Made available in DSpace on 2014-12-17T14:13:32Z (GMT). No. of bitstreams: 1 NilbaLS_Tese.pdf: 636235 bytes, checksum: 871e98d076a82a24e17c822a9ea7198e (MD5) Previous issue date: 2009-12-18 / Hypertensive syndromes in pregnancy (HSP) are configured as one of the major complications in the pregnancy and postpartum period and can lead premature newborn and subsequent hospitalization of the newborn to the Neonatal Intensive Care Unit (NICU). This study aimed to analyze the perceptions, meanings and feelings of mothers on the hypertensive syndromes in pregnancy and premature obstetric labor. The research was qualitative and has a theoretical methodological the Social Representations Theory(SRT) in the approach to the Central Nucleus Theory. The study included 70 women, mean age 29 years, predominantly school to high school, most of them married or in consensual union, primiparous and prevalence of cesarean delivery occurred between 32 and 37 weeks of pregnancy.The data were collected from may to december 2008 in the Maternity School Janu?rio Cicco in Natal , and obtained through the following instruments for data collection: questionnaire including questions about socio-demographic status; the Free Words Association Test (FWAT) and and verbalized mental image construction used three stimuli: such as pregnancy with high blood pressure, preterm birth and NICU, and interview with the following guiding question: what it meant for you to have a pregnancy with high blood pressure and consequently the birth of a premature baby? Data analysis was performed using multi-method obtained from the data processing by EVOC (Ensemble Programmes Permettant L 'Analyze des ?vocations) and ALCESTE (Analyse Lexicale par Contexte d'un Ensemble de Segment de Texte) and thematic analysis in categories. The results will be presented in four thematic units under the following representative universes: HSP, prematurity as a result of HSP, NICU and the social representations of mothers on the hypertensive disorder of pregnancy sequenced premature birth and hospitalization of the child in the NICU. The results obtained by multimethod analyses showed similar constructions and point to death as the central nucleus and negative aspects, coping strategies, need of care, knowledge about the disease, fragility and meanings of the NICU as peripheral elements. It is considered that the perceptions, meanings and feelings of puerperal women in relation to HSPs and to premature delivery are a negative social representation, with representational elements that may have influenced the adverse effects on the disease and its consequences. We suggest action on the peripheral elements of this representation, with adequate orientation, early diagnosis, effective conduct, receptive attitude on the part of the team, health promotion measures and effective public policies, in order to improve the care provided to puerperal women, making them feel welcome and minimizing their suffering / As s?ndromes hipertensivas da gravidez (SHG) s?o complica??es do per?odo grav?dico puerperal e podem levar ? prematuridade neonatal e consequente hospitaliza??o do rec?m-nascido em Unidade de Terapia Intensiva Neonatal (UTIN). O estudo objetivou compreender percep??es, significados e sentimentos de pu?rperas relativos ?s SHGs que tiveram como consequ?ncia o parto prematuro e a hospitaliza??o do filho na UTIN. ? um estudo qualitativo que teve como referencial te?rico metodol?gico a Teoria das Representa??es Sociais (TRS), na abordagem complementar da Teoria do N?cleo Central. Participaram do estudo 70 mulheres ; com idade m?dia de 29 anos; a maioria com n?vel m?dio de escolaridade; em uni?o consensual; prim?paras e com parto ces?rio ocorrido entre 32 e 37 semanas de gesta??o. Os dados foram coletados de maio a dezembro de 2008, na Maternidade Escola Janu?rio Cicco, em Natal/RN, por meio de: question?rio para caracteriza??o sociodemogr?fica das participantes; t?cnica de associa??o livre de palavras (TALP); constru??o verbalizada de imagens mentais; e entrevista, com a seguinte quest?o norteadora: O que significou para voc? ter uma gravidez com press?o alta e, como consequ?ncia, o nascimento de um filho prematuro? A an?lise de dados foi realizada por meio de multim?todos, a partir do processamento de dados pelos software EVOC (Ensemble de programmes permettant L analyse des evocations) e ALCESTE (An?lise lexical por contexto em um conjunto de segmentos de texto), e an?lise tem?tica categorial. Os resultados foram apresentados em quatro unidades tem?ticas, no ?mbito dos seguintes universos representativos: SHG; prematuridade como consequ?ncia das SHGs; UTIN; e as representa??es sociais de pu?rperas sobre as SHGs seguidas do nascimento prematuro e hospitaliza??o do filho na UTIN. Os resultados obtidos por meio dos multim?todos de an?lise apresentaram constru??es semelhantes entre si e apontam a morte como n?cleo perif?rico, aspectos negativos, estrat?gias de enfrentamento, necessidades de cuidados, conhecimento sobre a doen?a, fragilidade e significados da UTIN. Considera-se que as percep??es, significados e sentimentos de pu?rperas relativas ?s SHGs e ao parto prematuro constituem uma representa??o social negativa, com elementos representacionais que podem ter influenciado os efeitos adversos sobre a doen?a e suas consequ?ncias. Sugere-se atua??o sobre os elementos perif?ricos dessa representa??o, com orienta??es adequadas, diagn?stico precoce, condutas efetivas, postura acolhedora da equipe, atitudes de promo??o ? sa?de e pol?ticas p?blicas eficazes, de forma a melhorar a assist?ncia ?s mulheres/pu?rperas, acolhendo-as adequadamente e minimizando seus sofrimentos

As características e conceitos dos sistemas complexos adaptativos (SCA) e a dinâmica de sistemas podem ser utilizados como ferramentas altamente efetivas para analisar a organização de um sistema de saúde. Várias das propriedades dos SCA são relevantes para este propósito especialmente a emergência de padrões auto-organizativos. Os objetivos são descrever os fluxos intermunicipais de gestantes para a resolução da gravidez visando compreender os fatores que influenciam estes deslocamentos considerando os recursos hierárquicos disponíveis e propor modelos explicativos da regionalização ao cuidado ligado à gravidez e ao parto e à regulação do sistema. Esta pesquisa aplicou conceitos de sistemas complexos adaptativos para estudo dos fluxos de gestantes entre municípios no sistema de atenção ao parto e puerpério na região de Ribeirão Preto- São Paulo determinando as áreas de captação de pacientes e fatores que influenciam deslocamentos. Para isto foram construídas matrizes de origem-destino das gestantes que tiveram a resolução da gravidez na área do Departamento Regional de Saúde XIII (DRS XIII) sediado em Ribeirão Preto no ano de 2012. Foram utilizadas ferramentas ligadas ao fluxo de altas disponíveis no Observatório Regional de Atenção Hospitalar, aplicando modelos de interação espacial e análise de redes para determinar a suficiência das regiões e sub-regiões para a realização dos procedimentos selecionados e explorar os fatores determinantes dos deslocamentos de pacientes. Em 2012, os hospitais de Ribeirão Preto (sede da DRS XIII) receberam 3807 internações por parto de fora do município, das quais 597 foram provenientes de 114 municípios fora da jurisdição do DRS XIII. Observou-se que 25 % das pacientes se deslocaram a outro município para a resolução da gravidez, percorrendo uma distancia média ponderada de 27 km. Os fluxos de pacientes mostram uma alta concentração em Ribeirão Preto e Sertãozinho, embora grande parte dos casos derivados não requeriam serviços de alta complexidade. O DRS XIIII é suficiente como região para a resolução destes casos e se comporta como um importador de pacientes de uma região mais ampla que compreende ao menos 60 municípios. Vários municípios do DRS XIII também têm serviços suficientes para as necessidades de sua população. O sistema de regulação do estado e do DRS XIII e as preferências dos pacientes, famílias e médicos são determinantes mais importantes dos fluxos que as distancias geográficas. A evolução da demografia e epidemiologia, da geografia política e organizacional do SUS, da oferta de serviços e os comportamentos e preferências dos agentes (usuários, médicos e outros) devem ser analisadas em conjunto como sistemas dinâmicos para compreensão dos fluxos de pacientes e assim reformular as redes de serviços para responder melhor às necessidades da assistência materna e puerperal na região coberta pelo DRS III. / The characteristics and concepts of complex adaptive systems (CAS) and system dynamics can be used as highly effective tools to analyze the organization of a health system. Several of the properties of an CAS are relevant to this purpose, especially the emergence of self-organizing patterns. Objectives: To describe the intermunicipal flows of pregnant women at the end of the pregnancy, in order to understand the factors that influence these displacements considering the available hierarchical resources and propose explanatory models of the regionalization of care related to pregnancy, delivery and regulation of the system. This research applied concepts of complex adaptive systems to study the flows of pregnant women among municipalities in the maternal care system in the Ribeirão Preto - São Paulo region, determining the catchment areas of patients and analyzing the factors that influence their displacement. For this purpose, the research gathered origin-destination matrices of the pregnant women who had the pregnancy resolution in the area of the Regional Health Department XIII (DRS XIII), based in Ribeirão Preto, for the year 2012. The tools used for these matrices were built in the discharge-flow utility available at the Hospital Regional Observatory webpage. Using spatial interaction models and network analysis it was possible to determine the sufficiency of regions and sub-regions to perform the selected procedures and to explore the determinants of patient travel. In 2012, maternity hospitals in Ribeirão Preto (headquarters of DRS XIII) received 3807 hospitalizations related to deliveries coming from outside the municipality, of which 597 came from 114 municipalities outside the jurisdiction of DRS XIII. It was observed that 25% of the patients moved to another municipality for the events related to the end of the pregnancy, traveling a weighted average distance of 27 km. Patient flows show a high concentration in Ribeirão Preto and Sertãozinho, although a majority of the derived cases did not require services of high complexity. DRS XIIII is sufficient as a region to resolve these cases and behaves as an net importer of patients from a wider region comprising at least 60 municipalities. Several municipalities of DRS XIII also have sufficient services for the needs of their population. The system of regulation of the state and DRS XIII and the preferences of patients, families and doctors are more important determinants of flows than geographical distances. The evolution of demography and epidemiology, the political and organizational geography of the SUS, the service offerings and the behaviors and preferences of the agents (users, doctors and others) should be analyzed together as dynamic systems for understanding patient flows allowing to redesign the service networks to better respond to the needs of maternal and child care in the region covered by DRS XIII.

In the following chapters, I will discuss the effectiveness of radio and audiotapes as appropriate tools for health communication particularly suited to reaching deprived and isolated communities. I will refer to the striking achievements in radio and audiotape projects by drawing on the experiences of more than sixty radio and cassette projects concerned with primary health care in developing countries. I will present a detailed description of my Argentinean and South African radio experiences, focussing on how the two programmes came into existence, the different stages they have gone through, the problems and constraints encountered as well as their strengths and successes. I will describe the audiotape project I am involved in, and demonstrate how audiotapes can be used alone or in conjunction with radio for primary health education.

Indiana University-Purdue University Indianapolis (IUPUI) / Children's and adolescents' capacity to provide valid informed consent is one of the key ethical concerns in pediatric research, and the focus of this project. The original contribution to knowledge is the advancement of both conceptual and empirical bioethical approaches to research with vulnerable populations. First, a review of adolescent vulnerability is presented to highlight the complex interplay between capacity and other forms of vulnerability. This review is offered as an interdisciplinary analysis to better understand why the study of vulnerable populations is critical to the ethical advancement of clinical research. Results from this analysis suggest the need for enhanced screening techniques as well as the utilization of specialized staff to identify and reduce the impact of different forms of vulnerability. The primary tasks of the empirical portion of the dissertation were to: (1) Adapt a validated adult competency assessment tool for clinical research, the MacArthur Competency Assessment Tool for Clinical Research, to assess the capacity of children and adolescents to consent to clinical research; (2) Identify predictors that impact children and adolescents’ capacity to provide consent to clinical research; and (3) assess differences and similarities in capacity between healthy and chronically ill children and adolescents. Overall results suggest adolescent capacity to consent to research was similar to adults, and most strongly associated with their family's socioeconomic status as well as their level of health literacy. These findings contrast starkly with the age-based criterion for providing consent currently utilized in assent and consent determinations. These findings also provide insights into ways to ethically involve youth in complex biomedical research.

Text in Afrikaans / The Convention on the Rights of the Child was adopted by the United Nations General Assembly on 29 November 1989. Included in the inherent rights set out in the Convention is the right to the highest attainable standard of health. In implementing the Convention states parties must refer to the requirements of article 2 of the Convention, which places them under a duty to respect and ensure the rights in the Convention to each child. The term “respect” implies a duty of good faith to refrain from actions which would breach the Convention. The “duty to ensure”, however, requires states parties to take whatever measures are necessary in order to enable children to enjoy their rights. A state party must also review its legislation in order to ensure that domestic law is consistent with the Convention. South Africa showed commitment to protecting and promoting children’s health when it ratified the United Nations Convention on the Rights of the Child in 1995 and subsequently adopted the Constitution of the Republic of South Africa, 1996, which includes provisions guaranteeing the health rights of children. South Africa also showed commitment to give legislative effect to the protection and promotion of children’s health by reviewing the Health Act 63 of 1977 (reviewed as the National Health Act 61 of 2003) and the Child Care Act 74 of 1983 (reviewed as the Children’s Act 38 of 2005). The review of the Child Care Act 74 of 1983 revealed that the act is virtually silent on the issue of child health. This led to the decision to identify and evaluate existing policy and legislation, as well as pending relevant law reform and policy affecting child health in order to assess how well South African legislation addresses the issue. The research showed that although much legislation exists, none provides comprehensively for child health rights. The legislation that does exist contains obvious gaps. Most importantly, there is no reference to the core minimum requirements for the state in providing for the health of children, particularly in the way of health services and nutrition. Further, there is a complete lack of legislation which protects the health needs of disabled children. A comparative study was also undertaken. Legislation of India and Canada were evaluated in order to make recommendations as to how the gaps in South African legislation can be rectified. However, the research showed that South Africa has made far more significant progress in promoting a rightsbased approach to children’s health in legislation. In order to ensure that the health rights of children are protected and promoted, I propose more comprehensive legislative protection. / Private Law / LL.D.

The prevalence of Protein-Energy Malnutrition (PEM) in South Africa has been welldescribed in previous research studies and yet little is known about the nutritional status of toddlers in the Vosloorus Township. Using the research questions as the conceptual framework for the study, an exploratory descriptive survey was conducted to determine. • What factors give rise to malnutrition in the Vosloorus Township? • Why do toddlers on the PEM Programme fail to achieve their expected target weight? Data was collected by means of structured interviews from a sample of 50 mothers in the Vosloorus Township whose toddlers were on the PEM Programme. The fmdings indicated that the poor socio-economic conditions of the majority of households, especially unemployment, low levels of education and ignorance, contributed towards the development of malnutrition amongst toddlers and their failure to thrive on the PEM Programme. Recommendations to reduce levels of malnutrition and transform existing nutrition programmes were made. / Health Studies / M.A. (Nursing Science)

This dissertation consists of three empirical essays investigating different aspects of health care for children and families. The first essay examines the effectiveness of adherence to American Academy of Pediatrics guidelines for preventive pediatric health care. Using a national longitudinal sample of children age two years and younger, we investigate whether compliance with prescribed periodic well-child care visits has beneficial effects on child health. We find that increased compliance improves child health. In particular, higher compliance lowers future risks of fair or poor health, of some history of a serious illness and of having a health limitation. The second essay examines child health care utilization in relation to maternal labor supply. We test the hypothesis that working-mothers trade off the advantages of greater income against the disadvantages of less time for other valuable tasks, such as seeking health care for their children. This tradeoff may result in positive, negative, or no net impacts on child health investment. We estimate health care demand regressions that include separate variables for mother’s labor supply and her labor income. Our results indicate that higher maternal work hours reduce child health care visits; higher maternal earnings increase them. In addition, wage-employment, as opposed to self-employment, is detrimental to child health investment. A further finding is that preventive care demand for younger children is less sensitive to maternal time and income changes. We also find that detrimental time effects dominate beneficial income effects. The third essay studies intra-household resource allocation as it pertains to its demand for preventive medical care. We test the income-pooling hypothesis of the common preference model by using individual specific medical care consumption data and present evidence on the allocation of household resources to the medical needs of the child, husband and wife. Our results are in line with the findings of previous studies that emphasize the ongoing importance of the traditional gender role of woman as the primary caregiver. We find that the resources of the wife have a greater positive impact on child’s and her own preventive care demand than does the resources of the husband. In contrast to most studies from developing countries, we find that US families do not exhibit differential health care demand based on child gender. It is also noteworthy that the wife’s education level has a greater positive impact than that of her husband does on both the husband’s and her own preventive care utilization. / text

A qualitative, descriptive, exploratory and contextual study was undertaken to explore and describe how clinic nurses practice their role regarding growth development monitoring and anthropometric measurement of children and interpretation of their values. An accessible population of twelve clinic nurses of all categories were purposively recruited to participate in the study. In depth individual interviews were conducted to generate data. Interviews were audio-taped and transcribed by the researcher verbatim. The direct quotes of participants were coded and arranged into meaning units for analysis. Tech’s (1990:142-145) eight steps of analysis to analyse the textual qualitative data as cited by Creswell (2009:186) was used until themes, categories and subcategories were identified and developed. Data analysis was triangulated by using Atlas.ti computer software version 7.0 to organise text, audio data files coding, memos and findings into project files. An independent coder analysed data for validation using content analysis. Data analysis revealed that nurses had challenges in ways of doing practice evidenced by inconsistencies and discrepancies in GDM, APM of children and incorrect interpretation of their values. Non-compliance to protocols from both nurses and parents was a significant finding. Shortage of resources was reported as a major hindrance. Guidelines were formulated to guide clinic nurses. Recommendations were proposed that the matter be taken up by nurse managers, educators and leadership from the Department of Health / Health Studies / D. Litt. et Phil. (Health Studies)

Text in Afrikaans / The Convention on the Rights of the Child was adopted by the United Nations General Assembly on 29 November 1989. Included in the inherent rights set out in the Convention is the right to the highest attainable standard of health. In implementing the Convention states parties must refer to the requirements of article 2 of the Convention, which places them under a duty to respect and ensure the rights in the Convention to each child. The term “respect” implies a duty of good faith to refrain from actions which would breach the Convention. The “duty to ensure”, however, requires states parties to take whatever measures are necessary in order to enable children to enjoy their rights. A state party must also review its legislation in order to ensure that domestic law is consistent with the Convention. South Africa showed commitment to protecting and promoting children’s health when it ratified the United Nations Convention on the Rights of the Child in 1995 and subsequently adopted the Constitution of the Republic of South Africa, 1996, which includes provisions guaranteeing the health rights of children. South Africa also showed commitment to give legislative effect to the protection and promotion of children’s health by reviewing the Health Act 63 of 1977 (reviewed as the National Health Act 61 of 2003) and the Child Care Act 74 of 1983 (reviewed as the Children’s Act 38 of 2005). The review of the Child Care Act 74 of 1983 revealed that the act is virtually silent on the issue of child health. This led to the decision to identify and evaluate existing policy and legislation, as well as pending relevant law reform and policy affecting child health in order to assess how well South African legislation addresses the issue. The research showed that although much legislation exists, none provides comprehensively for child health rights. The legislation that does exist contains obvious gaps. Most importantly, there is no reference to the core minimum requirements for the state in providing for the health of children, particularly in the way of health services and nutrition. Further, there is a complete lack of legislation which protects the health needs of disabled children. A comparative study was also undertaken. Legislation of India and Canada were evaluated in order to make recommendations as to how the gaps in South African legislation can be rectified. However, the research showed that South Africa has made far more significant progress in promoting a rightsbased approach to children’s health in legislation. In order to ensure that the health rights of children are protected and promoted, I propose more comprehensive legislative protection. / Private Law / LL.D.

The prevalence of Protein-Energy Malnutrition (PEM) in South Africa has been welldescribed in previous research studies and yet little is known about the nutritional status of toddlers in the Vosloorus Township. Using the research questions as the conceptual framework for the study, an exploratory descriptive survey was conducted to determine. • What factors give rise to malnutrition in the Vosloorus Township? • Why do toddlers on the PEM Programme fail to achieve their expected target weight? Data was collected by means of structured interviews from a sample of 50 mothers in the Vosloorus Township whose toddlers were on the PEM Programme. The fmdings indicated that the poor socio-economic conditions of the majority of households, especially unemployment, low levels of education and ignorance, contributed towards the development of malnutrition amongst toddlers and their failure to thrive on the PEM Programme. Recommendations to reduce levels of malnutrition and transform existing nutrition programmes were made. / Health Studies / M.A. (Nursing Science)