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ORIGINAL ARTICLE12-04-2023
Work-related stress among nurses in the COVID-19 pandemic: What are the contributing factors?
- Tita Rohita
, - Nursalam Nursalam ,
- Muhammad Hadi ,
- Iqbal Pramukti ,
- Dedeng Nurkholik , [ … ],
- Ika Adelia Susanti
Abstract
ORIGINAL ARTICLEWork-related stress among nurses in the COVID-19 pandemic: What are the contributing factors?
Revista Brasileira de Enfermagem. 2023;76:e20220586
DOI 10.1590/0034-7167-2022-0586
- Tita Rohita ,
- Nursalam Nursalam ,
- Muhammad Hadi ,
- Iqbal Pramukti ,
- Dedeng Nurkholik ,
- Arifah Septiane ,
- Idyatul Hasanah ,
- Ika Adelia Susanti
Views0See moreABSTRACT
Objective:
To analyze the contributing factors of work-related stress among nurses in the COVID-19 pandemic.
Methods:
A cross-sectional study was conducted with 101 nurse practitioners from two hospitals in West Java, Indonesia. We distributed an online questionnaire to evaluate work-related stress and the data were analyzed using ordinal logistic regression.
Results:
More than half of the nurses experienced moderate work-related stress. The study revealed that nurses aged over 35 years old had a lower likelihood of experiencing work-related stress (AOR: 0.173; 95%CI: 0.038-0.782). Married nurses had a higher likelihood (AOR: 7.156; 95% CI: 1.456-35.163). Additionally, nurses with low and moderate workloads had a lower likelihood (AOR: 0.003; 95%CI: 0.000-0.051) and (AOR: 0.025; 95%CI: 0.005-0.116), respectively.
Conclusion:
The consideration of age, marital status, and workload is essential in effectively addressing work-related stress among nurse practitioners.
- Tita Rohita
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ORIGINAL ARTICLE12-04-2023
Incidence and risk factors of pressure injuries in critically ill patients with COVID-19
- Aline de Oliveira Ramalho ,
- Rodrigo Augusto Gonçalves Fonseca ,
- Eliane Mazócoli ,
- Alessandra Marin ,
- Paula Cristina Nogueira
Abstract
ORIGINAL ARTICLEIncidence and risk factors of pressure injuries in critically ill patients with COVID-19
Revista Brasileira de Enfermagem. 2023;76:e20220553
DOI 10.1590/0034-7167-2022-0553
- Aline de Oliveira Ramalho ,
- Rodrigo Augusto Gonçalves Fonseca ,
- Eliane Mazócoli ,
- Alessandra Marin ,
- Paula Cristina Nogueira
Views0See moreABSTRACT
Objective:
to analyze pressure injury (PI) incidence and risk factors in patients with COVID-19 admitted to an Intensive Care Unit and characterize the identified PIs.
Method:
a retrospective cohort study, consisting of 668 patients, carried out between March 2020 and February 2021. Clinical/demographic and PI variables were collected from medical records and electronic database. Data were analyzed using descriptive and inferential statistics. Logistic regression was performed to analyze risk factors for PI.
Results:
PI incidence was 30.2% (n=202), with the majority located in the sacral region (52.9%) and in stage 1 (39%). Risk factors were age (p<0.001), Diabetes Mellitus (p=0.005), length of stay (p<0.001), immunosuppression (p=0.034), nutritional risk (p=0.015) and mechanical ventilation (p<0.001).
Conclusion:
PI incidence in critically ill patients with COVID-19 was high.
- Aline de Oliveira Ramalho
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12-04-2023
La ética de la atención de enfermería a las personas transgénero
Revista Brasileira de Enfermagem. 2023;76:e20220797
Abstract
La ética de la atención de enfermería a las personas transgénero
Revista Brasileira de Enfermagem. 2023;76:e20220797
DOI 10.1590/0034-7167-2022-0797es
Views0See moreRESUMEN
Objetivos:
debatir sobre aspectos éticos en la atención de enfermería a personas transgénero.
Métodos:
estudio reflexivo fundamentado sobre los dilemas que se plantean en los cuidados de enfermería a personas transgénero. El relato se ha estructurado en torno a los cuatro principios bioéticos.
Resultados:
la atención sanitaria a las personas trans es compleja, transversal a muchos dispositivos y especialidades y longitudinal en el tiempo por lo que precisa de la actuación coordinada. Existe un marco ético en el que se encuadran los cuidados de enfermería que se precisan en la atención a este colectivo.
Consideraciones Finales:
la enfermera como agente de salud puede asumir diversas líneas generales en la atención a pacientes transgénero. Para ello, se debe brindar formación adicional no solo a los profesionales, también a los estudiantes de enfermería y de las demás ciencias de la salud.
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ORIGINAL ARTICLE12-04-2023
Working conditions in nursing in the face of Covid-19 from the perspective of precariousness
- Ana Paula Nogueira de Magalhães ,
- Diego de Oliveira Souza ,
- Fernanda Pereira de Macêdo ,
- Sabrina Ângela França da Silva Cruz ,
- Camila Pereira-Abagaro , [ … ],
- Roselia Arminda Rosales-Flores
Abstract
ORIGINAL ARTICLEWorking conditions in nursing in the face of Covid-19 from the perspective of precariousness
Revista Brasileira de Enfermagem. 2023;76:e20220679
DOI 10.1590/0034-7167-2022-0679
- Ana Paula Nogueira de Magalhães ,
- Diego de Oliveira Souza ,
- Fernanda Pereira de Macêdo ,
- Sabrina Ângela França da Silva Cruz ,
- Camila Pereira-Abagaro ,
- Roselia Arminda Rosales-Flores
Views0See moreABSTRACT
Objective:
To investigate working conditions in nursing when facing the Covid-19 pandemic, in light of aspects of precarious work.
Methods:
Cross-sectional study, with 131 nursing workers who worked against Covid-19 in hospitals in Alagoas State, Northeast Brazil. Data were collected online, using a workers’ health assessment questionnaire. The Chi -Square or Fisher’s Exact test and logistic regression were used.
Results:
among nursing workers, 71% had precarious contracts, 33.6% reported extended working hours and 23.7% were union members. In the multivariable analysis, having little hospital experience was a predictor for poor employment (OR= 2.408; 95%CI= 1.051-5.518). The predictor variables for lengthening the working day were being a nurse (OR= 3.824; 95%CI= 1.274-11.483); overtime (OR= 3.668; 95%CI= 1.009-13.333) and inadequate number of workers (OR= 10.872; 95%CI= 3.409-34.675). Being a nursing technician was a predictor of being a union member (OR= 8.967; 95%CI=2.560-31.410).
Conclusions:
The pandemic has accentuated the precariousness of working conditions in nursing professionals, especially among nurses.
- Ana Paula Nogueira de Magalhães
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12-04-2023
Estresse laboral entre enfermeiros na pandemia de COVID-19: Quais são os fatores contribuintes?
- Tita Rohita ,
- Nursalam Nursalam ,
- Muhammad Hadi ,
- Iqbal Pramukti ,
- Dedeng Nurkholik , [ … ],
- Ika Adelia Susanti
Abstract
Estresse laboral entre enfermeiros na pandemia de COVID-19: Quais são os fatores contribuintes?
Revista Brasileira de Enfermagem. 2023;76:e20220586
DOI 10.1590/0034-7167-2022-0586
- Tita Rohita ,
- Nursalam Nursalam ,
- Muhammad Hadi ,
- Iqbal Pramukti ,
- Dedeng Nurkholik ,
- Arifah Septiane ,
- Idyatul Hasanah ,
- Ika Adelia Susanti
Views0See moreRESUMEN
Objetivo:
Analizar los factores contribuyentes del estrés laboral entre enfermeros en la pandemia de COVID-19.
Métodos:
Estudio transversal realizado con 101 enfermeros de dos hospitales de Java Occidental, Indonesia. Se distribuyó un cuestionario en línea para evaluar el estrés laboral y los datos se analizaron mediante regresión logística ordinal.
Resultados:
Más de la mitad de los enfermeros experimentaron un estrés laboral moderado. El estudio reveló que los enfermeros mayores de 35 años tenían una menor probabilidad de experimentar estrés laboral (AOR: 0.173; IC95%: 0.038-0.782) y los enfermeros casados tenían una mayor probabilidad (AOR: 7.156; IC95%: 1.456-35.163). Los enfermeros con cargas de trabajo bajas y moderadas tenían una probabilidad menor, (AOR: 0.003; IC95%: 0.000-0.051) y (AOR: 0.025; IC95%: 0.005-0.116), respectivamente.
Conclusión:
Es fundamental considerar la edad, el estado civil y la carga de trabajo para un abordaje eficaz del estrés laboral entre los enfermeros.
- Tita Rohita
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12-04-2023
Fatores que afetam a atitude da comunidade em relação à vacinação contra a COVID-19: estudo transversal
- Chintia Gracelia Amalo ,
- Ezra Amarya Ekaristy ,
- Maretty Wattileo ,
- Martina Pakpahan ,
- Ester Silitonga
Abstract
Fatores que afetam a atitude da comunidade em relação à vacinação contra a COVID-19: estudo transversal
Revista Brasileira de Enfermagem. 2023;76:e20220597
DOI 10.1590/0034-7167-2022-0597
- Chintia Gracelia Amalo ,
- Ezra Amarya Ekaristy ,
- Maretty Wattileo ,
- Martina Pakpahan ,
- Ester Silitonga
Views0See moreRESUMEN
Objetivo:
El objetivo de este estudio fue analizar los factores que afectan la actitud de la comunidad hacia la vacunación contra el COVID-19 en el distrito de Tangerang.
Métodos:
Estudio transversal en el que se utilizó un muestreo por conveniencia para seleccionar a 400 encuestados. Los criterios de inclusión fueron vivir en el distrito de Tangerang, edad 18-55 años y trabajar. Se utilizó un cuestionario en línea, el cual pasó pruebas de validez y confiabilidad. Este estudio recibió aprobación ética.
Resultados:
La mayoría de los encuestados tenía un alto nivel de educación (48,50%), bajos ingresos (72,50%), alto conocimiento (78%) y una actitud positiva (76,50%) respecto a la vacunación contra el COVID-19. La prueba chi-cuadrado reveló una correlación entre el conocimiento y las actitudes hacia la vacunación contra el COVID-19 (p=0,001) y los niveles educativos (p=0,001). No hubo correlación entre los ingresos y las actitudes (p=0,094).
Conclusiones:
Los profesionales de la salud deben realizar una amplia socialización y visitas cara a cara con personas con acceso limitado a la información para promover una actitud positiva y ampliar el alcance de la vacunación contra el COVID-19.
- Chintia Gracelia Amalo
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ORIGINAL ARTICLE11-28-2023
Factors associated with psychopathological symptoms among nurses at a university hospital
- Sheila Janaína Oliveira Araújo Lima ,
- Danielle Christine Moura dos Santos ,
- Maria de Fátima de Souza Santos ,
- Felicialle Pereira da Silva ,
- Darine Marie Rodrigues da Silva , [ … ],
- Jael Maria de Aquino
Abstract
ORIGINAL ARTICLEFactors associated with psychopathological symptoms among nurses at a university hospital
Revista Brasileira de Enfermagem. 2023;76(1):e20220075
DOI 10.1590/0034-7167-2022-0075
- Sheila Janaína Oliveira Araújo Lima ,
- Danielle Christine Moura dos Santos ,
- Maria de Fátima de Souza Santos ,
- Felicialle Pereira da Silva ,
- Darine Marie Rodrigues da Silva ,
- Jael Maria de Aquino
Views0See moreABSTRACT
Objectives:
to analyze the factors associated with psychopathological symptoms among nurses at a university hospital.
Methods:
a cross-sectional study developed at a university hospital in Pernambuco, in which 90 nurses participated. A questionnaire with social and professional characteristics and the Symptom Assessment Scale were used.
Results:
an association was found between the variable changing profession and the presence of characteristic symptoms of psychoticism, somatization and anxiety among nurses.
Conclusions:
the emergence of psychopathological symptoms has influenced nurses’ desire to search for another profession. This evidence reinforces the need for greater investments in better working conditions and welcoming actions in the work environment, in order to provide a better quality of professional life and promote the health of these workers.
- Sheila Janaína Oliveira Araújo Lima
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11-28-2023
O diagnóstico e o tratamento da tuberculose latente por enfermeiros no Brasil: estratégia necessária
Revista Brasileira de Enfermagem. 2023;76(1):e760101
Abstract
O diagnóstico e o tratamento da tuberculose latente por enfermeiros no Brasil: estratégia necessária
Revista Brasileira de Enfermagem. 2023;76(1):e760101
DOI 10.1590/0034-7167.2023760101pt
Views0A prevenção da tuberculose (TB), de impedir a progressão da infecção para a TB ativa, é a principal estratégia para reduzir a sua incidência e para o alcance das metas definidas pela Organização Mundial da Saúde, conforme a estratégia End TB().O Brasil, que ocupa a 19ª posição quanto ao número de casos, assumiu seu compromisso […]See more
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ORIGINAL ARTICLE10-21-2019
Child and adolescent violence: oral story of women who attempted suicide
- Cíntia Mesquita Correia ,
- Nadirlene Pereira Gomes ,
- Normélia Maria Freire Diniz ,
- Isabela Carolyne Sena de Andrade ,
- Cátia Maria Costa Romano , [ … ],
- Gilmara Ribeiro Santos Rodrigues
Abstract
ORIGINAL ARTICLEChild and adolescent violence: oral story of women who attempted suicide
Revista Brasileira de Enfermagem. 2019;72(6):1450-1456
DOI 10.1590/0034-7167-2017-0814
- Cíntia Mesquita Correia ,
- Nadirlene Pereira Gomes ,
- Normélia Maria Freire Diniz ,
- Isabela Carolyne Sena de Andrade ,
- Cátia Maria Costa Romano ,
- Gilmara Ribeiro Santos Rodrigues
Views0See moreABSTRACT
Objective:
To unveil expressions of intrafamily violence experienced in childhood and/or adolescence by women who attempted suicide.
Method:
This is a study with a qualitative approach based on Oral Story. Participants were ten women with a history of suicide attempt, who experienced intrafamily violence in childhood and/or adolescence. The research was carried out at the Center for the Study and Prevention of Suicide, linked to a Toxicological Information Center in the city of Salvador, Bahia, Brazil.
Results:
From the orality of women, the study allowed the emergence of the following representative categories of intrafamily abuse experienced in childhood and/or adolescence: psychological violence, rejection, neglect, physical violence and sexual violence.
Final considerations:
The study alerts to intrafamily violence as an aggravation related to suicidal behavior, offering elements that help in the identification of their expressions, which will raise awareness to suicidal behavior and consequently suicide prevention.
- Cíntia Mesquita Correia
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ORIGINAL ARTICLE07-08-2020
Cognition and quality of life relationship among the elderly community: a cross-sectional study
- Barbara Maria Lopes da Silva Brandão ,
- Alice Maria Barbosa da Silva ,
- Rafaella Queiroga Souto ,
- Fabia Alexandra Pottes Alves ,
- Gleicy Karine Nascimento de Araújo , [ … ],
- Hulda Vale de Araújo
Abstract
ORIGINAL ARTICLECognition and quality of life relationship among the elderly community: a cross-sectional study
Revista Brasileira de Enfermagem. 2020;73:e20190030
DOI 10.1590/0034-7167-2019-0030
- Barbara Maria Lopes da Silva Brandão ,
- Alice Maria Barbosa da Silva ,
- Rafaella Queiroga Souto ,
- Fabia Alexandra Pottes Alves ,
- Gleicy Karine Nascimento de Araújo ,
- Viviane Cristina Fonseca da Silva Jardim ,
- Hulda Vale de Araújo
Views0See moreABSTRACT
Objective:
to assess cognitive functions and their association with quality of life among elderly people enrolled in a Family Health Unit (FHU) of Primary Health Care in Recife-PE.
Methods:
a quantitative, descriptive, cross-sectional study in which elderly aged 60 years and over were studied.
Results:
76.7% of the elderly were women and the age group was less than or equal to 70 years. 68.6% had cognitive impairment, and in the quality of life assessment it was found that the social participation facet had the highest mean score among the elderly (14.25), while the lowest was observed in the sensory functioning facet (9.10). There was an association between cognitive decline and quality of life.
Conclusion:
most of the elderly had good quality of life rates, but low cognitive level. Using screening tools allows early detection of health problems, guiding the nursing staff in the construction of preventive measures.
- Barbara Maria Lopes da Silva Brandão
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ORIGINAL ARTICLE03-30-2020
Meanings assigned by families about children’s chronic disease diagnosis
Revista Brasileira de Enfermagem. 2020;73(2):e20180742
Abstract
ORIGINAL ARTICLEMeanings assigned by families about children’s chronic disease diagnosis
Revista Brasileira de Enfermagem. 2020;73(2):e20180742
DOI 10.1590/0034-7167-2018-0742
Views0See moreABSTRACT
Objectives:
to understand the meanings assigned by family caregivers about children’s chronic disease diagnosis.
Methods:
qualitative study, which used as theoretical framework the Symbolic Interactionism, and methodological, the Grounded Theory. It was held in a pediatric unit in Southern Brazil, in 2016, through interviews submitted to open and axial analysis, with the participation of 20 family caregivers of hospitalized children.
Results:
relatives, interacting with the nursing/health staff, perceive children’s disease at birth. They are diagnosed with chronic disease by the physician and deny it. Subsequently, they accept and seek information on care.
Conclusions:
the results pointed out the stages that relatives experience by assigning meanings to about children’s chronic disease diagnosis. These meanings provide subsidies for nurses’ actions, which need to be aware of children’s and family’s needs in order to offer comprehensive and humanized care.
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ORIGINAL ARTICLE04-03-2020
Nurse as an integrator in healthcare management of children with chronic condition
- Deborah Dinorah de Sá Mororó ,
- Rejane Maria Paiva de Menezes ,
- Ana Angélica Rêgo de Queiroz ,
- Carlos Jordão de Assis Silva ,
- Wanesca Caroline Pereira
Abstract
ORIGINAL ARTICLENurse as an integrator in healthcare management of children with chronic condition
Revista Brasileira de Enfermagem. 2020;73(3):e20180453
DOI 10.1590/0034-7167-2018-0453
- Deborah Dinorah de Sá Mororó ,
- Rejane Maria Paiva de Menezes ,
- Ana Angélica Rêgo de Queiroz ,
- Carlos Jordão de Assis Silva ,
- Wanesca Caroline Pereira
Views0See moreABSTRACT
Objectives:
to understand the practice of the nurse in healthcare management of children with chronic condition in the hospital setting.
Methods:
analytical study of qualitative approach with theoretical and methodological reference of institutional ethnography. Developed in the pediatric unit of a university hospital, in a municipality in Northeastern Brazil. Data collections techniques were: participant observation, documentary analysis and semi-structured interview. Participants of the study totaled twenty professionals, including nurses, social workers, psychologists, pharmacists, nutritionists, physiotherapists, and doctors. For data analysis, it was used the Bardin’s Content Analysis with interface of the Atlas.ti software.
Results:
categories of analysis were “Nurse as mediator of healthcare management”; “Nursing process as a mechanism of healthcare management”.
Final
considerations: the nurse proved to be essential for healthcare management of the child with chronic condition, acting as mediator of the relationship between the doctor, the members of the health team, the user and their family.
- Deborah Dinorah de Sá Mororó
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ORIGINAL ARTICLE09-18-2020
Nursing recommendations for facing dissemination of COVID-19 in Brazilian Nursing Homes
- Rosimere Ferreira Santana ,
- Marcos Barragan da Silva ,
- Daniela Aparecida da Silva Rebouças Marcos ,
- Cristiane dos Santos Rosa ,
- Willi Wetzel Junior , [ … ],
- Romulo Delvalle
Abstract
ORIGINAL ARTICLENursing recommendations for facing dissemination of COVID-19 in Brazilian Nursing Homes
Revista Brasileira de Enfermagem. 2020;73:e20200260
DOI 10.1590/0034-7167-2020-0260
- Rosimere Ferreira Santana ,
- Marcos Barragan da Silva ,
- Daniela Aparecida da Silva Rebouças Marcos ,
- Cristiane dos Santos Rosa ,
- Willi Wetzel Junior ,
- Romulo Delvalle
Views0See moreABSTRACT
Objective:
to develop a protocol of recommendations for facing dissemination of COVID-19 in Brazilian Nursing Homes.
Method:
a study of experts’ recommendations using a structured form applied through the Delphi Technique, obtaining 100% agreement among professionals after four rounds of analysis. The population comprised six nurses members of the Scientific Department of Gerontological Nursing of the Brazilian Association of Nursing (Associação Brasileira de Enfermagem)
Results:
the protocol was structured in a nucleus of nursing interventions to face the spread of COVID-19 in Nursing Homes, consisting of 8 actions.
Final considerations:
the protocol can help nurse managers to organize assistance to face the pandemic, which can be adaptable to each reality, making training nurses and health teams easier.
- Rosimere Ferreira Santana
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REVIEW12-21-2020
Skill acquisition of safe medication administration through realistic simulation: an integrative review
Revista Brasileira de Enfermagem. 2020;73:e20190880
Abstract
REVIEWSkill acquisition of safe medication administration through realistic simulation: an integrative review
Revista Brasileira de Enfermagem. 2020;73:e20190880
DOI 10.1590/0034-7167-2019-0880
Views0See moreABSTRACT
Objective:
to investigate evidence that indicates the contribution of realistic high, medium or low fidelity simulation to acquire knowledge, skills and attitudes in safe medication administration by nursing students.
Methods:
an integrative review of experimental studies from MEDLINE, LILACS, Web of Science, Scopus and Science Direct. The descriptors “nursing students”, “simulation”, “high fidelity simulation training”, “medication errors” and “pharmacology” were used to identify 14 studies that answered the research question, and were assessed for accuracy methodological level and level of evidence.
Results:
there was a sample of quasi-experimental studies, (level 3 of evidence; 78.6%) and randomized clinical trials (level 2 of evidence; 21.4%), whose expressive majority showed superiority of the simulation strategy over the traditional methodology (71.4%).
Conclusion:
using low and high fidelity simulators, standardized patients and virtual simulation can promote acquisition of essential skills for patient safety.
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ORIGINAL ARTICLE12-07-2020
Sarcopenia screening in elderly in primary health care: nurse knowledge and practices
- Rutielle Ferreira Silva ,
- Maria do Livramento Fortes Figueiredo ,
- Juan José Tirado Darder ,
- Ana Maria Ribeiro dos Santos ,
- Maria Antonieta Rubio Tyrrell
Abstract
ORIGINAL ARTICLESarcopenia screening in elderly in primary health care: nurse knowledge and practices
Revista Brasileira de Enfermagem. 2020;73:e20200421
DOI 10.1590/0034-7167-2020-0421
- Rutielle Ferreira Silva ,
- Maria do Livramento Fortes Figueiredo ,
- Juan José Tirado Darder ,
- Ana Maria Ribeiro dos Santos ,
- Maria Antonieta Rubio Tyrrell
Views0See moreABSTRACT
Objective:
Describe the knowledge and practices of the Primary Health Care nurse on sarcopenia screening in the elderly.
Methods:
Qualitative study conducted with 24 Primary Health Care nurses. The data was collected through semi-structured interviews, recorded and later transcribed. The speeches were grouped in thematic categories, later analyzed, supported by Paulo Freire’s reference.
Results:
The findings showed that the primary care nurses’ knowledge of sarcopenia screening in the elderly was incipient and fragile. This reality is reflected in a gap in practice, although some instruments already require the registration of characteristics indicative of sarcopenia, such as the evaluation of the calf circumference.
Final Considerations:
The need to train nurses to perform sarcopenia screening and to implement a promotional and preventive care plan, which will result in improving the quality of life of the elderly assisted in Primary Care, was highlighted.
- Rutielle Ferreira Silva
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ORIGINAL ARTICLE10-21-2019
Inclusion of mental health in primary health care: care strategy in the territory
Revista Brasileira de Enfermagem. 2019;72(6):1677-1682
Abstract
ORIGINAL ARTICLEInclusion of mental health in primary health care: care strategy in the territory
Revista Brasileira de Enfermagem. 2019;72(6):1677-1682
DOI 10.1590/0034-7167-2018-0806
Views0See moreABSTRACT
Objective:
To analyze the strategies, challenges and possibilities of the articulation between mental health and primary health care from the perspective of health managers.
Method:
Exploratory, qualitative research carried out with 28 managers of mental health and primary care. The data were collected through semi-structured interviews between July and November 2013 and submitted to thematic content analysis.
Results:
The inclusion of mental health actions in primary care made it possible, in the view of managers, to increase users’ access to the care they need. This care strategy allows the extension of care practices in the territory, with matrix support as the main tool for the implementation of this care strategy.
Final considerations:
The articulation between primary care and mental health is a powerful device for psychosocial care, but it demands a new conformation of the Psychosocial Care Centers (Caps) and primary care services.
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