Orientador: Carmen Maria Casquel Monti Juliani / Resumo: INTRODUÇÃO: A regulação de acesso é compreendida como importante ferramenta de gestão do sistema de saúde. OBJETIVO: Conhecer o perfil e demanda de urgência e emer-gência encaminhadas a um serviço de alta complexidade antes e após um sistema de regulação. MÉTODO: Estudo transversal, avaliando, por meio de análise estatística, dois períodos o primeiro de março de 2015 a setembro de 2016 e o segundo de outubro de 2016 a abril de 2018. RESULTADOS: Houve predominância dos moradores de Botucatu sendo 82% adultos e as especialidades mais buscadas foram oftalmologia, clínica médica e ortopedia. 10450 casos foram regulados pela Central de Regulação de Ofertas de Serviços de Saúde, em análise comparativa do período anterior e posterior da implantação da plataforma notou-se aumento na demanda de atendimento dos municípios e na distribuição das especialidades solicitadas. Das solicitações aceitas e encaminhadas ao Hospital das Clínicas prevaleceu o público mascu-lino e as principais hipóteses diagnósticas foram relacionadas à fratura, trauma, afecções car-díacas e acidente vascular cerebral. Após realizou-se um cálculo amostral que evidenciou 12,5% a realização de contrarreferência, analisando a amostra a maioria eram homens com média de idade de 40 anos e o tempo médio de regulação dos casos foi de 1 hora, 43 minutos e 48 segundos com as principais queixas relacionadas à fratura, dor abdominal, infarto agudo do miocárdio e dispneia. CONCLUSÃO: Houve diferença significativa comparando o... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: BACKGROUND: Access regulation is understood as an important health system manage-ment tool. AIM: To know the profile and demand of urgency and emergency sent to a high complexity service before and after a regulation system. METHOD: Cross-sectional study, evaluating, through statistical analysis, two periods from March 2015 to September 2016 and the second from October 2016 to April 2018. RESULTS: Population of Botucatu was predo-minantly 82% and specialties most sought were ophthalmology, medical clinic and orthope-dics. 10450 cases were regulated by the Central of Regulation of Health Service Offerings, in a comparative analysis of the period before and after the implementation of the platform, there was an increase in the demand for care of the municipalities and in the distribution of the spe-cialties requested. Of the requests accepted and sent to Hospital das Clínicas, the male public prevailed and the main diagnostic hypotheses were related to fracture, trauma, cardiac affecti-ons and stroke. After a sample calculation that showed a 12.5% counterreference, the sample was mostly men with a mean age of 40 years and mean time to regulate the cases was 1 hour, 43 minutes and 48 seconds with the main complaints related to fracture, abdominal pain, acute myocardial infarction and dyspnea. CONCLUSION: There was a significant difference comparing the two periods, evidencing the increase after the insertion of the platform, contri-buting to the regulation and flow of the patien... (Complete abstract click electronic access below) / Mestre

Introdução: O escorpionismo é reconhecido como um problema de saúde pública em alguns países em desenvolvimento devido à significativa incidência e gravidade, particularmente entre crianças e idosos com comorbidades. No Brasil, estima-se que ocorram cerca de 58.000 acidentes com mais de 80 óbitos por ano, o que representa uma incidência anual aproximada de 30 casos/100.000 habitantes/ano. Justifica-se, portanto, o presente estudo, tendo em vista que, no Município de Santarém-PA, na Amazônia, há dificuldade de acesso aos serviços de saúde pela população local, devido à extensão territorial da região. Objetivo: Analisar como se processa a ocorrência de acidente escorpiônico no Município de Santarém-PA. Método:O estudo foi observacional, exploratório, prospectivo, descritivo e qualitativo. Foram sujeitos do estudo, 19 pacientes vítimas de acidente escorpiônico atendidos no PSM, no período de Novembro de 2016 a Fevereiro de 2017. Dados relativos às características pessoais, de condições de vida e de trabalho foram extraídos dos prontuários e confirmados por ocasião das entrevistas realizadas enquanto estiveram internados na unidade hospitalar. Também foram levantados dados clínicos. Utilizou-se de instrumento para a captura dos dados. Os procedimentos éticos foram resguardados.Resultados: Em relação à caracterização dos sujeitos, verificou-se que dos 19 entrevistados 14 (73,7%) eram do sexo masculino. Quanto à faixa etária, 5 (26,3%) tinham idade entre 5 e 10 anos, e 2 (10,6%) entre 11-20 anos, os demais eram adultos ente 21 e 60 anos. Em relação ao tempo de estudo, mesmo levando em consideração os sujeitos menores de idade, alguns dos sujeitos adultos possuíam baixa escolaridade, sendo o maior número de anos de estudo entre 8 e 10 anos, em 7 (36,8%) dos entrevistados. A maior parte dos acidentes ocorreu na zona rural: 13 (68,5%). Quanto aos sintomas, a dor local foi relatadapor 18 (94,7%); a sensação de choque por 18 (94,7%). O tempo de chegada à unidade hospitalar, após a picada, foi maior que uma hora em 15 (78,9%) dos casos. A análise qualitativa dos depoimentos revelou cinco Temas: Situação em que ocorreu o acidente escorpiônico; Trajetória percorrida pelo paciente até o tratamento;Providências após a ocorrência do acidente; Manifestações clínicas apresentadas pelas vítimas dos acidentes escorpiônicos; O que foi feito com o escorpião (lacrau).Estes temas evidenciam a experiência dos sujeitos no manejo do agravo; a forma como se processa o percurso até a unidade de atendimento, evidenciando falhas no acesso e vulnerabilidade programática; e algumas características relacionadas ao modo de vida dos indivíduos. Conclusão: Verificou-se dificuldade no acesso aos serviços de saúde, relacionada à distância geográfica entre as comunidades rurais e o Município de Santarém, onde há o tratamento específico para o acidente escorpiônico, além da necessidade de percorrer várias unidades de saúde até a obtenção do tratamento adequado; a severidade das manifestações locais e sistêmicas; o desconhecimento da população local acerca do manejo apropriado do agravo escorpiônico; e afalta de informações a respeito de ações de prevenção e de tratamento correto. Propõe-se, portanto, uma cartilha para ser utilizada junto às comunidades, para instrumentalizá-las sobre as melhores ações a serem adotadas na prevenção e por ocasião do acidente. / Introduction: Scorpionism is recognized as a public health problem in some developing countries due to its significant incidence and severity especially among children and elderly with comorbidities. It is estimated that about 58,000 accidents occur in Brazil with over 80 deaths per year, representing an approximate annual incidence of 30 cases/100,000 inhabitants per year. The present study is justified since in the Municipality of Santarém-PA, in the Amazon region, there is great difficulty of access to health services by the local population due to the territorial extension. Objective: Analyze how the scorpion accident occurs in the municipality of Santarém-PA. Method:The study was observational, exploratory, prospective, descriptive and qualitative. Nineteen patients who were victims of scorpionic accidents were included in the study. They were treated at the PSM during November 2016 through February 2017. Data on personal characteristics and living and working conditions were extracted from the medical records and confirmed at the time of the interviews while the patients were at the hospital. Clinical data was also collected. An instrument was used to collect the data. The ethical procedures were preserved. Results: In relation to the characterization of the subjects, it was verified that 14 out of the 19 interviewed (73.7%) were male. As for the age group 5 (26.3%) were aged between 5 and 10 years old and 2 (10.6%) between 11 and 20 years old. The others were adults ranging from 21 and 60 years. Regarding the schooling, taking into consideration even the underage subjects, the majority of the adult subjects had low schooling and 7 (36.8%) with the greatest number of years of schooling ranged only from 8 to 10 years. Most accidents occurred in the rural area 13 (68.5%). Regarding to the symptoms, the local pain was pointed out by 18 (94.7%); the shock sensation by 18 (94.7%). The time of arrival at the hospital after the accident was over one hour in 15 (78.9%) cases. The qualitative analysis of the testimonies revealed five themes: Situation in which the scorpionic accident occurred; Trajectory traveled by the patient to the treatment site, Measures taken after the occurrence of the accident; Clinical manifestations presented by the patients; What had been done with the scorpion (lacrau). The themes revealed evidence of the experience by which the subjects dealt with the situation; the flow of the trajectory to the service unit evidencing access failures and programmatic vulnerability; and some characteristics related to the way of life of individuals. Conclusion:There was difficulty in accessing health services, related to the geographical distance between rural communities and the Municipality of Santarém, where there is the specific treatment for the scorpionic accident, as well as the need to go through several health units until obtaining the treatment; the severity of local and systemic manifestations; the lack of knowledge of the local population about the proper management of the scorpionism; preventive actions and the lack of information regarding to the correct treatment. Therefore, it is proposed a hornbook to be used at the communities, to instrumentalize the population on the best actions to be taken for prevention and after the accident.

Orientador: Carmen Maria Casquel Monti Juliani / Banca: Sandra Thomé / Banca: Nilce Emy Tomita / Resumo: O Sistema Único de Saúde (SUS) atualmente passa por grandes transformações e conquistas, acompanhadas por algumas dificuldades na consolidação dos seus princípios. O funcionamento do sistema de referência e contrarreferência em saúde, proposto para contribuir com a garantia dos princípios de integralidade, equidade e universalidade, é um desafio que enfrentamos. Faz-se necessário um sistema de referência e contra-referência que funcione de forma a promover a integração entre os serviços, para que em rede possam oferecer uma assistência de qualidade ao usuário. O objetivo desta pesquisa foi compreender a organização do sistema de referência e contra referência no contexto do Sistema Único de Saúde na Estratégia Saúde da Família no município de Bauru/SP, a partir da experiência dos gestores que vivenciam essa prática. A pesquisa, qualitativa, utilizou o referencial da fenomenologia. Foram entrevistados gestores da ESF do município e chefias das unidades, totalizando seis entrevistados. Emergiram dos depoimentos três categorias: Categoria A: O sistema de saúde, com os temas: política de Saúde, não garantia da integralidade, resolubilidade, lógica/modelo dominante no sistema e cultura da população; Categoria B: O funcionamento do sistema de referência e contra-referência, cujos temas foram a visão do sistema de referência e contrareferência, operacionalização da referência no município, importância da reorganização da referência, importância da contrarreferência e desafios da comunicação entre os níveis de atenção e usuários; Categoria C: Fatores estruturais do sistema local de saúde. abrangendo os temas demanda reprimida, organização dos serviços, atenção básica insuficiente, priorização das vagas urgências/emergências, retrabalho e custos para o sistema, perspectivas de melhoria da rede de atenção a saúde, perspectivas... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The Unified Health System (SUS) has undergone great changes. It has also made great achievements that have been accompanied by difficulties in the consolidation of its principles. The functioning of the health referral and counter-referral system, which has been proposed in order to contribute so as to ensure the principles of integrality, equity and universality, is a challenge that has been faced. A referral and counter-referral system that works so as to promote integration between the services is necessary in order to provide quality care to users in the form of a network. This study aimed at understanding the organization of the referral and counter-referral system in the context of the Unified Health System in the Family Health Strategy in the city of Botucatu/SP based on the experience of managers who live such practice. The qualitative research used the phenomenology framework. ESF managers in the city as well as health unit managers were interviewed, totaling 06 respondents. Three categories emerged from their statements: Category A: The health system, with the following themes: health policy, non-guarantee of integrality, resolubility, logic/dominant model in the system and the population's culture; Category B: the functioning of the referral and counter-referral system, whose themes were the view of the referral and counter-referral system, referral operationalization in the city, importance of referral re-organization, importance of counter-referral and communication challenges between care levels and users; Category C: structural factors of the local health system, including the following themes: repressed demand, service organization, insufficient primary care, prioritization of places for emergencies, re-work and costs for the system, perspectives of improvement in the health care network, perspectives for matrix-based strategies. The data show a system that... (Complete abstract click electronic access below) / Mestre

Atà 2000, o controle da hansenÃase no Brasil foi verticalizado. Desde entÃo, o processo de descentralizaÃÃo dessa doenÃa deu inÃcio a aÃÃes que priorizaram o nÃvel primÃrio de atenÃÃo à saÃde. Entretanto, a assistÃncia ainda permanece centralizada em algumas unidades de saÃde, como o Centro Nacional de ReferÃncia em Dermatologia SanitÃria D. LibÃnia (CDERM), em Fortaleza, CearÃ. O referido centro responde por 84% da detecÃÃo dos casos de hansenÃase do MunicÃpio. O objetivo deste estudo foi investigar os fatores associados à demanda excessiva de casos, em nÃvel secundÃrio de atenÃÃo, representado por esse centro de referÃncia. Um estudo transversal foi realizado com 600 usuÃrios, selecionados aleatoriamente nos ambulatÃrios do CDERM. Foram coletados dados socioeconÃmicos e demogrÃficos sobre o conhecimento da doenÃa e a percepÃÃo dos serviÃos. Oitenta e dois por cento dos participantes tinham baixa situaÃÃo socioeconÃmica, 90% vieram encaminhados por outras unidades de saÃde e 87% tinham a forma multibacilar. Sessenta e nove por cento receberam atendimento prÃvio em outras unidades de saÃde, 49% jamais ouviram falar de hansenÃase, 24% referiram sentir medo da doenÃa ou terem sofrido discriminaÃÃo, 39% dos usuÃrios referiram que o atendimento ininterrupto no horÃrio do almoÃo favorece a permanÃncia no CDERM, 57% e 27%, respectivamente, referiram que a medicaÃÃo complementar nunca faltou no CDERM e nas Unidades BÃsicas de SaÃde (UBS). Sessenta e um por cento consideraram que o compromisso dos profissionais no CDERM foi Ãtimo, contra 14% nas UBS. Os atores relatados pelos usuÃrios, especialmente logÃsticos e de qualidade de atendimento e dos profissionais, poderiam explicar a concentraÃÃo de usuÃrios nesse centro de referÃncia. / Until 2000, the Leprosy control in Brazil was a vertically integrated program. After this date, the program was considered a priority for primary care. However, the program remained centralized in some reference centers such as the D. LibÃnia National Reference Center for Sanitary Dermatology, located in Fortaleza, CearÃ, Brazil (CDERM), responsible for 84% of the case detection in this municipality. The goal of this study was to investigate the factors associated with use of these services, and the potential for integration into primary health care. A cross-sectional survey was conducted with 600 users randomly selected in the outpatient clinic of the CDERM with the objective of determining the factors associated with demand for these services. Social, economic and demographic data, knowledge about the disease and perception about the services were collected. Eighty two percent of the participants had low social and economic status, 90% were referred from other health units; 87% had the multibacillary form. Sixty-nine per cent reported previous visits to other health units (HU). Fortynine per cent have never heard about leprosy, 24% reported fear of being discriminated against or suffering discrimination. Complementary medication was never missed for 57% treated in the CDERM and for 27% in other HUs. The commitment of the professionals was considered exemplary by 61% in the CDERM and by 14% in the other HUs. These facts reported by users, especially logistic ones and those related to the quality of the assistance and of the professionals might explain the concentration of users in this reference center.

As aÃÃes de controle da tuberculose (TB) encontram-se no Ãmbito da AtenÃÃo PrimÃria à SaÃde e visam interromper a cadeia de transmissÃo e possÃveis adoecimentos na comunidade. O objetivo desse trabalho foi dimensionar o acesso ao diagnÃstico e ao tratamento da tuberculose, as aÃÃes de controle desenvolvidas pelas equipes da SaÃde da FamÃlia (SF) em Fortaleza e o grau de conhecimento dos profissionais de saÃde. Trata-se de um estudo transversal descritivo. Foram selecionados oito Centros de SaÃde da FamÃlia entre os que mais atenderam casos de tuberculose no primeiro trimestre de 2011. A populaÃÃo de estudo foi constituÃda de enfermeiros, mÃdicos, agentes comunitÃrios de saÃde (ACS) e usuÃrios portadores de TB em tratamento. Foram realizadas entrevistas com os usuÃrios e os profissionais enfermeiros e mÃdicos. Um questionÃrio de conhecimento acerca da transmissÃo, diagnÃstico, prevenÃÃo, tratamento e acompanhamento da tuberculose foi aplicado com ACS, enfermeiros e mÃdicos. Os profissionais de nÃvel superior eram formados por 31 enfermeiros e 17 mÃdicos, sendo 39 do sexo feminino. A idade mÃdia foi de 38,4 anos. A maioria (n= 135) dos ACS, 81,8%, possuÃa o ensino mÃdio completo. Trabalhar na funÃÃo hà trÃs anos ou mais foi significativo para participaÃÃo em treinamentos (p= 0,0001). O atendimento inicial do tratamento de TB foi conseguido em atà uma semana. A consulta de acompanhamento do mÃdico e do enfermeiro foi classificada, pelos doentes, como boa, clara e esclarecedora acerca da doenÃa, do tratamento, das medicaÃÃes e seus efeitos adversos. A oferta de vale transporte era irregular e nÃo havia cesta bÃsica. Houve discordÃncia das respostas dos usuÃrios e profissionais nas aÃÃes de exame e investigaÃÃo de contatos domiciliares. Entretanto, eles concordaram quanto à nÃo realizaÃÃo de busca ativa de sintomÃticos respiratÃrios e trabalhos educativos na comunidade. Enfermeiros, mÃdicos e ACS apresentaram proporÃÃo de acerto superior a 70% do questionÃrio acerca da tuberculose. NÃo houve diferenÃas estatisticamente significantes entre enfermeiros e mÃdicos no nÃmero total de acertos, por questÃo ou bloco temÃtico. Os ACS que atuavam hà trÃs anos ou mais apresentaram maior mÃdia de acertos (p= 0,0414). As fragilidades no controle da tuberculose na Ãrea das equipes estudadas envolvem as aÃÃes voltadas Ãs famÃlias e à comunidade, como a investigaÃÃo de contatos, trabalhos educativos na comunidade, busca de sintomÃticos respiratÃrios, prejudicando o acesso ao diagnÃstico precoce da doenÃa. / Actions to control this disease lie within the Primary Care/ Family Health Program and aim to break the chain of transmission and possible illnesses in the community. The aim of this study was to measure the access to diagnosis and treatment of tuberculosis, the control measures developed by Family Health teams in Fortaleza and the degree of knowledge of health professionals. This was a cross-sectional study. Eight Family Health Centers that served more cases of tuberculosis in the first quarter of 2011 were selected. The study population consisted of nurses, physicians, community health worker and TB patients on treatment. Interviews were conducted with TB patients and nurses and doctors. Moreover, nurses, doctors and community health workers answered a survey of knowledge about transmission, diagnosis, prevention, treatment and monitoring of tuberculosis. High level professionals were composed of 31 nurses and 17 doctors. There were 39 women. Mean age was 38.4 years. The most (81.8%) of community health workers had completed high school. Working in the service for three years or more was significant for participation in trainings (p= 0,0001). The initial care of TB treatment was achieved within one week. The follow-up care by doctor or nurse was classified by patients as good, clear and informative about the disease, treatment, medications and their adverse effects. The provision of bus passes was irregular and there was no food aid. There were disagreement responses of users and professionals in the actions of examination and investigation of household contacts. However, they agreed not to perform an active search for respiratory symptoms and educational work in the community. Nurses, doctors and community health workers had ratio of greater than 70% correct answers in tuberculosis. There were no statistically significant differences between nurses and physicians in the total number of correct answers, per question or thematic group. The community health workers who had work up to three years or more had a higher average (p= 0,0414). The weaknesses in tuberculosis control in the teams studied area occurred in actions aimed to involve families and the community, such as research of contacts, educational work in the community, search for respiratory symptoms, hampering access to early diagnosis.

Made available in DSpace on 2015-09-25T12:23:47Z (GMT). No. of bitstreams: 1 ValkeniaAlvesSilva.pdf: 2095017 bytes, checksum: e1266e96d8079940733091b12b37e198 (MD5) Previous issue date: 2011-08-08 / This study aimed to evaluate the actions of tuberculosis control in Campina Grande-PB. This is a study performed by the adaptation of instruments of the Primary Care Assessment Tool (PCAT), prepared by Satrfield (2002), adapted and validated to Brazil by Macincko and Almeida (2006), adjusted for TB by Villa and Ruffino-Netto (2009). The study included 116 TB patients diagnosed from May/2010 to January/2009 living in the city of Campina Grande- PB. Interviwees answered each question using a questionary with Likert scales of five scores. Data were analyzed using the nonparametric Kruskal-Wallis (H Test), which is a non- parametric ANOVA with a criterion of classification. As a posteriori test was used Dunn's method to compare in pairs the matters referred and check the statistical differences. There were more male, incomplete elementary education and masonry housing . Patients do not seek the APS as a gateway to the health system, most diagnosis of TB was made by secondary care services and tertiary. About the variables of access to diagnosis, 43.2% of TB patients had no difficulties of getting access to care (3.91), 49.4% always managed medical consultation within 24 hours (3.65); 56.7% never or rarely had difficulty on getting around (3.67), 44.5% of patients always lost days of work (2.87), 62.9% used motorized transport (2.68), 56, 8% had to pay for transportation (2.69) to go to the SS and 53.1% did not seek the nearest health unit to their home when they started to show the first symptoms of TB, the only variable that is statistically significant. It was observed that the conformation that are organized as health services have weaknesses in the decentralization of TB diagnosis process for the APS, that is necessary to adopt strategies that enable people's access measures to control the disease. / O presente estudo objetivou avaliar as ações de controle da tuberculose no município de Campina Grande-PB. Trata-se de um estudo transversal realizado a partir da adaptação do instrumento componente do Primary Care Assessment Tool (PCAT), elaborado por Starfield (2002), adequado e validado para o Brasil por Macincko e Almeida (2006), sendo adaptado para a atenção à TB por Villa e Ruffino-Netto (2009). Participaram do estudo 116 doentes de TB diagnosticados no período de janeiro/2009 a maio/2010, residentes no município de Campina Grande-PB. Os entrevistados responderam cada pergunta do questionário segundo uma escala do tipo Likert com 5 escores. Os dados foram analisados através do teste não-paramétrico de Kruskall-Wallis (Teste H), que é uma ANOVA não-paramétrica a um critério de classificação. Como teste a posteriori foi usado o método do Dunn para comparar aos pares as questões referidas e verificar diferenças estatísticas. Houve predomínio do sexo masculino, baixa escolaridade e adulto jovem. Os doentes não buscaram o nível de Atenção Primária à Saúde como porta de entrada do sistema de saúde, a maioria dos diagnósticos de TB foi realizado nos serviços de atenção secundária e terciária. Com relação às variáveis de acesso ao diagnóstico, 43,2% dos doentes de TB não apresentaram dificuldades de acesso para conseguir atendimento (3,91); 49,4% sempre conseguiram consulta médica no prazo de 24 horas (3,65); 56,7% nunca ou quase nunca tiveram dificuldade de deslocamento (3,67); 44,5% dos doentes sempre perderam dia de trabalho (2,87); 62,9% utilizaram transporte motorizado (2,68); 56,8% tiveram que pagar pelo transporte (2,69) para deslocar-se ao SS e 53,1% não procuraram a unidade de saúde mais próxima de seu domicilio quando começaram a apresentar os primeiros sintomas da TB, sendo a única variável que apresentou diferença estatística significativa. Observou-se que a conformação como estão organizados os serviços de saúde apresentam fragilidades no processo de descentralização do diagnóstico da TB para à Atenção Primária à Saúde, sendo necessária a adoção de estratégias que viabilizem o acesso da população as ações de controle da doença.

In the U.S., the number of persons who cannot afford health care continues to rise. Providing a "safety net" for such persons is becoming increasingly important. Medical professional volunteerism provides access to health care for people who have little or no access to health care otherwise. At a not-for-profit free health clinic in Tampa, Florida, hundreds of physicians have volunteered their time in an attempt to reduce the health care gap in their community. The clinic sees thousands of persons who have very limited options in regards to their health care. This study investigates the reasons physicians volunteer and the barriers physicians face when providing free medical service. Through a survey, shadowing sessions, and focused in-depth videotaped interviews with volunteer physicians concerning the risks, rewards, experiences, and barriers of professional volunteering, a greater understanding of this important topic was obtained. This applied visual anthropological project was developed in collaboration with the free clinic in order to provide a product which would be of use to the organization at the end of the research process. This research led to an enhanced understanding of this population as well as recommendations in volunteer physician recruitment strategies.

This study evaluated the associations of individual and neighborhood level risk factors with physical health, mental health, and stress in a diverse urban county. Relatively little research has attempted to disentangle the interactive individual characteristics and neighborhood conditions underlying health outcomes and disparities. To address this, survey data were collected and analyzed from 1,107 residents living in one of the 114 census tracts in DeKalb County, GA. Using multilevel structural equation modeling techniques, this study found that neighborhood level measures of the social and built environment were not associated with the health outcomes under study after controlling for neighborhood level income and education. Alternatively, individual level perceptions of the social and built environment and measures of access to health care were significantly associated with physical health, mental health, and perceived stress. This study also found that the association between low individual income and poor physical health was more pronounced for participants who lived in low-income neighborhoods than participants who lived in high-income neighborhoods. Additionally, this study found that Black residents reported significantly better mental health compared to White residents when they lived in high-income neighborhoods, and Black participants reported significantly more stress compared to White participants when they lived in low-income neighborhoods. Results of this study further scientific understanding of the role of neighborhood processes in health disparities and potentially help inform the development of programs and policies related to neighborhood conditions and health disparities.

The existence of unfair differences or disparities in access to and quality of health care is well known. However, the nature of disparities at different stages of the health seeking pathway and interventions to reduce them are less clear. Applying the tools of statistics and quasi experimental design-- interrupted time series, propensity score matching, hierarchical models---we can analyze how care is accessed in low, middle and high income countries and assess for disparities. The results are sometimes surprising and underscore the need to generate context specific evidence to ensure targeting of programs. My first paper evaluates the impact of a controversial policy, mandating of health insurance, on reducing disparities in health care access and affordability. Using longitudinal survey data from five states in USA (2002-2009), I show that living in MA, where health insurance is mandated, results in a higher probability of being insured and having a personal doctor and lower probability in forgoing care due to costs as compared to similar border states. The beneficial effect of the mandate is greatest in traditionally "disadvantaged" groups defined by race, income, education or employment status. My second paper examines gender disparities in access to medicines in sub Saharan Africa--Uganda, Kenya, Nigeria, Ghana, Gambia. Using medicines specific survey data, I construct a novel seven stage access to medicines pathway and assess gender disparities along it applying the Institute of Medicine framework. Contrary to prevailing belief, I find few gender differences in unadjusted outcomes which cease to be significant on controlling for health status and country characteristics. My third paper assesses disparities by educational attainment in process and outcomes of care. I use unique data extracted from an electronic medical record of diabetic patients in Mexico City. Using a matching algorithm, I control for only differences in health need and find few significant differences in processes and outcomes of care. The unmatched traditional regression based risk adjustments tend to overestimate the significance and magnitude of the association. The three papers demonstrate the need to use more sophisticated statistical tools to appropriately measure disparities and ensure the effectiveness of health programs.

The purpose of this dissertation is to effectively understand, measure, and model the impact of Access to Care (AC) on Patient Safety (PS) through the creation of a model that evaluates their interdependence. Through the use of statistical tools and through the combination of variables that define patient access to health care and patient safety, a Patient Access and Safety (PACSA) index is developed. The calculated Patient Access and Safety index provides information to both providers and patients about the impact of access and safety on treatment outcomes. The input variables used to support this research are Patient Access Factors (PAF) (Age, Insurance Type, Visit Type, List Price, and Days To an Appointment) and Patient Safety Factors (PSF) (Severity of Diagnosis, Race, and Gender). In this model, 7,535 observations were used from a single organization based in South Florida, in order to develop the index. The PACSA index offers a tool that helps providers, healthcare staff and patients evaluate patient safety as it is impacted by access to healthcare through the calculated index. This index produces an equation that examines the relationship between access to care and patient safety using the following relationship: PACSA=∑_(i=0)〖(.645〖PSF〗_i- .645〖PAF〗_i )+0.399〗An extensive literature review identifies the connection between AC and PS and the relationships governing these two concepts. Although large organizations like the World Health Organization (WHO), Agency for Healthcare Research and Quality (AHRQ), and Institute of Healthcare Improvement (IHI) have studied these concepts independently, there has not been a study that used a factor or index to describe the relationship. As the healthcare delivery system becomes more complex, and consumers demand better treatment outcomes, there is a growing need to analyze these concepts jointly. This study focuses on diabetic retinopathy (DR). This is a condition experienced by chronic Diabetic patients, and it is one of the major causes of blindness (National Eye Institute, 2009). The increase in the occurrence of Diabetes worldwide has heightened the disease and inspired clinical research. In 2002, it was estimated that the disease stemming from Diabetes, namely DR, accounted for about 5% of world blindness, representing almost 5 million blind people. If left untreated or undetected, about 2% of people become blind, and about 10% develop severe visual impairment. By the year 2030, a possible 36 million people will have acute visual impairments and 7.2 million people will possibly be blind worldwide. In the United States, there are 18 million people with Diabetes, and 30% have Diabetic Retinopathy (5.3 million Americans over the age of 18) (ATA Report 2004; AHRQ, 2004; WHO, 2004). Although this study focused on DR, the model has been designed with the ability to be applied to other diseases and conditions. The goal of creating the PACSA index is to help healthcare workers understand when to schedule patients within the context of access and safety. Current appointment schedules, which are the tools used by healthcare workers, use a “New patient vs. Follow up patient” design. The PACSA challenges the current scheduling schema. No longer will patients be categorized into “New vs. Follow Up” visits. Instead, they will be evaluated for access to care requirements and patient safety needs from the initial point of entry into the health system. The recommendation is to start designing schedules based on PACSA (low PACSA, medium PACSA, and high PACSA). In this new paradigm, the low PACSA would describe patients that have low disease complexity, low number of risk factors, and can wait a little longer for their appointment without having complications of disease from lack of treatment. On the contrary, the high PACSA would include a subset of patients that have high disease complexity, high number of risk factors, and require immediate appointment and medical continuity of care to have the best treatments and outcomes. The PACSA index can serve as a visual guide for decisions regarding access and patient safety requirements. Two key components of quality within healthcare include access to care and patient safety. To create “congruent system integration” (Maier-Speredelozzi, 2007), there must exist synchronization of all healthcare delivery operations. The Patient Access and Safety Index (PACSA) provides a framework for integrating these two components. This research and the indices developed can offer benefits to health care organizations, patients, physicians, and government entities by providing a versatile tool to help improve access to health care and patient safety.