The objectives of this thesis are to: 1) obtain a snapshot of callers of 211 Toronto, a free information and referral service, understanding how representative they are of Toronto’s general population; 2) understand how 211 Toronto callers seeking health-related information use the information they obtain when contacting the service and their overall level of satisfaction, and; 3) better understand the experience and information needs of recent immigrants struggling to navigate an unfamiliar health care system. The study had three phases: 1) a cross-sectional phone interview with 211 Toronto callers; 2) a follow-up phone interview of 211 Toronto callers who had asked health-related questions; and, 3) qualitative interviews with callers who were Spanish speakers from Latin American countries. Participants were randomly selected adult callers living within the boundaries of Toronto’s Census Metropolitan Area (CMA). Respondents were compared with the general adult population living in Toronto’s CMA, using 2001 Census data, to identify under- or overrepresented population groups. A sub-set of callers who had asked health-related questions was followed up to understand how they had used the information received and their level of satisfaction with the service. Qualitative interviews were conducted with callers who were recent immigrants and native Spanish speakers from Latin America to explore their post-migration experiences. Recent immigrants experience significant information challenges. Health-related questions reflect the multifaceted nature of the concept of health in the experience of users. Negative experiences with the health care system are common. Recent immigrants have access to disorganized, confusing, often poor quality information. 211 Toronto represents an efficient and effective way to gain access to information but does not achieve its full potential. Newcomers should receive timely, appropriate, and reliable information on existing health and health-related services as soon as possible after they relocate to Canada. Appropriate information should also be made available to potential immigrants in their countries of origin. Information and communication technologies should be used to support newcomers, increasing the efficiency and effectiveness of services such as 211 Toronto.

The objectives of this thesis are to: 1) obtain a snapshot of callers of 211 Toronto, a free information and referral service, understanding how representative they are of Toronto’s general population; 2) understand how 211 Toronto callers seeking health-related information use the information they obtain when contacting the service and their overall level of satisfaction, and; 3) better understand the experience and information needs of recent immigrants struggling to navigate an unfamiliar health care system. The study had three phases: 1) a cross-sectional phone interview with 211 Toronto callers; 2) a follow-up phone interview of 211 Toronto callers who had asked health-related questions; and, 3) qualitative interviews with callers who were Spanish speakers from Latin American countries. Participants were randomly selected adult callers living within the boundaries of Toronto’s Census Metropolitan Area (CMA). Respondents were compared with the general adult population living in Toronto’s CMA, using 2001 Census data, to identify under- or overrepresented population groups. A sub-set of callers who had asked health-related questions was followed up to understand how they had used the information received and their level of satisfaction with the service. Qualitative interviews were conducted with callers who were recent immigrants and native Spanish speakers from Latin America to explore their post-migration experiences. Recent immigrants experience significant information challenges. Health-related questions reflect the multifaceted nature of the concept of health in the experience of users. Negative experiences with the health care system are common. Recent immigrants have access to disorganized, confusing, often poor quality information. 211 Toronto represents an efficient and effective way to gain access to information but does not achieve its full potential. Newcomers should receive timely, appropriate, and reliable information on existing health and health-related services as soon as possible after they relocate to Canada. Appropriate information should also be made available to potential immigrants in their countries of origin. Information and communication technologies should be used to support newcomers, increasing the efficiency and effectiveness of services such as 211 Toronto.

Evidence suggests that employment for women can reduce poverty and inequality resulting in improved living standards. The garment industry is an important source of income for Indian women. This thesis tested the effects of garment work as an income source on women’s health-care utilization practices and decision-making in comparison to both agricultural labourers and general women in India. Cross-sectional data collected from India’s National Family Health Survey-3 was used to generate descriptive statistics. Statistical modeling was used to test the effect of garment work on a) barriers to health care services and b) decision-making abilities of Indian women. Results suggest garment workers are younger, more educated, urban, and wealthier, make more cash earnings, and have more access and control over their own money as compared to agricultural labourers. Results indicate female garment workers report facing fewer barriers to accessing health care services. As well, access to cash earnings increases their decision-making abilities.

Yes / Background: To contain the spread of COVID-19 within the UK over the past year, there have been a series of local and national lockdowns. These restrictions are likely to have impacted upon the health and well-being of marginalised groups who rely on now closed social and community support services to stay healthy. An understanding of the experiences of marginalised people is important; therefore, this study aimed to explore the impact of the COVID-19 restrictions on the health and well-being of marginalised groups in the UK. Methods: In summer 2020, a rapid telephone survey was conducted by trained, trusted volunteers with 76 participants who were from marginalised groups. As part of this survey, 64 participants consented to describe their experience of lockdown. These case studies were thematically analysed to identify patterns of meaning. Results: Findings indicate that lockdown led to the deterioration of health of participants, impacted adversely on their socio-economic positions and affected access to food and essential supplies. In addition, government public health messaging was considered confusing and inadequate. Conclusions: This study highlights the need for pathways into services which support marginalised groups to remain accessible during periods of restrictions and essential supplies and food to be mapped and protected for marginalised individuals within our local communities. / NHS England; Improvement

Since the early 1990s, the Estonian health sector has been undergoing a number of reforms. At the same time, a number of legislative acts have also been established, forming a new legal basis for the health system. The introduction of a social health insurance in 1992 was the first reform in the Estonian health sector reorganisation, followed by a primary health care (PHC) reform, a hospital reform and a number of public health reforms. The aim of this thesis is to analyse these health sector reforms in Estonia, focusing on the outcomes of the health system from the population’s perspective. Proceeding from this general aim, the specific objectives of the thesis are as follows: 1) To analyse the PHC reform in terms of the access to the health services and the acceptability and satisfaction with these services. 2) To analyse the health insurance reform in terms of the acceptability and satisfaction with the new system. 3) To analyse the public health reforms and their impact on the health of the population. The empirical data were gathered with the following research methods: reviews of official health statistics and population surveys in 1998, 2002 and 2005 based on face-to-face interviews using structured questionnaires. The main results can be summarised in relation to the objectives of the thesis: 1) The primary health care reform has been implemented and most of the objectives have been achieved. In general, people accept the changes in the PHC system and the satisfaction with the family doctors has increased. Access to the PHC services is good. Based on the results of a population study in 2002 and 2005, more than half of the respondents could see the family doctor on the same day they made an appointment. Almost a half of the respondents (49%) were satisfied with the access to the health services. Satisfaction with the PHC services and family doctors were found to have positive effects on satisfaction with access to health services. Although people with chronic conditions were less satisfied with the access to the health services they did not experience organisational barriers in their access to such services. 2) The health insurance reform has been implemented and a high level of financial protection has been maintained. The solidarity principle of the health insurance system guarantees access to health services for all the insured people. About half of the population is satisfied with the present system. Compared to 2002, the percentage of satisfied people has increased in 2005, while the percentage of very dissatisfied persons has decreased. The most important predictor of satisfaction with the health insurance was the satisfaction with the existing PHC system. The satisfaction with the health insurance was higher in 2002 as well as 2005 among those respondents who had visited a family doctor or a specialist or were admitted in a hospital during the last 12 months before the survey, but lower among those who had visited a dentist. A small majority preferred the solidarity principles and comprehensive financing of health service by health insurance. The attitudes regarding financing principles were related to the personal contacts with the health services. The respondents who had used the PHC or ambulance services preferred a more comprehensive financing of health services, while those who had had contacts with a specialists or dentists would prefer less comprehensive financing if the waiting lists were short. More than three quarters of the respondents were informed about their rights concerning the access to the health services. Personal contacts with family doctors and specialists had positive impact on the level of awareness. 3) Some progress has been made in connection with the public health reforms. A number of national programs and projects to prevent the most essential health risks have been initiated. As a result, there is some evidence of a positive impact on the health of the population – positive trends in dietary habits and decreasing infant mortality, number of abortions, and incidences of sexually transmitted infections and tuberculosis. At the same time, however, the proportion of smokers and consumers of strong alcohol has not decreased. Moreover, there has been an explosive increase of new cases of HIV-infections in 2000, which is one of the most serious public health problems today. Greater progress has been achieved in the areas where health promotion and health education activities have been supported by political decisions to make a healthy choice for the population easier. However, a comprehensive national health policy and strategy is still lacking in Estonia. In public health, this is evidenced by a lack of long-term planning and understanding of the significance of intersectoral co-operation. Discussion. Up to now, the major reforms in the Estonian health system have been implemented. However, the environment is changing and the health system has to respond to these changes. The next step should therefore be to reach a public agreement about the common values of the health system and setting long-term health policy goals. To improve the effectiveness of policy implementation and reform, the importance of systematic research and evaluation should also be stressed.

It has long been argued that the organization of the U.S. health care system is shaped by the struggles between capital and labor, and this relationship is of increasing significance today. Transformations from an industrial to a service economy, rising insurance costs, neoliberal social policies, and decreased labor union power have increased the number of Americans with reduced access to health care, especially for service workers and women. This dissertation is an ethnographic study of how workers in two leading unions in the “new” unionism movement, the Retail, Wholesale, and Distribution Service Union (RWDSU) and the United Steelworkers (USW) in urban Central Appalachia, characterize union membership and economic (and benefit) transformations that threaten security for working and middle class families. Using health care as a case study, this dissertation demonstrates the ways in which economic transformations are making health care less affordable for working and middle class families. Through a discussion of the importance of union membership that highlights job protection in the face of the expansion and increasing feminization of service work and the decline in work sponsored benefits, this dissertation details how these processes reduce access to and affordability of health care. In so doing, this research highlights individual pragmatic action and broader union activism in seeking economic and health security for their families. More broadly, new unionism tactics are described in the actions of a Central Labor Council as it seeks to renew community alliances and link rank-and-file concerns of job security to current labor issues, including the Employee Free Choice Act and Right-to-Work legislation, on local, state, and national levels. This dissertation links access to health care problems in this community to broader national issues (e.g. job protection, service work, and outsourcing) and highlights how union members, individually and collectively, are participating in “new” unionism tactics to maintain job security and secure resources, including health care, for their families.

Objetivos: Apresentar características do processo migratório de Bolivianos no Município de São Paulo, explorando, num contexto de saúde global, a relação entre os Sistemas de saúde do Brasil e da Bolívia; destacando os respectivos processos históricos, noções de acesso universal e semelhanças que possam vir a ser fundamentais na compreensão da problemática específica da alta incidência de Tuberculosos entre bolivianos residentes na capital do Estado de São Paulo. Métodos: Trata-se de um estudo de abordagem qualitativa e exploratória em que foi realizado um levantamento teórico bibliográfico capaz de apresentar a problemática do tema. Dentre os métodos foi utilizado o descritivo e a pesquisa histórica para caracterizar os processos de implementação e reforma dos sistemas de saúde do Brasil e da Bolívia. Resultados: As fortes correntes migratórias internacionais levam a uma discussão do papel do Estado na garantia dos direitos do migrante, dentre eles, o acesso universal a saúde. Neste trabalho foi possível caracterizar a dinâmica do mundo em constante modificação e ausência de fronteiras no contexto da saúde globalizada. Usando como base o imigrante Boliviano com Tuberculose no Município de São Paulo, analisou-se os Sistemas de Saúde Universal Brasil e Bolívia. Por fim, através deste trabalho foi possível perceber que após o processo migratório há uma combinação de fatores que propiciam o aumento de TB nesta comunidade. / Objective: We attempted to present some of the characteristics of the migratory process of Bolivians in São Paulo. We attempted to observe the relationship between the health systems of Brazil and Bolivia. We observe the historical processes of creation of two health systems; highlight how countries perceive universal access to healthcare. And we highlight the similarities and differences of the two health systems. The purpose is that this will serve to help understand the high incidence of tuberculosis in the Bolivian citizens living in Sao Paulo. Methods: This is a qualitative and exploratory study. This study conducted a bibliographical theoretical research. This served to explore the issue of Bolivians in São Paulo. The main method used was a descriptive and historical research. This allowed the characterization of the processes of implementation and reform of health systems in Bolivia and Brazil. Results: This study shows that international migration flows have resulted in a renewed discussion of the role of the state in ensuring the rights of migrants. This discussion was particularly seen in the problem of universal access to healthcare. In this work it was possible to characterize the dynamics of the ever-changing world. We also observed the lack of geographical boundaries in the context of global health. When looking at the case of Bolivian immigrants with tuberculosis in São Paulo, we analyzed the relevance of the differences between Universal Health Systems in 9 Brazil and Bolivia. Finally, this worked allowed to realize that the migratory process of Bolivians to Sao Paulo consists of a combination of factors that potentiate the increase of tuberculosis in this immigrant community.

O Sistema Único de Saúde estabelece a Unidade Básica de Saúde como porta de entrada para o atendimento aos problemas/demandas de saúde. É nesse espaço, tradicionalmente conhecido como recepção e, mais recentemente como acolhimento, que as demandas dos usuários devem ser apresentadas e confrontadas com as possibilidades do serviço em responder a elas. O estudo teve como objetivo geral, caracterizar a atividade de recepção dos usuários do setor Saúde da Criança de uma Unidade Básica de Saúde, e como específicos, identificar e analisar as demandas por assistência à saúde que emergem na atividade de recepção e caracterizar e analisar as respostas oferecidas pelo serviço. Trata-se de um estudo de caso, com abordagem qualitativa que integrou um projeto mais amplo aprovado por Comitê de Ética em Pesquisa, desenvolvido em um Centro de Saúde Escola. A observação livre foi utilizada para a coleta dos dados, realizada durante duas semanas típicas de agosto de 2007, por observadores treinados que conheciam o serviço. A amostra foi constituída por 42 observações, conduzidas na recepção do setor saúde da criança. Os sujeitos da pesquisa foram os trabalhadores de enfermagem que desempenhavam a atividade de recepção e os respectivos usuários que demandavam o atendimento. Para a análise, os dados registrados nas observações foram digitados e inseridos no software para pesquisa qualitativa N-Vivo 8, que ajudou a sistematizar a análise. Os textos foram submetidos à análise de conteúdo que resultou nas seguintes categorias: cumprimentos, demandas apresentadas pelos usuários, investigação por parte do trabalhador, respostas oferecidas pelos trabalhadores, supervisão e queixa do serviço. Os resultados evidenciaram que os usuários demandavam o serviço com diferentes necessidades, porém destacaram-se as demandas de ordem biológica, seguida de acesso a cuidado programado, que em sua maioria relacionava-se à solicitação de consulta médica. A investigação do trabalhador de enfermagem limitou-se à própria queixa, restringindo-se ao âmbito biológico. Entretanto, houve investigações ampliadas para além do biológico. Em relação à resposta do trabalhador, as mais expressivas referiram-se a 23 encaminhamentos para atendimento fora do dia (atendimento médico equivalente ao pronto atendimento), nove agendamentos para consulta de enfermagem e quatro para consulta médica. Apenas um caso foi encaminhado para atendimento de enfermagem e um caso para grupo de aleitamento materno. A supervisão ocorreu somente em quatro casos. Constatou-se um esforço do trabalhador em oferecer a consulta de enfermagem como alternativa para a resolução da demanda apresentada, além da tentativa de garantir a entrada da criança ao serviço por meio da queixa clínica. Entretanto, várias queixas relacionadas à dificuldade de acesso foram evidenciadas. A investigação evidenciou que a equipe de enfermagem basicamente desenvolveu como atividade de recepção encaminhamentos que prioriza o atendimento individual. Permanece, portanto, como desafio, a reorganização do serviço, com vistas à real implantação do acolhimento como diretriz para a atuação da equipe, no sentido de cumprir os princípios do Sistema Único de Saúde / The Brazilian National Health System sets the Primary Care Services as a gateway for attending the problems/needs of health. Its in this place, traditionally known as reception and, more recently as welcoming, that users needs must be presented and confronted to the possibilities of the service to answer for them. This study had as the overall objective to characterize the activity of reception for the users of Child Health Sector of the one Primary Care Service. The specifics objectives were to identify and analyze the needs for healthcare presented in the reception and to characterize and analyze the answers offered by the service. Its a study of case, with qualitative approach, which was part of a broader Project approved by the Ethical Committee in Research, developed in a Health-School Center. Data were collected through free observation during two typical weeks of August 2007, by trained observers who knew the service. The sample consisted of 42 observations, conducted at the reception area of Child Health Sector. The subjects were nursing workers who performed the reception activity and the respective users who needed the attendance. For the analysis, registered data of the observations were typed and inserted in the N-Vivo 8 software program for the qualitative research, which helped to systematize the analysis. The texts were submitted to content analysis, which resulted in the following categories: greetings of the worker, problems presented by users, inquiry and answer provided by the workers, supervision and complaint of service. The results showed that users demanded services with different needs. The biological problems were predominant, followed by access to care programs, which mostly related to the request for medical appointment. The inquiry of nursing worker was limited to the complaint itself, getting restricted to the biological scope. However, there were some inquiries beyond the biological. Regarding to the workers answer, the most expressive ones were related to 23 referrals for unscheduled attendance (medical attendance equivalent to the emergency attendance), nine appointments for nursing consultation and four for the medical one. Only one case was referred to nursing attendance as an alternative for solving the problem. The supervision occurred only in four cases. There was an effort of the workers to provide consultation to nursing as an alternative to resolving the demands presented in addition to trying to ensure the child\'s access to the service through clinical complaint. However, several complaints related to the difficulty of access were evidenced. This research showed that the nursing staff basically carried on activity of reception, referrals that prioritizes individual care. Therefore, it remains as challenge, the reorganization of service, for the implementation of welcoming as a guideline for the performance of team of nurse, to meet the principles of the Brazilian National Health System

A busca por um serviço adequado às necessidades dos usuários, com qualidade, resolutivo e capaz de estabelecer um novo processo de trabalho centrado no usuário gerou um dos princípios do Sistema Único de Saúde (SUS) caracterizado pelo acesso universal, onde a utilização dos serviços de saúde representa o centro do funcionamento dos sistemas de saúde. Este estudo do tipo quali-quantitativo, tem por objetivo analisar o acesso aos serviços e o que ele representa em relação ao Sistema Único de Saúde (SUS). Procurou-se destacar as dificuldades e os possíveis meios facilitadores para sua prática diária na perspectiva de profissionais de saúde e usuários em três unidades de saúde, com diferentes estratégias de atendimento. Foram aplicados questionários com perguntas fechadas semiestruturadas e abertas, cujos resultados foram submetidos à análise quantitativa, pela técnica descritiva de análise de frequência, e análise qualitativa pela técnica da análise do conteúdo. Durante a aplicação dessa modalidade qualitativa de pesquisa aplicada aos profissionais surgiu uma categoria: Qualificação do acesso, meios inclusivos e meios excludentes. Em relação aos usuários as categorias emergentes foram as que constituem as dimensões do acesso sistematizado por Fekete: geográfica, organizacional (obstáculos na entrada e pós-entrada), sociocultural e econômica. Os resultados encontrados foram os seguintes: Para os profissionais foi garantir o acesso aos serviços com qualidade. Essa pesquisa demonstrou que a falta de informação é um obstáculo para os usuários acessarem os serviços de saúde. Verificou-se também a dificuldade que usuários possuem em acessar os serviços especializados. Notou-se a importância do acolhimento e o estabelecimento de vínculo entre profissionais e usuários para um melhor atendimento. / The search for an adequate service to the needs of users with quality, resolute and able to establish a new work process focused on user generated one of the principles of the Unified Health System (SUS) characterized by universal access, where the use of service health is the center of the functioning of health systems. This study of qualitative and quantitative, aims to analyze access to services and what it represents in relation to the Unified Health System (SUS). Sought to highlight the difficulties and possible facilitators means for their daily practice from the perspective of health professionals and patients in three health units with different strategies of care. Questionnaires were applied with semi-structured questions closed and open, the results were subjected to quantitative analysis by descriptive technique of frequency analysis, qualitative analysis and the analysis of the technical content. During the application of qualitative research method applied to professional came a category: Access Qualification, inclusive and exclusive media means. Regarding users emerging categories were those which constitute the dimensions of access systematized by Fekete: geographic, organizational (obstacles in the entry and post-entry), socio-cultural and economic. The results were as follows: For professionals was to ensure access to quality services. This research has shown that lack of information is an obstacle for users to access health services. There was also the difficulty that users have in accessing specialized services. It was noted the importance of acceptance and the establishment of relationship between professionals and users to a better care.

Objetivos: O objetivo deste estudo foi avaliar o acesso ao diagnóstico e ao tratamento de doentes com Tuberculose e coinfectados pelo HIV, no município de São José do Rio Preto- SP. Materiais e Métodos: Trata-se de uma pesquisa avaliativa, de abordagem quantitativa que utilizou o modelo de estudo transversal. Foram entrevistados 106 doentes no período de junho de 2006 a julho de 2007, que estavam em tratamento nas Unidades de Saúde que desenvolvem o Programa de Controle da Tuberculose (PCT) do município. Utilizou-se o instrumento \"Primary Care Assessment Tool,\" adaptado para atenção à tuberculose. Para análise dos dados foram usadas técnicas de estatística descritiva como análise de freqüência, média, desvio-padrão, intervalo de confiança, teste t de Student e teste de Mann-Whitney Resultados: Dos 106 doentes entrevistados, 11 foram excluídos por não terem sido submetidos ao teste de anti HIV Desta forma 95 doentes participaram deste estudo, sendo que 76,8% apresentavam TB e não-coinfecção pelo HIV e 23,2% apresentavam TB e coinfecção pelo HIV. A maioria (66,3%) era do sexo masculino, 69,5% possuia ensino fundamental, 50,5% declarou residir em casa própria e 98,9% possuia casa de alvenaria. A partir dos dados observados houve diferenças estatisticamente significativas quanto as variáveis acesso ao diagnóstico cujos doentes com TB e coinfectados quase nunca ou às vezes procuram o posto de saúde mais próximo da residência e os doentes com TB quase sempre procuram o posto de saúde mais próximo da residência. Como também, houve diferenças estatisticamente significativas no acesso ao tratamento sendo que, o profissional da saúde visita mais vezes os doentes acometidos pela coinfecção quando comparados com os doentes que não apresentam a coinfecção e os doentes coinfectados quase nunca realizam o tratamento da doença em um posto de saúde perto da residência. Considerações finais: Os resultados do estudo apontam para a necessidade de maior integração e comunicação entre o PCT e o DST/Aids, fator este, considerado como facilitador tanto no acesso dos doentes ao diagnóstico quanto ao tratamento da doença. / Objetives: The aims of this study were to characterize the patients with Tuberculosis and coinfected with AIDS as to their sociodemographic aspects (gender, schooling, place of living and type of residence); to analyze the access to the diagnose and treatment of these patients; to identify the disagreements among groups of patients with TB and those co-infected with TB/AIDS regarding the access to diagnose and treatment and in this way to evaluate the access to diagnose and treatment of persons with Tuberculosis and co-infected with HIV living in São José do Rio Preto, São Paulo State. Material and Methods: This is an evaluative research with a quantitative approach using a cross-sectional study model developed at the Health Units developing the Tuberculosis Control Program (TCP) in São José do Rio Preto. The patients received medical attention from June 2006 to June 2007. Techniques of descriptive analysis were used to analyze the data, such as frequency analysis, mean (average), standard deviation, and confidence interval. Results: Of the 106 patients interviewed 11 were excluded because they have not done the anti-HIV test. Therefore, the study population was composed of 95 patients. Of these, 76.8% presented TB and not coinfection with HIV, and 23.2% presented both TB and co-infection with HIV. The majority (66.3%) was male, 69.5% have Elementary Education, 50.5% reported to be homeowners, and 98.9% live in a brick-made house. From these results, we can imply that there were statistically significant differences as to the variables access to diagnose of those patients with TB and those co-infected who hardly ever or sometimes seek for the nearest Health Unit, and the patients with TB who most of the time seeks for the nearest Health Unit. There have been also statistically significant differences as to the access to treatment once the health professional visits more times the patients with co-infection in comparison to the patients who did not present co-infection and those co-infected. The co-infected patients hardly ever receive treatment at the nearest Health Unit. Final Comments: The study results point out to the necessity of a greater integration and communication between both programs TCP and sexually transmitted disease - aids (STD/AIDS). This factor is considered as a facilitator to both the access of patients to diagnose and treatment of the disease.