health

Abstract: ABSTRACT: BACKGROUND: Little is known about the impact of implementing nursing-oriented best practice guidelines on the delivery of patient care in either hospital or community settings. METHODS: A naturalistic study with a prospective, before and after design documented the implementation of six newly developed nursing best practice guidelines (asthma, breastfeeding, delirium-dementia-depression (DDD), foot complications in diabetes, smoking cessation and venous leg ulcers). Eleven health care organisations were selected for a one-year project. At each site, clinical resource nurses (CRNs) worked with managers and a multidisciplinary steering committee to conduct an environmental scan and develop an action plan of activities (i.e. education sessions, policy review). Process and patient outcomes were assessed by chart audit (n=681 pre-implementation, 592 post-implementation). Outcomes were also assessed for four of six topics by in-hospital/home interviews (n=261 pre-implementation, 232 post-implementation) and follow-up telephone interviews (n = 152 pre, 121 post). Interviews were conducted with 83/95 (87%) CRNs, nurses and administrators to describe recommendations selected, strategies used and participants perceived facilitators and barriers to guideline implementation. RESULTS: While statistically significant improvements in 5% to 83% of indicators were observed in each organization, more than 80% of indicators for breastfeeding, DDD and smoking cessation did not change. Statistically significant improvements were found in > 50% of indicators for asthma (52%), diabetes foot care (83%) and venous leg ulcers (60%). Organizations with > 50% improvements reported two unique implementation strategies which included hands-on skill practice sessions for nurses and the development of new patient education materials. Key facilitators for all organizations included education sessions as well as support from champions and managers while key barriers were lack of time, workload pressure and staff resistance. CONCLUSIONS: Implementation of nursing best practice guidelines can result in improved practice and patient outcomes across diverse settings yet many indicators remained unchanged. Mobilization of the nursing workforce to actively implement guidelines and to monitor the delivery of their care is important so that patients may learn about and receive recommended healthcare.

 health;  quality;  assessment;  

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Abstract: ABSTRACT: This article is the lead article in the Human Resources for Health journals first quarterly feature. The series of seven articles has been contributed by Management Sciences for Health (MSH) under the theme of leadership and management in public health and will be published article by article over the next few weeks. The journal has invited Dr Manuel M. Dayrit, Director of the WHO Department of Human Resources for Health and former Minister of Health for the Philippines to launch the feature with an opening editorial to be found in the journals blog.This opening article describes the human resource challenges that managers around the world report and analyses why solutions often fail to be implemented.Despite rising attention to the acute shortage of health care workers, solutions to the human resource (HR) crisis are difficult to achieve, especially in the poorest countries. Although we are aware of the issues and have developed HR strategies, the problem is that some old systems of leading and managing human resources for health do not work in todays context.The Leadership Development Program (LDP) is grounded on the belief that good leadership and management can be learned and practiced at all levels. The case studies in this issue were chosen to illustrate results from using the LDP at different levels of the health sector.The LDP makes a profound difference in health managers attitudes towards their work. Rather than feeling defeated by a workplace climate that lacks motivation, hope, and commitment to change, people report that they are mobilized to take action to change the status quo. The lesson is that without this capacity at all levels, global policy and national HR strategies will fail to make a difference.

 health;  human resources;  

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 health;  capacitacionssp;  women;  human resource;  

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 education;  health;  capacitacionssp;  

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Abstract: Introduction Although rates of invasive cervical cancer have declined precipitously over the past 50 years, nearly 10,000 new cases and 3700 deaths result from this cancer annually. Given the efficacy of early detection, invasive cervical cancer should no longer constitute a health threat; however, national studies reveal that many women, especially older women, do not receive Papanicolaou (Pap) tests. Methods In this complementary study, we examined data from the National Health Interview Survey focusing on the correlates of screening for women aged 55 years or older, an age group in which invasive cervical cancer rates escalate and rates of obtaining Pap tests decline. To more richly understand grounded perspectives, we queried 25 women who were rarely or never screened about factors and circumstances underlying their decision not to obtain a Pap test. Results Quantitative data indicate an association between Pap test use and demographic factors (being married, being younger, and having suburban or urban residence) and access to preventive care (obtaining mammograms, having a regular source of health care, and having contact with an obstetrician/gynecologist). Participants who provided qualitative data echoed this theme of inadequate use of preventive services, particularly among women with weak social ties, who were older, and who lived in rural areas. Shortages of health care professionals and a lack of continuity of care and privacy contribute to suboptimal prevention. Conclusion A vicious cycle emerges: many women decline to pursue preventive care because of competing health and financial demands and insufficient resources to seek care. When such women do go to the doctor’s office, they feel chastised by providers, which alienates them and thwarts future preventive care.

 cancer;  health;  screening;  cervical;  poverty;  

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Abstract: Introducción. El objetivo del Sistema de Residencia es la adquisición de competencias profesionales. El examen clínico estructurado objetivo (ECEO) constituye una valiosa herramienta de evaluación. Para optimizar la evaluación de las competencias clínicas de los médicos residentes implementamos un ECEO, experiencia que se describe. Población, material y métodos. Implementamos un ECEO con 7 estaciones en 25 residentes de 1 año de Pediatría. Se estimó mediana y percentilos de puntaje total y cada estación. Se realizó encuesta de satisfacción de usuario. Resultados. Sobre un puntaje total de 100, la mediana obtenida fue de 50,6 (rango intercuartílico: 45-59). La estación “Pautas madurativas” mostró el mayor puntaje y “Caso interactivo” el menor. En la encuesta de satisfacción, 22 residentes consideraron que esta metodología permitió identificar puntos débiles en su formación. Conclusiones. El ECEO es una metodología de evaluación aplicable en nuestro medio. Los residentes consideran que les permite identificar puntos débiles en su formación. Palabras clave: competencia profesional, evaluación.

 education;  health;  capacitacionssp;  OSCE;  

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Abstract: Socioeconomic and health-related data at the county level are now available through the Community Health Status Indicators (CHSI) database. These data are useful for assessing the health of communities and regions. Users of the CHSI data can access online reports and an online mapping application for visualizing patterns in various community-related measures. It also is possible to download these data to conduct local analyses. This paper describes a spatial analysis of poverty in the United States at the county level for 2000. Spatial statistical techniques in a geographic information system were used to quantify significant spatial patterns, such as concentrated poverty rates and spatial outliers. The analysis revealed significant and stark patterns of poverty. A distinctive north–south demarcation of low versus high poverty concentrations was found, along with isolated pockets of high and low poverty within areas in which the predominant poverty rates were opposite. This pattern can be described as following a continental poverty divide. These insights can be useful in explicating the underlying processes involved in forming such spatial patterns that result in concentrated wealth and poverty. The spatial analytic techniques are broadly applicable to socioeconomic and health-related data and can provide important information about the spatial structure of datasets, which is important for choosing appropriate analysis methods.

 Geography;  USA;  health;  inequality;  poverty;  

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Abstract: Although the concept of needs assessment in continuing medical education is well accepted, there is limited information on needs assessment in postgraduate medical education. We discuss the learning needs of postgraduate trainees and review the various methods of needs assessment such as: questionnaire surveys, interviews, focus groups, chart audits, chart-stimulated recall, standardized patients, and environmental scans in the context of post graduate medical education.

 education;  health;  capacitacionssp;  

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Abstract: OBJECTIVES: Despite the broad range of continuing medical education (CME) offerings aimed at educating practicing physicians through the provision of up-to-date clinical information, physicians commonly overuse, under-use, and misuse therapeutic and diagnostic interventions. It has been suggested that the ineffective nature of CME either accounts for the discrepancy between evidence and practice or at a minimum contributes to this gap. Understanding what CME tools and techniques are most effective in disseminating and retaining medical knowledge is critical to improving CME and thus diminishing the gap between evidence and practice. The purpose of this review was to comprehensively and systematically synthesize evidence regarding the effectiveness of CME and differing instructional designs in terms of knowledge, attitudes, skills, practice behavior, and clinical practice outcomes. REVIEW METHODS: We formulated specific questions with input from external experts and representatives of the Agency for Healthcare Research and Quality (AHRQ) and the American College of Chest Physicians (ACCP) which nominated this topic. We systematically searched the literature using specific eligibility criteria, hand searching of selected journals, and electronic databases including: MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, The Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Abstracts of Reviews of Effects (DARE), PsycINFO, and the Educational Resource Information Center (ERIC). Two independent reviewers conducted title scans, abstract reviews, and then full article reviews to identify eligible articles. Each eligible article underwent double review for data abstraction and assessment of study quality. RESULTS: Of the 68,000 citations identified by literature searching, 136 articles and 9 systematic reviews ultimately met our eligibility criteria. The overall quality of the literature was low and consequently firm conclusions were not possible. Despite this, the literature overall supported the concept that CME was effective, at least to some degree, in achieving and maintaining the objectives studied, including knowledge (22 of 28 studies), attitudes (22 of 26), skills (12 of 15), practice behavior (61 of 105), and clinical practice outcomes (14 of 33). Common themes included that live media was more effective than print, multimedia was more effective than single media interventions, and multiple exposures were more effective than a single exposure. The number of articles that addressed internal and/or external characteristics of CME activities was too small and the studies too heterogeneous to determine if any of these are crucial for CME success. Evidence was limited on the reliability and validity of the tools that have been used to assess CME effectiveness. Based on previous reviews, the evidence indicates that simulation methods in medical education are effective in the dissemination of psychomotor and procedural skills. CONCLUSIONS: Despite the low quality of the evidence, CME appears to be effective at the acquisition and retention of knowledge, attitudes, skills, behaviors and clinical outcomes. More research is needed to determine with any degree of certainty which types of media, techniques, and exposure volumes as well as what internal and external audience characteristics are associated with improvements in outcomes.

 education;  health;  capacitacionssp;  CME;  

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 mapping;  health;  distribution;  

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 education;  health;  capacitacionssp;  

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 simulation;  clustering;  health;  spatial;  

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 canada;  health;  access;  

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 education;  health;  capacitacionssp;  

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 GIS;  epidemiology;  clustering;  health;  spatial;  space-time;  westnilevirus;  

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Abstract: This paper describes selected earlier approaches to graphically relating events to each other and to time; some new combinations are also suggested. These are then combined into a unified prototyping environment for visualization and navigation of electronic health records. Google Earth (GE) is used for handling display and interaction of clinical information stored using openEHR data structures and archetypes. The strength of the approach comes from GEs sophisticated handling of detail levels, from coarse overviews to fine-grained details that has been combined with linear, polar and region-based views of clinical events related to time. The system should be easy to learn since all the visualization styles can use the same navigation.The structured and multifaceted approach to handling time that is possible with archetyped openEHR data lends itself well to visualizing and integration with openEHR components is provided in the environment.

 Geography;  Visualization;  health;  infovis;  

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 clustering;  health;  spatial;  statistical;  

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 education;  health;  capacitacionssp;  

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 education;  health;  capacitacionssp;  

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 disease;  health;  spatial;  epidemic;  flu;  hierarchy;  

Abstract: The spread of highly pathogenic H5N1 avian influenza into Asia, Europe, and Africa has resulted in enormous impacts on the poultry industry and presents an important threat to human health. The pathways by which the virus has and will spread between countries have been debated extensively, but have yet to be analyzed comprehensively and quantitatively. We integrated data on phylogenetic relationships of virus isolates, migratory bird movements, and trade in poultry and wild birds to determine the pathway for 52 individual introduction events into countries and predict future spread. We show that 9 of 21 of H5N1 introductions to countries in Asia were most likely through poultry, and 3 of 21 were most likely through migrating birds. In contrast, spread to most (20/23) countries in Europe was most likely through migratory birds. Spread in Africa was likely partly by poultry (2/8 introductions) and partly by migrating birds (3/8). Our analyses predict that H5N1 is more likely to be introduced into the Western Hemisphere through infected poultry and into the mainland United States by subsequent movement of migrating birds from neighboring countries, rather than from eastern Siberia. These results highlight the potential synergism between trade and wild animal movement in the emergence and pandemic spread of pathogens and demonstrate the value of predictive models for disease control.

 health;  modeling;  epidemic;  avianflu;  

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 evaluation;  education;  health;  

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Abstract: BACKGROUND: A key challenge for modelling infectious disease dynamics is to understand the spatial spread of infection in real landscapes. This ideally requires a parallel record of spatial epidemic spread and a detailed map of susceptible host density along with relevant transport links and geographical features. RESULTS: Here we analyse the most detailed such data to date arising from the UK 2001 foot and mouth epidemic. We show that Euclidean distance between infectious and susceptible premises is a better predictor of transmission risk than shortest and quickest routes via road, except where major geographical features intervene. CONCLUSION: Thus, a simple spatial transmission kernel based on Euclidean distance suffices in most regions, probably reflecting the multiplicity of transmission routes during the epidemic.

 disease;  health;  epidemic;  footandmouth;  uk;  

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Abstract: Introduction Social, cultural, and economic environments are associated with high rates of disease incidence and mortality in poor Appalachian regions of the United States. Although many historical studies suggest that aspects of Appalachian culture (e.g., fatalism, patriarchy) include values and beliefs that may put Appalachians at risk for poor health, other cultural aspects may be protective (e.g., strong social ties). Few recent studies have explored regional cultural issues qualitatively. The purpose of this study was to examine social and cultural factors that may be associated with health and illness in an Appalachian region. Methods Ten focus groups were conducted in southern West Virginia and included five groups of men and five groups of women. Cultural norms associated with residents of rural Appalachia, such as faith, family values, and patriarchy, were examined. Results Both men and women in the focus groups have a sense of place, strong family ties, and a strong spiritual belief or faith in God. Patriarchy as a cultural value was not a strong factor. Conclusion There are limits to how qualitative data may be used, but findings from this study help increase understanding of the social and cultural environments of people living in rural Appalachia and how these environments may affect health.

 Geography;  USA;  health;  inequality;  poverty;  appalachia;  

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Abstract: Introduction West Virginia is the only state that lies entirely within Appalachia. West Virginians tend to be poorer and more likely to lack health insurance than the general U.S. population. The purpose of this qualitative study was to 1) obtain an understanding of attitudes about breast and cervical cancer screening among women aged 25 to 64 years; 2) determine factors that motivate women to be screened for breast and cervical cancer; and 3) evaluate educational materials about breast and cervical cancer screening for use in this population. Methods The West Virginia Breast and Cervical Cancer Screening Program (WVBCCSP) is a comprehensive public health program, funded by the Centers for Disease Control and Prevention, dedicated to removing barriers to breast and cervical cancer screening and providing screenings to underserved women aged 25 to 64 years. The program partnered with RMS Strategies, Inc, to conduct six focus groups in three communities in West Virginia. Women were recruited by telephone based on program eligibility guidelines. Results Results indicated that women were concerned about health care costs and lack of health insurance. Cost, fear, and embarrassment were identified as the top barriers to breast and cervical cancer screening. Participants believed that community-based educational campaigns would increase screening and promote use of the WVBCCSP. Conclusion Understanding why low-income Appalachian women do not get screened for breast and cervical cancer and determining motivational factors that encourage screening are important to increase screening rates among this population. Breast and cervical cancer efforts that use the words, knowledge, and suggestions of the women they serve are more likely to be effective and have a larger impact.

 cancer;  health;  cervical;  appalachia;  breast;  

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 Geography;  health;  inequality;  poverty;  appalachia;  

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 health;  editorial;  inequality;  poverty;  appalachia;  

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 health;  Humanization;  

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 education;  health;  capacitacionssp;  

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 health;  quality;  calidad;  salud;  

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 health;  management;  

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Abstract: Traditional biosurveillance algorithms detect disease outbreaks by looking for peaks in a univariate time series of health-care data. Current health-care surveillance data, however, are no longer simply univariate data streams. Instead, a wealth of spatial, temporal, demographic and symptomatic information is available. We present an early disease outbreak detection algorithm called Whats Strange About Recent Events (WSARE), which uses a multivariate approach to improve its timeliness of detection. WSARE employs a rule-based technique that compares recent health-care data against data from a baseline distribution and finds subgroups of the recent data whose proportions have changed the most from the baseline data. In addition, health-care data also pose difficulties for surveillance algorithms because of inherent temporal trends such as seasonal effects and day of week variations. WSARE approaches this problem using a Bayesian network to produce a baseline distribution that accounts for these temporal trends. The algorithm itself incorporates a wide range of ideas, including association rules, Bayesian networks, hypothesis testing and permutation tests to produce a detection algorithm that is careful to evaluate the significance of the alarms that it raises.

 algorithm;  disease;  health;  epidemic;  

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Abstract: BACKGROUND: This paper combines the literature on public health, on economics of health and on economics of technological innovation to discuss the peculiarities of labour in the health care sector. METHOD AND FRAMEWORK: The starting point is the investigation of the economic peculiarities of medical care. RESULTS AND DISCUSSIONS: This investigation leads to the identification of the prevalence of non-market forms of medical care in the countries of the Organisation for Economic Co-operation and Development (OECD). Furthermore, the health care system has a distinctive characteristic from other economic sectors: it is the intersection between social welfare and innovation systems. The relationship between technological innovation and cost in the health care sector is surveyed. Finally, the Brazilian case is discussed as an example of a developing country. CONCLUSION: The peculiarities of labour in the health care sector suggest the need to recognize the worth of sectoral labour and to cease to treat it separately. This process should take into account the rapid development of the health innovation system and one important consequence: the obsolescence of the acquired knowledge. One way to dignify labour is to implement continued education and training of health professions personnel.

 health;  human resources;  

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 GIS;  health;  review;  access;  

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Abstract: Human resources are the most important assets of any health system, and health workforce problems have for decades limited the efficiency and quality of Latin America health systems. World Bank-led reforms aimed at increasing equity, efficiency, quality of care and user satisfaction did not attempt to resolve the human resources problems that had been identified in multiple health sector assessments. However, the two most important reform policies - decentralization and privatization - have had a negative impact on the conditions of employment and prompted opposition from organized professionals and unions. In several countries of the region, the workforce became the most important obstacle to successful reform.This article is based on fieldwork and a review of the literature. It discusses the reasons that led health workers to oppose reform; the institutional and legal constraints to implementing reform as originally designed; the mismatch between the types of personnel needed for reform and the availability of professionals; the deficiencies of the reform implementation process; and the regulatory weaknesses of the region.The discussion presents workforce strategies that the reforms could have included to achieve the intended goals, and the need to take into account the values and political realities of the countries. The authors suggest that autochthonous solutions are more likely to succeed than solutions imported from the outside.

 health;  human resources;  

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 health;  geographic;  distribution;  doctors;  

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 education;  health;  capacitacionssp;  

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Abstract: Improving the health system can reduce the effects of health disparities, but it can do little to eliminate them. An upsurge in new research is documenting the impact of physical, social, and economic environmental factors: air quality, housing conditions, racism, relationship to community institutions, and neighborhood economic conditions, all of which affect health status over time. A combined focus on community and the policies that affect communities environments presents opportunities for altering and ameliorating the underlying forces at the heart of the determinants of health. This Perspective presents examples of successful community involvement and policy change.

 health;  policy;  

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 health;  quality;  Cuidado;  

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Abstract: OBJECTIVE: To review the extent to which the literature supports the position that a medical home is important and to review the extent to which insurance is related to having a medical home. METHODS: A review of literature concerning the benefits of a medical home on effectiveness, costs, and equity (reducing disparities) was conducted. RESULTS: International and within-nation studies indicate that a relationship with a medical home is associated with better health, on both the individual and population levels, with lower overall costs of care and with reductions in disparities in health between socially disadvantaged subpopulations and more socially advantaged populations. Although important in facilitating use overall, insurance does not guarantee a medical home. CONCLUSIONS: A medical home, with its 4 key features, provides better effectiveness as well as more efficient and more equitable care to individuals and populations. A concerted attempt to provide a means of universal financial access as well as a medical home should be of high priority for the United States.

 health;  medical home;  

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Abstract: Assistimos em tempos recentes à emergência de uma série de novos discursos no campo da saúde pública, mundial e nacionalmente, tais como a promoção da saúde, vigilância da saúde, saúde da família, redução de vulnerabilidade, entre outros. Contudo, uma efetiva consolidação dessas propostas e seu mais conseqüente desenvolvimento parecenos depender de transformações bastante radicais no nosso modo de pensar e fazer saúde, especialmente em seus pressupostos e fundamentos filosóficos. É na condição de uma desconstrução teórica, com vistas a contribuir para a reconstrução em curso nas práticas de saúde, que se quer trazer ao debate a presente reflexão. Nesse sentido, examinase o cuidado sob três perspectivas conceituais: como categoria ontológica, como categoria genealógica e como categoria crítica. A hermenêutica realizada na interface dessas três perspectivas permite apontar direções onde parece produtivo um esforço de reconstrução das práticas de saúde: um ativo movimento de profissionais e serviços de saúde no sentido de se voltarem ativamente à presença do outro no espaço assistencial, a otimização e diversificação das formas e qualidade da interação eu-outro nesses espaços e o enriquecimento dos horizontes de saberes e fazeres em saúde numa perspectiva decididamente interdisciplinar e intersetorial.

 health;  

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 health;  spatial;  cluster;  

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Abstract: The literature on equity in health care delivery agrees that adjusting for “medical need” is a necessary component in assessing whether the delivery of care is equitable, that is, whether it varies with ability to pay. To date, most studies measuring income-related inequality in the delivery of health care have employed crude measures of health status to adjust for medical need and have acknowledged this as a limitation. This study examines how using more complete health status measures affects estimates of income-related inequality for U.S. adults. The findings suggest that previous studies may understate the extent of pro-rich inequality.

 health;  inequality;  access;  income;  

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Abstract: Objetivos: describir dispositivos pedagógicos necesarios para planificar la capacitación en epidemiología y reflexionar sobre la enseñanza de epidemiología dentro de la educación médica en nuestro país. Revisión: Las teorías y evidencias del campo de la educación muestran que hay modelos que producen aprendizaje significativo sobre todo los que promueven un estudiante activo. La investigación sobre las experiencias de grado y la enseñanza de epidemiología es limitada. Respecto a los postgrados la evidencia describe que la epidemiología es enseñada a través de cursos y talleres sobre apreciación crítica. La educación en epidemiología aparece hoy fragmentada, descontextualizada y basada en conferencias con poco nexo a la práctica. Las carreras de pregrado siguen mayoritariamente adscriptas a un modelo basado en disciplinas. La epidemiología es enseñada durante un año de la carrera y nunca más se vuelve a revisar. Son excepciones la Universidad Nacional de Rosario, la de Cuyo, la Universidad Nacional del Sur y la de Tucumán, a las que se suman algunas Universidades privadas. Conclusiones: La gradualidad, texto unificado, integración en el desarrollo curricular, fomento de autoaprendizaje, aprendizaje contextual y reflexión en acción son instrumentos claves para planificar la enseñanza en epidemiología y deberían incorporarse a la mayoría de los programas.

 epidemiology;  education;  health;  capacitacionssp;  

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Abstract: Imbalance in the health workforce is a major concern in both developed and developing countries. It is a complex issue that encompasses a wide range of possible situations. This paper aims to contribute not only to a better understanding of the issues related to imbalance through a critical review of its definition and nature, but also to the development of an analytical framework. The framework emphasizes the number and types of factors affecting health workforce imbalances, and facilitates the development of policy tools and their assessment. Moreover, to facilitate comparisons between health workforce imbalances, a typology of imbalances is proposed that differentiates between profession/specialty imbalances, geographical imbalances, institutional and services imbalances and gender imbalances.

 health;  human resources;  

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 education;  health;  medicine;  capacitacionssp;  

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Abstract: Designers and implementers of decentralization and other reform measures have focused much attention on financial and structural reform measures, but ignored their human resource implications. Concern is mounting about the impact that the reallocation of roles and responsibilities has had on the health workforce and its management, but the experiences and lessons of different countries have not been widely shared. This paper examines evidence from published literature on decentralizations impact on the demand side of the human resource equation, as well as the factors that have contributed to the impact. The elements that make such an impact analysis exceptionally complex are identified. They include the mode of decentralization that a country is implementing, the level of responsibility for the salary budget and pay determination, and the civil service status of transferred health workers.The main body of the paper is devoted to examining decentralizations impact on human resource issues from three different perspectives: that of local health managers, health workers themselves, and national health leaders. These three groups have different concerns in the human resource realm, and consequently, have been differently affected by decentralization processes. The paper concludes with recommendations regarding three key concerns that national authorities and international agencies should give prompt attention to. They are (1) defining the essential human resource policy, planning and management skills for national human resource managers who work in decentralized countries, and developing training programs to equip them with such skills; (2) supporting research that focuses on improving the knowledge base of how different modes of decentralization impact on staffing equity; and (3) identifying factors that most critically influence health worker motivation and performance under decentralization, and documenting the most cost-effective best practices to improve them. Notable experiences from South Africa, Ghana, Indonesia and Mexico are shared in an annex.

 health;  human resources;  

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 education;  health;  capacitacionssp;  

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 health;  capacitacionssp;  human resource;  

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 education;  health;  capacitacionssp;  

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