo são analisadas quatro classes de NAsH da Marinha do Brasil, das quais três operam no Comando da Flotilha do Amazonas, subordinada ao Comando do 9° Distrito Naval: “Oswaldo Cruz”, composta por dois navios – “Oswaldo Cruz” (U18) e “Carlos Chagas” (U19) –; “Dr. Montenegro” (U16); e “Soares Meirelles” (U21). A quarta classe – NAsH “Tenente Maximiano” – opera no Comando da Flotilha de Mato Grosso, subordinada ao Comando do 6° Distrito Naval (Ladário-MS). Propõe-se analisar suas capacidades operativas e hospitalares no combate à covid-19 visando empregá-los como navios-hospitais.Dado o limitado número de leitos em unidades especializadas, não é raro que se considerem alta precoce ou transferência para unidades menos complexas a fim de disponibilizar vagas para casos mais gravesA instalação de um HCamp a bordo de um NAsH possibilitaria apoiar os sistemas de saúde de diversos municípios do Amazonas, desde a capital Manaus até regiões ribeirinhas, e de outros estados. Outro ponto importante a ressaltar é a possibilidade de utilizar aeronaves no apoio à operação do navio, fornecendo flexibilidade e celeridade no transporte de pacientes.No processo para tomar a decisão correta, a engenharia de produção se torna mecanismo fundamental no assessoramento dos gestoresProblem Structuring Methods), que buscam organizar temas e perguntas para os quais são inicialmente elaboradas propostas de decisãoUma das etapas do processo de tomada de decisão compreende os métodos de estruturação de problemas . Desenvolvida por Checklandbrainstorming para demonstrar as percepções do grupo sobre todas as informações possíveis, sem interferências ou julgamentos para definir o problema. No segundo estágio foi construída uma figura rica  ou em atividades de evacuação aeromédica, extremamente importantes para a atuação eficiente de um navio-hospital, pois proporcionam flexibilidade e celeridade no transporte e atendimento de pacientes; ecapacidade hospitalar: considera os tipos de atendimento médico disponíveis, como salas de cirurgia e unidades de terapia intensiva (UTI), e a capacidade de ampliar o número de leitos por meio da instalação de um HCamp a bordo.Para a análise proposta, um critério extremamente importante seria a autonomia, mas como todos os navios avaliados apresentam valores (em dias) muito semelhantes, esse critério não comporá o problema.O método THOR baseia-se em três conceitos axiomáticos/teorias para uso simultâneo: modelagem de preferência (aproximando-o da escola francesa – modelo não compensatório), teoria da utilidade multiatributo (aproximando-o da escola americana – modelo compensatório) e teorias que tratam da informação imprecisa. A utilização conjunta destas teorias permite quantificar a atratividade de cada alternativa ao criar uma função de agregação não transitivaSegundo Gomesapresentar um algoritmo híbrido que engloba conceitos da teoria dos conjuntos aproximativos (TCA), teoria dos conjuntos nebulosos (TCN), teoria da utilidade e modelagem de preferências;ordenar alternativas discretas em processos decisórios transitivos ou não;eliminar critérios redundantes, levando em conta se há dualidade na informação por meio da TCA e se ocorre imprecisão no processo decisório mediante a utilização da TCN.quantificar a imprecisão, utilizando-a no método de apoio multicritério à decisão;permitir a entrada de dados simultâneos de diferentes decisores, possibilitando que expressem seu(s) juízo(s) de valor em escala de razões, intervalos ou ordinal;viabilizar que os decisores, caso não sejam capazes de atribuir pesos a tais critérios, trabalhem sem fazê-lo, uma vez que podem usar um recurso que atribui pesos aos critérios em escala ordinal, o que permite classificar o THOR, portanto, como método cardinal e parcialmente ordinal;eliminar a necessidade de atribuição de um valor, normalmente arbitrário para a concordância, conforme alguns algoritmos que têm a modelagem de preferências como base.Para aplicar a metodologia é necessário que o decisor represente a importância relativa entre os critérios na forma de um peso, estabeleça um limite de preferência (p) e de indiferença (q) para cada critério j, estabeleça a discordância e a pertinência dos valores dos pesos atribuídos a cada critério, assim como a pertinência da classificação da alternativa no critérioDiante da falta de segurança e da imprecisão no julgamento de valor empregado nos métodos de apoio multicritério à decisão, faz-se necessário quantificar a imprecisão para cada peso e para cada classificação das alternativas. Os decisores devem expressar os níveis de certeza por meio de índices de pertinência, associando a um elemento do universo um número real do intervalo . Um índice de pertinência igual a 1 corresponde a absoluta certeza, ou seja, o decisor está plenamente seguro do peso atribuído ao critério, enquanto um índice de pertinência igual a 0 indica absoluta incerteza. Utilizam-se dois índices de pertinência para refletir o grau de incerteza dos tomadores de decisão, um deles referindo-se aos pesos dos critérios e o outro à classificação das alternativas em cada critério1, S2 e S3. Na utilização do algoritmo S1, as alternativas só têm sua atratividade pontuada em situações nas quais ocorre aPjb. O índice j representa cada critério analisado. Desta forma, comparando a alternativa “a” com a “b”, identificam-se os critérios em que ocorre aPjb, levando em consideração os limites de preferência , indiferença (I designa indiferença) e discordância, verificando se a condição imposta é satisfeita. Se for satisfeita, sabe-se que “a” domina “b”. As relações P, I e Q estão expressas nas Dadas duas alternativas, “a” e “b”, três situações devem ser consideradas na utilização do THOR: SA notação “g(a)” representa o desempenho  da alternativa “a” em um determinado critério.As 2, as alternativas têm sua atratividade pontuada em situações nas quais ocorre aPjb e aQjb. Já na utilização do algoritmo S3, as alternativas têm sua atratividade pontuada em situações nas quais ocorre aPjb, aQjb e aIjb. Nos algoritmos S2 e S3, verifica-se um cenário mais flexível, no qual uma menor diferença entre as alternativas permite classificar uma alternativa como melhor que a outraNa utilização do algoritmo S1 e S2,Recomenda-se que o THOR seja utilizado preferencialmente em situações de pseudocritério e quase-critério, uma vez que o método pode ser utilizado em sua capacidade total. A utilização do THOR em situações de verdadeiro critério, quando os valores de p e q assumem valor igual a zero, leva à igualdade dos ordenamentos correspondentes a SEntre suas principais contribuições, destacam-se a aplicação do método multicritério THOR na reciclagem de resíduos no Brasiljb, deteriorando o ganho apenas nesse caso. O THOR 2 é uma evolução do método THOR original, que inclui também a depreciação da pontuação nas situações de preferência forte e indiferença. Dessa forma, o THOR 2 representa uma significativa contribuição, uma vez que toda a incerteza presente na atribuição das classificações das alternativas e dos pesos é quantificada.O THOR leva em consideração apenas a multiplicação pelo índice na situação aQ–Para viabilizar este estudo foi realizada pesquisa de literatura para obter os dados operativos e hospitalares de cada navio analisado. Por se tratar de navios militares, muitos dados são sigilosos, e portanto foram utilizados apenas parâmetros disponibilizados em fontes oficiais e ostensivas da Marinha do Brasil–Foram coletados também dados em artigos acadêmicos que abordam a atuação dos NAsH em ações cívico-sociaisA Os valores de pesos, limites de preferência (p), limites de indiferença (q) e discordância para cada critério foram atribuídos por análise conjunta com especialistas da área.Utilizando-se os dados apresentados na 1, os quatro navios obtiveram exatamente a mesma pontuação, não sendo possível concluir qual seria o melhor navio para cumprir a missão.Na situação S2, que considera as relações de sobreclassificação aPjb e aQjb para ocorrer a dominância, observa-se que o NAsH “Oswaldo Cruz” apresenta soma ligeiramente superior ao “Soares Meirelles”, sendo matematicamente o melhor navio na análise proposta. Entretanto, na prática, os dois podem ser considerados tecnicamente empatados, pois a diferença relativa entre eles é extremamente pequena . Ainda no cenário S2, observa-se que os NAsH “Tenente Maximiano” e “Dr. Montenegro” apresentaram as menores notas, com diferenças relativas maiores em relação aos dois mais bem classificados, podendo ser descartados do processo de escolha.Ao analisar o algoritmo S3, a situação mais flexível, nota-se que o NAsH “Oswaldo Cruz” novamente obteve a maior soma, dessa vez com uma diferença relativa mais considerável para o segundo colocado, o que confirma sua escolha como o navio mais adequado a ser empregado no combate à pandemia.Com relação ao algoritmo SPortanto, chega-se à seguinte classificação final: em primeiro lugar, NAsH “Oswaldo Cruz; em segundo, NAsH “Soares Meirelles”; em terceiro, NAsH “Tenente Maximiano”; e em quarto, NAsH “Dr. Montenegro”.Avaliando os motivos que levaram à classificação final das alternativas, é possível observar que “Oswaldo Cruz” e “Soares Meirelles” obtiveram os dois melhores resultados porque apresentam as maiores capacidades de evacuação e hospitalar, respectivamente – os dois critérios com maior peso (4) atribuído pelos especialistas na análise proposta. Indo um pouco mais além, observa-se que o “Soares Meirelles” obtém a maior nota em três dos seis critérios avaliados, mas não apresenta boas notas nos restantes. Já o “Oswaldo Cruz” (o primeiro colocado) obtém a maior nota somente na capacidade de evacuação, porém mantém regularidade nos outros critérios, levando-o a ser o navio mais indicado. Talvez o fator primordial para a escolha do “Oswaldo Cruz” seja o fato de ser o único navio dentre as alternativas capaz de operar com aeronave, fazendo com que obtenha a maior nota da capacidade de evacuação e com maior distância relativa.Em face do exposto, fica claro que o objetivo deste artigo foi atingido ao apontar o NAsH “Oswaldo Cruz” como o mais adequado para o combate à pandemia no Amazonas. Ressalta-se que o método THOR 2 pode ser utilizado para resolver problemas reais dos mais variados tipos – táticos, operacionais e estratégicos –, sendo assim um método de grande utilidade para a tomada de decisão.Além disso, a facilidade, flexibilidade, confiabilidade e rapidez de aplicação do método podem facilitar sobremaneira os cálculos, muitas vezes complicados, que envolvem o apoio multicritério à decisão.Por fim, sugere-se que este modelo de ordenação de alternativas usando o THOR 2 pode ser expandido a outras aplicações na área da saúde.


Scientific Reportshttps://doi.org/10.1038/s41598-020-64992-4, published online 19 May 2020Correction to: The Acknowledgements section in this Article is incomplete.“The authors would like to thank CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - for financial support and schorlarship for Andrea Latanza Gomes Mathez, and FAPESP for research funding.”should read:“The authors would like to thank CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - for financial support and scholarship for Andrea Latanza Gomes Mathez, and FAPESP (14/06597-2) for research funding.”