Submitted by Renata Lopes (renatasil82@gmail.com) on 2017-05-11T11:12:28Z No. of bitstreams: 1 fabianaericadesouza.pdf: 846109 bytes, checksum: c389e51ef160b3fc341e50a829e8f0a4 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2017-05-11T13:25:53Z (GMT) No. of bitstreams: 1 fabianaericadesouza.pdf: 846109 bytes, checksum: c389e51ef160b3fc341e50a829e8f0a4 (MD5) / Made available in DSpace on 2017-05-11T13:25:53Z (GMT). No. of bitstreams: 1 fabianaericadesouza.pdf: 846109 bytes, checksum: c389e51ef160b3fc341e50a829e8f0a4 (MD5) Previous issue date: 2017-02-21 / Introdução: Além das implicações que o uso abusivo de substâncias psicoativas pode ocasionar para a vida das pessoas, há um conjunto de crenças e percepções dos profissionais de saúde que pode contribuir para o aumento das barreiras relacionadas ao acesso e vinculação dos usuários de álcool e outras drogas aos serviços de saúde existentes. Estudos apontam que a capacitação dos profissionais da atenção primária para a compreensão do contexto em que se situa o usuário e o uso de drogas é uma das necessidades para o alcance do cuidado integral a este público alvo. Objetivos: Este estudo visa analisar os saberes e práticas de agentes comunitários de saúde (ACS) capacitados pelo Projeto Caminhos do Cuidado, direcionados a usuários de álcool e outras drogas à luz da estratégia de redução de danos. Método: Esta pesquisa utilizou o método qualitativo, realizando entrevistas semi-estruturadas como fonte de coleta de dados e análise de conteúdo para a sistematização dos dados. Foram entrevistados seis ACS, atuantes em equipes da Estratégia Saúde da Família (ESF) do município de Ubá, MG. Resultados: Os dados demonstram que mesmo aqueles profissionais que conhecem o conceito de redução de danos e relatam a possibilidade de utilizar-se desta abordagem para o cuidado de usuários de álcool e outras drogas no contexto da atenção primária, não conseguem ofertar cuidados que se aproximam desta estratégia. Isto ocorre uma vez que os entrevistados não respeitam a liberdade de escolha, pautam-se pelo proibicionismo e pelo ideal de abstinência. Esta dificuldade prática em desenvolver o cuidado baseado nesta abordagem se relaciona com a percepção moralizante sobre o uso de drogas, sua associação ao crime e o foco na possibilidade de se extinguir o uso de drogas das sociedades. Considerações finais: A adesão às práticas pautadas na abordagem de redução de danos passa pela discussão do papel das drogas na sociedade, estando relacionada à percepção que os profissionais possuem do uso e do usuário de drogas. Para avançar em direção a este cuidado na atenção primária é necessário investir em práticas de matriciamento que podem e devem ser ofertadas pelos Núcleos de Apoio à Saúde da Família, pelos CAPS e demais equipes, de forma a redefinir as práticas dos profissionais de maneira permanente. / Introduction: Besides the implications that abusive use of psychoactive substances can cause on people's lives, there is a set of beliefs and perceptions of health professionals that can contribute to the increase of barriers related to access and attachment of alcohol and other drugs to existing health services. Studies point out that the training of primary care professionals to understand the context in which the user is located and the use of drugs is one of the necessities to reach the integral care of this target public. Objectives: This study aims to analyze the knowledge and practices of Community Health Agents trained by the Care Pathway Project, aimed at users of alcohol and other drugs from the perspective of the Harm Reduction (HR) strategy. Method: This research used the qualitative method, performing semistructured interviews as a source of data collection and analysis of content for data systematization. Six Community Health Agents were interviewed, working in teams of the Family Health Strategy of Ubá, MG. Results: The data show that even those professionals who know the concept of HR and report the possibility of using this approach to care for alcohol and other drug users in the context of Primary Health Care cannot provide care that is close to this strategy. This occurs because the interviewees do not respect freedom of choice, they are based on prohibitionism and the ideal of abstinence. This practical difficulty in developing care based on this approach is related to the moralizing perception about drug use, its association with crime and the focus on the possibility of extinguishing the use of drugs by societies. Final considerations: The adhesion to practices guided by the HR approach involves the discussion of the role of drugs in society and is related to the professionals' perception of the use of drugs and their users. In order to move towards this care in primary attention, it is necessary to invest in parenting practices that can and should be offered by the Primary Health Care Nucleus, the Psychosocial care center and other teams, in order to redefine the practices of professionals on a permanent basis.

A l'adolescence, les patients porteurs de maladie chronique depuis l'enfance passent une étape de transition des soins, qui implique la sortie des services pédiatriques et l'entrée dans les services pour adultes. Cette étape pose de nombreux défis et elle est reconnue comme une période à risque de rupture de soins. Pour éviter ces situations, des recommandations internationales et des programmes variés ont été proposées. En France, il n'existe pas de recommandation générique pour la transition. Notre objectif était de proposer un programme générique, pertinent et faisable pour la transition des jeunes porteurs de maladies chroniques variées dans un grand nombre de services en France. Pour cela nous avons employé une méthode mixte : 1) Revue systématique des études interventionnelles au niveau international ; 2) Enquête qualitative des pratiques de transition existantes dans un ensemble de services hospitaliers d'Ile de France ; 3) Enquête de consensus national pour l'élaboration d'un programme de transition pertinent et faisable par la méthode Delphi. Nous avons observé que l'existence de programmes de transition était très dépendante des services : certains ne proposant pratiquement aucune adaptation de la prise en charge, d'autres proposant des programmes très structurés. Globalement, les programmes sont peu spécifiques des pathologies. A l'issue de ce travail de thèse, nous avons proposé un programme générique qui peut être considéré comme un tronc commun. Il pourra notamment permettre aux professionnels impliqués dans le suivi de pathologies peu étudiées dans le contexte de la transition de proposer des pratiques essentielles et minimales aux patients concernés. / At the end of their adolescence, patients with chronic disease since childhood go through a phase of healthcare transition, which involves the discharge of pediatric services and the entry into adult care services. This step poses many challenges and is recognised as a high risk period of discontinuity in care pathway. To avoid these situations, international recommendations and various programs have been proposed. In France, there is no generic recommendation for transition to adult care.The final goal of this thesis work was to propose a generic, relevant and feasible program for the transition of young people with varied chronic diseases into a large number of services in France.For this purpose, we used a mixed method research including: 1) Systematic review of intervention studies at the international level; 2) Qualitative study of existing transition practices in a set of hospital services in the Ile de France region (including Paris and its surroundings); 3) National consensus survey for the development of a relevant and feasible transition program using the Delphi method.We observed that the existence of transition programs was highly dependent on services: some offering almost no adaptation of care during this process, others offering highly structured programs. Overall, the programs were not really specific to pathologies.At the end of this thesis work, we proposed a generic program which can be considered as a common core of transition practices. Among other thing, it will allow professionals involved in the follow-up of pathologies that are under-studied in the context of the transition to propose essential and minimal practices to their patients.

Patient-centredness and patient empowerment have been gaining importance in health policy and society already since the 1990s (Fumagalli et al. (2015), Castro et al. (2016)). For example, increasing patient empowerment has been one of the declared national health objectives in Germany since 2003 because patient orientation and participation provide important impulses for a demand-oriented and efficient design of healthcare systems and services (Bundesministerium für Gesundheit (2018)). A transition is taking place from an institution-based view of care provision to a more patient-based view that considers patients as co-managers of their individual care process and well-being (Kayser et al. (2019)). This transition also encompasses the developments towards integrated care1, i. e. a closer coordination between inpatient, outpatient and home care services, broadening the traditional focus from acute care to better integrate healthpromoting, preventive and post-treatment or palliative services as part of the whole continuum of care across sector boundaries (Minkman (2012), World Health Organization (2016), Expert Group on Health Systems Performance Assessment (2017)). These developments are particularly relevant for patients with long-term, chronic diseases or multimorbidities as their needs are often more complex and not exclusively medically determined (Smith and O’Dowd (2007), Hujala et al. (2016)).

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Background: Antenatal Psychosocial Assessment (APA) has recently been introduced into routine antenatal care, but the ways in which maternity service providers assess and respond to maternal stress are subject of debate. There is a lack of consensus on the instrument(s) of choice and lack of evidence regarding appropriate interventions. Further, national guidelines have not kept apace with the conceptual shift from ‘postnatal depression’ to ‘perinatal anxiety and depression’. Adopting the Medical Research Council Complex Interventions Framework, the ARMS research aimed to inform the development of interventions that support women who are experiencing, or at risk of, mild-moderate mental health disorder in pregnancy. Methods: A mixed methods approach was adopted. In the quantitative element (Study Part 1) participants (n=191) completed a questionnaire when attending for their first formal antenatal appointment, using a procedure and materials that had been previously tested in a pilot study. Details including mental health assessment and referrals were obtained from their health records, following delivery. In the qualitative element (Study Part 2) a sub-sample of women (n=22) experiencing high levels of maternal stress took part in up to three serial in-depth interviews during pregnancy and the early postnatal period.Findings: Maternal stress was found to be common. Using the Edinburgh Postnatal Depression Scale (EPDS) threshold of ≥10, approximately 1 in 4 women were classed as high depression (halving to 1 in 8 at the more conservative threshold of ≥13). Almost 1 in 3 women were classed as high anxiety, using the state scale of the State-Trait Anxiety Inventory (STAI-S, threshold ≥41), compared with 1 in 5 using the two-item GAD (threshold ≥3). Fewer than half of the women identified as high anxiety were identified by both measures. Factor analyses of the symptom measures were consistent with wider literature suggesting a three-item anxiety component of the EPDS; however, concurrent validation using regression analyses did not indicate that the EPDS could be used as an anxiety case finding instrument. Women reported that maternal stress had significant impact on their lives that may not be captured with existing clinical approaches. Women commonly found it difficult to self-assess severity of maternal stress and the assessment process could itself act as an intervention. The research provided the first validation of the depression case finding questions in UK clinical practice. The Whooley items completed in clinical practice identified only half of the possible cases identified by the EPDS, at both commonly adopted EPDS thresholds. Inclusion of the Arroll 'help' question as a criterion improved specificity of the assessment completed in clinical practice but substantially compromised sensitivity, missing 9 in 10 possible cases. Women’s mental health history and treatment history were similarly under-reported, particularly concerning anxiety. APA was introduced into routine clinical practice without attention to topics of relevance to women, context of disclosure or to provision of adequate resources for consistently responding to identified need. Women experiencing, or at risk of, mild-moderate disorder were thus usually ineligible for further support. Implications: Care pathways are needed that encompass both assessing and responding to maternal stress, where communication with health professionals, subsequent referral and management are addressed. The development, implementation and evaluation of low-cost resources embedded in such pathways are a priority and the research presented in the thesis offers a foundation on which to build.