Orientador: Luciane Miranda Guerra / Dissertação (mestrado profissional) - Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba / Made available in DSpace on 2018-08-24T15:51:59Z (GMT). No. of bitstreams: 1 Gouvea_GiovanaRenata_M.pdf: 538374 bytes, checksum: 2e8ad5071e1ef0c3d82469fbc7c222c8 (MD5) Previous issue date: 2014 / Resumo: Em 2013, mais de 250 mil Agentes Comunitários de Saúde (ACS) e mais de 22 mil Equipes de Saúde Bucal (ESB) estavam atuando no Brasil com a finalidade de colaborar nas ações de promoção da saúde, na prevenção das doenças e de contribuir para fortalecer a capacidade da população no enfrentamento dos problemas de saúde. A proposição do presente estudo do tipo transversal foi: comparar o processo de trabalho e o conhecimento em saúde bucal de ACS que atuam com e sem Equipe de Saúde Bucal. No total, 162 sujeitos participaram do estudo, sendo 81 ACS vinculados a Unidade de Saúde da Família com Equipe de Saúde Bucal e 81 ACS vinculados a Unidade de Saúde da Família sem Equipe de Saúde Bucal. Foi utilizado um formulário contendo dados de renda, escolaridade e tempo de serviço como ACS, 7 itens sobre processo de trabalho, comportamentos, autopercepção em saúde bucal e acesso das famílias ao serviço odontológico, além de 12 questões validadas sobre conhecimentos do processo saúde-doença. Foi aplicado o teste Mann-Whitney para verificar diferenças entre os grupos de ACS com relação ao conhecimento em saúde-doença bucal. Os testes Qui-Quadrado e Exato de Fischer foram utilizados para verificar diferenças entre os grupos de ACS sobre o processo de trabalho, comportamento, autopercepção e acesso. O nível de significância adotado nos testes foi de 5%. Os resultados mostraram que as diferenças observadas entre os grupos de ACS foram estatisticamente significativas (p<0,05) quando se analisou o total de escores do questionário de conhecimentos sobre saúde-doença bucal (p< 0,0021). Com relação às outras variáveis do estudo, somente as questões que abordaram o tema capacitação em saúde bucal (p<0,0002) e acesso das famílias ao serviço odontológico (p<0,0001) obtiveram diferenças estatisticamente significativas quando comparados os dois grupos de ACS. Conclui-se que o conhecimento sobre processo saúde/doença bucal dos ACS vinculados a Unidade de Saúde da Família com Equipe de Saúde Bucal é melhor, e que o número de ACS que já passou por capacitação em Saúde Bucal foi significativamente maior no grupo com ESB / Abstract: In 2013, over 250 000 Community Health Agents (ACS ) and more than 22 thousand Oral Health Teams ( ESB ) were working in Brazil in order to collaborate in activities promoting health, preventing disease and contribute to strengthen the capacity of the population in coping with health problems. The proposition of this cross-sectional study was: to compare the work process and knowledge of oral health that act ACS with and without Dental Health Team. In total, 162 subjects participated in the study, with 81 linked ACS Unit Family Health Oral Health Team with ACS and 81 linked to the Family Health Unit without Dental Health Team. A form containing data on income, education and tenure as ACS, 7 items on the work process, behavior, self-perception of oral health and household access to dental care was used, and 12 validated questions on knowledge of the health- disease. The Mann- Whitney test was used to evaluate differences between groups of ACS with regard to knowledge in oral health and disease. The Chi-square and Fisher's Exact tests were used to assess differences between groups of ACS over the work process, behavior, self-awareness and access. The significance level used in the tests was 5 % . The results showed that the observed differences between the groups of ACS were statistically significant (p < 0.05) when analyzing the total scores of knowledge about oral health and disease (p < 0.0021) questionnaire. Regarding other variables in the study, only questions that focused on training in oral health (p < 0.0002) and household access to dental care (p < 0.0001) had statistically significant differences when comparing the two groups of ACS . We conclude that knowledge about oral health/disease linked to the ACS Unit Family Health with Dental Health Team process is better, and that the number of ACS who has had training in oral health was significantly higher in the group with ESB / Mestrado / Odontologia em Saude Coletiva / Mestra em Odontologia em Saúde Coletiva

Orientador: Fabio Luiz Mialhe / Dissertação (mestrado profissional) - Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba / Made available in DSpace on 2018-08-25T11:36:18Z (GMT). No. of bitstreams: 1 Oliveira_AnaPauladosSantos_M.pdf: 1297678 bytes, checksum: 528b0a6394cfde83f64ad68aedb28474 (MD5) Previous issue date: 2014 / Resumo: O trabalho desenvolvido pelo Agente Comunitário de Saúde tem ganhado espaço nas discussões entre pesquisadores, em função do impacto de suas ações sobre os indicadores de morbimortalidade em saúde. Contudo, identifica-se ainda uma escassez de estudos que abordem em profundidade o significado da qualidade do trabalho do Agente Comunitário de Saúde, a partir da ótica dos atores sociais envolvidos nos serviços de saúde, fator que se torna essencial para discussão e implementação de ações de assistência singular as comunidades assistidas pela Estratégia Saúde da Família. Neste contexto, buscou-se avaliar os significados da qualidade do trabalho do Agente Comunitário de Saúde, a partir da percepção dos usuários, do enfermeiro instrutor-supervisor de Unidade de Saúde da Família e do Agente Comunitário de Saúde. Para tanto, optou-se pela realização de uma pesquisa qualiquantitativa, que foi desenvolvida no município de Pirassununga-SP, com amostra probabilística de 240 usuários, distribuídas proporcionalmente por equipes da Estratégia Saúde da Família. Logo, a amostra de enfermeiros instrutores-supervisores e Agente Comunitário de Saúde foi intencional, composta por 47 Agentes Comunitários de Saúde e 09 enfermeiros instrutores-supervisores da Estratégia Saúde da Família, perfazendo um total de 296 pessoas. Os dados foram coletados através de entrevistas gravadas, posteriormente transcritas e analisados pela técnica de análise do Discurso do Sujeito Coletivo e Análise Temática de Conteúdo. Através deste estudo identificou-se que há pontos de convergência e de divergência entre os entrevistados, contudo, de um modo geral o atual trabalho desenvolvido pelo Agente Comunitário de Saúde atende as expectativas dos atores sociais que compõe o cenário da Estratégia Saúde da Família. Todavia, faz-se necessário alguns ajustes organizacionais para que todos os envolvidos possam se beneficiar diretamente com essa nova proposta de atuação, dessa categoria profissional que veio compor o Sistema Único de Saúde / Abstract: The work done by the Community Health Agent has gained ground in discussions between researchers, due to the impact of their actions on indicators of morbidity and mortality in health. However, still-identifies a shortage of studies that address in depth the meaning of quality of work of the Community Health Agent, from the perspective of the social actors involved in health services, a factor that becomes essential to discuss and implement actions singular care communities assisted by the Family Health Strategy. In this context, we sought to evaluate the significance of the quality of work of the Community Health Agent, from the perception of users, the nurse instructor-supervisor Health Unit Family and Community Health Agent. Therefore, it was decided by conducting a qualitative and quantitative survey, which was conducted in the city of Pirassununga-SP, with a random sample of 240 users distributed proportionally by teams of the Family Health Strategy. Therefore, the sample of nurses, instructors and supervisors Community Health Agent was intentional, consisting of 47 community health workers and nurses 09 trainers-supervisors of the Family Health Strategy, totaling 296 people. Data were collected through interviews recorded, transcribed and analyzed using analysis of Collective Subject Discourse and Thematic Content Analysis. Through this study it was identified that there are points of convergence and divergence among respondents, however, generally the actual work done by the Community Health Agent meets the expectations of social actors that make up the landscape of the Family Health Strategy. However, it is necessary that some organizational adjustments so that everyone involved can benefit directly from this new proposed action, this professional category that came to compose the Public Health System / Mestrado / Odontologia em Saude Coletiva / Mestra em Odontologia em Saúde Coletiva

While the concept of the community health worker (CHW) has existed since the mid-20th century, their function as a legitimate branch of the broader workforce in the United States has been tenuous. Their unique roles have the potential to reduce health disparities within marginalized communities, but stakeholder development of this position risks diminishing the crucial skills of these workers. Anthropological research on these workers has typically assessed them in the developing world, while public health research has focused primarily on their ability to impact specific health outcomes through quantitative studies. As a result of the limited and predominantly quantitative assessments of these workers, further research is needed to assess the lived realities of these workers at the grassroots level in the United States. The overarching aim of this project was to document the lived experience of CHWs in Indiana. Additionally, this project assessed their participation in advocacy and the impact of policy development on these workers. A collaborative approach was utilized in this project that embedded the researcher within a CHW organization while also amplifying the voice of the research partners. The project drew on the theoretical lenses of moral economy, deservingness, structural vulnerability, and the “regimes of care” and “politics of care.” The results demonstrate that CHWs face a variety of challenges within the professional workforce but have significant impacts within their communities. These workers emphasize empowerment through advocacy and building client self-sufficiency. Their participation in advocacy is split between impacts at the micro-, macro-, and professional-level. However, legislating the scope and responsibilities of this position by stakeholders unfamiliar with this model risks changing the foundation of the position itself. Steps to incorporate CHWs within the workforce must be collaborative and take into account their lived experience and input in order to allow them agency over the development of their position and to retain the most significant contributions. The contributions of this project are severalfold. First, this project advances theoretical debates within anthropology related to moral economy, regimes of care, politics of care while also addressing the legitimacy of CHWs as a complimentary member of the health care workforce. The findings also illustrate how the political economy of Indiana shapes the moral economy of care within which CHWs operate. Lastly, the project produced applied findings for CHWs, employers, and stakeholders to consider in further development of this position.

Sensory inputs of hearing and vision during early childhood development support the achievement of language, speech and educational milestones. The early detection of sensory impairment is essential for facilitating early childhood development, socio-emotional well-being and academic success, in addition to obtaining sustainable educational development goals. The majority of children with sensory impairment live in low- and middle-income countries where services are often unavailable or inaccessible, because of the absence of systematic screening programmes for children, prohibitive equipment cost, a shortage of trained personnel and centralised service-delivery models. Therefore, research is needed to investigate whether a community-based mobile health (mHealth) supported service-delivery model for hearing and vision screening can increase access to hearing and vision services for children in resource-constrained settings. This study aimed to describe an implemented hearing and vision screening programme and evaluate its success in terms of acceptability (consent return numbers), coverage (number of eligible children screened), referral rates and quality indicators (duration of tests and number of hearing tests conducted under conditions of excessive noise levels). The study also explored the challenges faced during a community-based screening programme and the strategies developed to address these. Four non-professionals were appointed and trained as community health workers (CHWs) to conduct combined sensory screening using mHealth technology (hearScreen application, hearXGroup, South Africa and Peek Acuity application, Peek Vision, United Kingdom) on smartphones at preschools in low-income communities in Cape Town, South Africa. The consent form return rate was 82.0%, and the coverage rate was 94.4%. An average of 501 children were screened each month, at a cost of US$5.63 per child. The number of children who failed hearing and vision screening was 435 (5.4%) and 170 (2.1%), respectively. Failing of hearing tests was associated with longer test times (odds ratio [OR]: 1.022; 95% confidence interval [CI]: 1.021–1.024) and excessive background noise levels at 1 kHz (e.g. OR for left ear: 1.688; 95% CI: 1.198–2.377). Failing of visual screening tests was associated with longer test duration (OR: 1.003; 95% CI: 1.002–1.005) and younger age (OR: 0.629; 95% CI: 0.520–0.761). The study also aimed to describe and compare the performance of two screening protocols that were used in this preschool hearing screening programme to determine optimal referral criteria that is responsive to available resources. Secondary data analysis was done to compare a protocol using a single-frequency fail criterion (which 2,147 children were screened with between 1 October 2017 and 25 February 2018) with a screening protocol using a two-frequency fail criterion (which 5,782 children were screened with between 26 February 2018 and 30 November 2018). For both protocols, screening was done at a 25 dB hearing level (HL) at 1000, 2000 and 4000 Hz. Both protocols included an immediate rescreen at the frequencies that were failed. The referral rate was 8.7% (n = 186) for the one-frequency fail protocol and 4.3% (n = 250) for the two-frequency fail protocol. Compared to the one-frequency fail protocol, children screened with the two-frequency fail protocol were 52.9% less likely to fail (OR: 0.471; 95% CI: 0.385–0.575). Gender (OR: 0.807; 95% CI: 0.531–1.225) and age (OR: 0.996; 95% CI: 0.708–1.402) had no significant effect on screening outcomes. Maximum permissible ambient noise levels (MPANLs) were exceeded in 44.7% of cases in at least one ear at 1000 Hz across both protocols. There was no significant difference between the protocols for both true positive cases and false positive cases. Protocol (OR: 1.338; 95% CI: 0.854–2.098), gender (OR: 0.807; 95% CI: 0.531–1.225) and age (OR: 0.996; 95% CI: 0.708–1.402) demonstrated no significant effect on the odds of producing true positive results. Average time for conducting the screening was 72.8 s (78.66 SD) for the one-frequency fail protocol and 64.9 s (55.78 SD) for the two-frequency fail protocol. Estimating the prevalence and describing the characteristics of sensory loss in a preschool population in low-income communities are important steps to ensure adequate planning and successful implementation of community-based hearing and vision care in this context. The study therefore also investigated the prevalence and characteristics of hearing and vision loss among preschool children (4 to 7 years) in an underserved South African community after implementing mHealth-supported community-based hearing and vision services. Children who failed hearing and vision screening were seen for follow-up assessments at their preschools. Follow-up assessments were also performed with smartphones and hearing and vision testing applications (hearTest application, hearX Group, South Africa and PeekAcuity app, Peek Vision, United Kingdom). A total of 10,390 children were screened at 298 preschools over 22 months. Of the children screened, 5.6% and 4.4% of children failed hearing and vision screening, respectively. Community-based follow-up hearing tests were done at the preschools on 88.5% (514) of the children, of whom 240 children (54.2% female) presented with hearing loss. A preschool-based follow-up vision test was conducted on 400 children (88.1%). A total of 232 children (46.1% female) had a vision impairment, and a further 32 children passed the test but had obvious signs of ocular morbidity. Logistic regression analysis found that age was a significant predictor of vision loss (p < 0.001): with every 1-year increase in age, participants were 51.4% less likely to have vision loss (OR: 0.49, 95% CI: 0.39–0.60). Age was not a significant predictor for hearing loss (OR: 0.821; 95% CI: 0.667–1.011). Gender was not a significant predictor of hearing loss (OR: 0.850; 95% CI: 0.658–1.099) or vision loss (OR: 1.185; 95% CI: 0.912–1.540). The prevalence of hearing loss at a pure tone average (PTA) of 25 dB HL ranged between 2.3% (240 out of 10,390; assuming none of the non-attenders and children who were unable to be tested had hearing loss) and 3.1% (321 out of 10,390; assuming all the non-attenders and children who were unable to be tested presented with hearing loss). The prevalence of vision loss ranged between 2.2% (232 out of 10,390; assuming none of the non-attenders had vision loss) and 2.8% (286 out of 10,390; assuming all the non-attenders presented with vision loss). Findings of this research project indicate that mHealth-supported CHW-delivered hearing and vision screening in preschools provide a low-cost, efficient and accessible service that can improve the provision of affordable hearing and vision care. This service-delivery model is affordable and scalable, because the same staff, needing minimal training, and the same equipment are used to screen for both vision and hearing. Timely identification of sensory losses is essential to ensure optimal outcomes and can be facilitated through community-based hearing and vision services by trained CHWs using mHealth technology. Future studies should aim to report on outcomes and the uptake and impact of interventions on the children diagnosed with sensory impairments following identification through a decentralised screening programme. / Thesis (PhD (Audiology))--University of Pretoria, 2021. / Sonova AG / Hear the World Foundation / Speech-Language Pathology and Audiology / PhD (Audiology) / Unrestricted

Dans de nombreux pays à travers le monde, la délégation de tâches fait partie des stratégies couramment utilisées pour optimiser la performance des organisations de santé. En Haïti, le recours aux Agents de Santé Communautaire Polyvalents (ASCP) dans l’offre des soins de santé primaire en est une application de cette stratégie. L’objectif principal visé par celle-ci est de réduire les pénuries de ressources humaines de la santé et d’améliorer la couverture sanitaire universelle. Afin de contribuer à l’atteinte de cet objectif et à l’avancement des connaissances sur la délégation des tâches aux ASCP, cette thèse aborde des questions de recherche peu étudiées, pourtant essentielles à la compréhension et à l’implantation réussie de cette intervention. Ces questions concernent le fonctionnement de la délégation des tâches aux ASCP, dont les mécanismes à travers lesquels cette intervention parvient à produire des effets positifs sur la performance des organisations de santé. Cette thèse de doctorat évalue également le bien-fondé de l’implantation de la délégation des tâches aux ASCP en Haïti, son niveau d’implantation dans le département sanitaire du nord d’Haïti et les facteurs contextuels qui facilitent ou entravent l’implantation de cette intervention dans ce département. La méthodologie utilisée à cet effet combine trois approches complémentaires. La première est la synthèse réaliste de Pawson et al. (2005). Celle-ci a été choisie pour son potentiel à offrir une compréhension approfondie du fonctionnement des interventions complexes. La seconde approche méthodologique utilisée se rapporte à l’évaluation du bien-fondé de l’implantation de la délégation des tâches aux ASCP en Haïti. Plus spécifiquement, il s’agit d’une analyse logique. Ce type d’analyse permet d’évaluer d’une part la plausibilité des hypothèses sur lesquelles reposent les interventions, et d’autre part, de déterminer l’adéquation des ressources et processus de celles-ci au regard des objectifs visés. Enfin, la troisième approche méthodologique mise en œuvre est une analyse de l’implantation. Cette dernière étudie la façon dont les interventions interagissent avec leur contexte d’implantation, y compris les facteurs contextuels qui déterminent leurs niveaux d’implantation. Pour la mener à bien, tout comme pour réaliser la synthèse réaliste et l’analyse logique de la délégation des tâches aux ASCP en Haïti, des données ont été collectées et analysées. Celles-ci proviennent essentiellement d’une recension des écrits sur la délégation des tâches aux ASCP, de l’examen des documents relatifs à la conception et l’implantation de cette intervention en Haïti et d’entrevues non dirigées réalisées auprès de 35 intervenants dans ce pays. Ce faisant, plusieurs résultats intéressants ont été obtenus. Ils apportent une contribution nouvelle à l’amélioration des connaissances sur la délégation des tâches aux ASCP. Les résultats obtenus peuvent être également utilisés pour favoriser l’implantation réussie de cette intervention en Haïti et éventuellement dans d’autres contextes. Ils incluent notamment une théorie de moyenne portée qui explique le fonctionnement de la délégation des tâches aux ASCP, ainsi que des preuves à l’appui de la plausibilité ou de la validité du modèle logique qui sous-tend l’implantation de cette intervention en Haïti. Les résultats obtenus mettent aussi en lumière plusieurs déficiences dans la conception ou planification de la délégation des tâches aux ASCP en Haïti qui peuvent être corrigées pour accroître les chances d’atteindre les objectifs visés. Parmi celles-ci, il y a l’insuffisance des ressources (financières, matérielles et humaines) planifiées ou engagées et des manquements dans la sélection des ASCP. Par ailleurs, des avancées notables ont été observées dans l’implantation de la délégation des tâches aux ASCP dans le département sanitaire du nord d’Haïti. De plus, cette thèse de doctorat révèle plusieurs facteurs contextuels entravant ou facilitant la mise en œuvre de la délégation des tâches aux ASCP dans ce département. Ceux-ci sont en lien avec la planification et le suivi de l’implantation de l’intervention, le contexte institutionnel, l’environnement politique et autres. En somme, cette thèse apporte une contribution à la compréhension du fonctionnement de la délégation des tâches aux ASCP et à la façon dont cette intervention améliore la performance des organisations de santé. Elle suggère également des pistes de recherche pour l’avancement des connaissances dans ce domaine, ainsi que des voies d’améliorations pour favoriser l’atteinte des objectifs visés par la délégation des tâches aux ASCP en Haïti ou ailleurs. / In many countries around the world, delegation of tasks is one of the commonly used strategies to optimize the performance of healthcare organizations. In Haiti, the use of Polyvalent Community Health Agents (ASCP) in the provision of primary health care is an application of this strategy. Its main objective is to reduce shortages of health human resources and improve universal health coverage. In order to contribute to the achievement of this objective and to the advancement of knowledge on the delegation of tasks to ASCPs, This thesis addresses understudied research questions, yet essential to the understanding and successful implementation of this intervention. These questions concern the functioning of the delegation of tasks to the ASCPs, including the mechanisms through which this intervention succeeds in producing positive effects on the performance of the organizations. This doctoral thesis also assesses the well-founded of the implementation of the delegation of tasks to the ASCPs in Haïti, its level of implementation in the northern health department of Haïti and the contextual factors that facilitate or hinder the implementation of this intervention in this department. The methodology used for this purpose combines three complementary approaches. The first one is the realistic synthesis of Pawson et al. (2005). This was chosen for its potential to provide an in-depth understanding of how complex interventions work. The second methodological approach used relates to the assessment of the well-founded of implementing the delegation of tasks to the ASCPs in Haïti. More specifically, it is a logical analysis. This type of analysis allows to evaluate, on the one hand, the plausibility of the hypotheses on which the interventions are based, and, on the other hand, to determine the adequacy of the resources and processes of these regarding the objectives targeted. Finally, the third methodological approach implemented is an analysis of the implementation. This approach studies how interventions interact with their implementation context, including the contextual factors that determine their levels of implementation. To carry it out, as well as to carry out the realistic synthesis and the logical analysis of the delegation of tasks to the ASCPs in Haïti, data was collected and analyzed. These come mainly from a review of the literature on the delegation of tasks to the ASCPs, an examination of the documents relating to the design and implementation of this intervention in Haiti and unstructured interviews conducted with 35 stakeholders in this country. In doing so, several interesting results were obtained. They bring a new contribution to improving knowledge about delegation of tasks to ASCPs. The results obtained can also be used to support the successful implementation of this intervention in Haiti and possibly in other contexts. They include a middle range theory that explains how delegation of tasks to ASCPs works, as well as evidences supporting the plausibility or validity of the logic model underlying the implementation of this intervention in Haiti. The results obtained also highlight several shortcomings in the design or planning of the delegation of tasks to ASCPs in Haiti that can be corrected to increase the chances of achieving the intended objectives. Among these are the lack of resources (financial, material, and human) planned or committed and the shortcomings in the selection of ASCPs. In addition, notable progress has been observed in the implementation of the delegation of tasks to the ASCPs in northern health department of Haïti. This doctoral thesis reveals also several contextual factors hindering or facilitating the implementation of the delegation of tasks to the ASCPs of this department. These relate to the planning and monitoring of the implementation of the intervention, the institutional context, the political environment, and others. In sum, this thesis contributes to the understanding of how delegation of tasks to ASCPs works and how this intervention improves performance for healthcare organizations. It also suggests avenues of research for the advancement of knowledge in this field and recommends some improvement pathways to foster the achievement of the objectives targeted by the delegation of tasks to ASCPs in Haïti or elsewhere.

The ever-increasing prevalence of diabetes mellitus and its associated healthcare costs in the United States has led to our healthcare system's need for cost-effective health resources and chronic disease management. The interventions of Community Health Workers (CHWs) can cost-effectively improve population health and prevent the unnecessary utilization of some medical services especially in rural, low-income, minority populations, where there is often limited access to healthcare. The purpose of this study is to investigate the relationship between the number of total CHWs in rural counties and the mean diabetes-related preventable hospitalization rates in Latino patients diagnosed with diabetes in those rural counties. The main goal of this research study is to contribute to the existing literature about the importance of CHWs especially in rural counties and the effect their presence has on diabetes-related preventable hospitalizations. Quantitative rural county data sets were analyzed to determine the correlation between the number of CHWs per rural county and the rate of diabetes-related preventable hospitalizations per rural county. Due to the COVID-19 pandemic outbreak, this research project was modified to be completed in a timely manner. A statistically insignificant moderately negative linear relationship was found between the two variables. Therefore, there was not enough statistical evidence in the sample to say that this correlation exists in the rural America population. Future research is needed to investigate this relationship more thoroughly.

Early diagnosis and prompt treatment is one of the malaria control strategies used to minimize malaria morbidity and mortality. One of the mechanisms to implement early diagnosis and prompt treatment is community access to diagnostic services and effective antimalarial drugs. However, in Ethiopia the health system is underdeveloped and much of the rural population has limited access to modern health services. Therefore, the Ethiopian government introduced the Health Extension Programme(HEP) which is a community-based health care delivery system aimed at accessing essential health services through its health extension workers (HEWs). Involvement of the HEWs in prescribing and dispensing antimalarial drugs is shown to have improved community access to antimalarial drugs. However, there is insufficient knowledge of HEWs compliance to malaria treatment guidelines and patient adherence of patients treated by HEWs. The objectives of this study has been to describe the HEWs practice in malaria treatment, to evaluate adherence of patients to antimalarial drugs, to explore the factors influencing the HEWs malaria treatment practice and patient adherence, and to develop the guidelines to support the HEWs in malaria treatment practice. A qualitative study design was used to study the HEWs practice in malaria treatment along with patient adherence. Data were collected using in-depth face-to-face interviews, focus group discussion and patient medical record review and were analysed according to Tesch’s steps. The study revealed that the HEWs adequately comply with malaria treatment guidelines during diagnosis of malaria, as well as during the prescribing and dispensing of antimalarial drugs. However, there are some factors influencing the performance of HEWs. These are: shortage of diagnostic kit/RDT, shortage of antimalarial drugs, patient pressure to obtain coartem, work load, and community beliefs with regard to antimalarial drugs effectiveness. This study also revealed that the HEWs follow up after treatment of patients and good community support systems improved patient adherence to antimalarial drug use. Factors negatively influencing patient adherence were identified to include: forgetfulness, fear of shortage of drugs, adverse drug effects, duration of treatment, rapid relief of malaria symptoms and inadequate awareness of the consequence of incomplete dosage. Guidelines were developed to support the HEWs in malaria treatment practice with the aim to improve patient adherence to antimalarial drugs / Health Studies / D. Litt. et Phil. (Health Studies)

Thesis (MPA (School of Public Management and Planning))--Stellenbosch University, 2008. / The role of Community Health Workers (CHWs) in the HIV/AIDS Programme is directly dependent on the support systems provided by nurses, NGOs, the community, institutional frameworks, and government funding and stress management institutions. The Home-based caregivers that work in the HIV/AIDS Programme are CHWs who need maximum support from the above- mentioned institutions. The community is also reeling with the aggravating consequences of HIV/AIDS. CHWs play a role in trying to take care of the HIV patients within the home environment. People are cared for by the people they associate with and people who live with them. In order for CHWs to maximise their contribution to the HIV/AIDS Programme, there should be commitment from all stakeholders involved in the programme. Forty-one people from formal and non-formal structures took part in the study. The formal structures refer to clinics and hospitals, whereas informal structures refer to Home-based care (HBC) groups, volunteers, NGOs and international donor agencies. The study was conducted over a period of eight weeks. The study was conducted at Cork, Calcutta and Mkhuhlu clinics, and Mkhuhlu Home-based care and on USAID field officers. The results of the study suggested that with support systems from the relevant institutions, CHWs are able to carry their community obligations in an effective and efficient manner. These findings have positive relationship implications towards the reduction of HIV infections in the community. Hospitals that are faced with overcrowding also benefit in a way, when terminally ill patients are cared for at HBC centres.

INTRODUÇÃO: Diabetes Mellitus tipo 2 é uma doença caracterizada por um conjunto de desordens causadas pelo estado de hiperglicemia. Apresenta uma fase assintomática que pode durar anos e, muitas vezes, o diagnóstico só é feito na presença de complicações crônicas. É causa de grande preocupação para os responsáveis pela saúde pública mundial, devido à alta taxa de prevalência, que aumenta progressivamente, e à grande proporção de casos não diagnosticados. É importante identificar esses indivíduos para reduzir a morbimortalidade, assim como os gastos dispendidos, por meio de medidas de prevenção. No Brasil, o Sistema Único de Saúde dispõe de agentes comunitários de saúde, profissionais constituintes da Estratégia de Saúde da Família, considerados uma grande inovação do sistema de saúde pelo vínculo que criam com a população, favorecido pelas visitas domiciliares periódicas. Este trabalho teve como objetivo construir um instrumento de rastreamento de pacientes em risco de desenvolver Diabetes Mellitus tipo 2 ou casos ainda não diagnosticados da doença, utilizando o trabalho dos agentes comunitários de saúde. MÉTODOS: Os participantes foram selecionados a partir da lista de cadastros da Unidade de Saúde da Família Dr. Carlos Alberto Amorim, no município de Sorocaba, e por sorteio de um indivíduo com 20 anos ou mais para cada domicílio previamente sorteado. Inicialmente, foi aplicado um questionário baseado em fatores de risco estabelecidos. Após isso, ocorreu coleta de exames laboratoriais na Unidade de Saúde da Família (glicemia de jejum e hemoglobina glicada) e foi solicitado o Teste Oral de Tolerância à Glicose 75g aos participantes com glicemia de jejum entre 100 e 126mg/dL e hemoglobina glicada menor que 6,5%. Foram realizadas: descrição das características da amostra, descrição das prevalências encontradas de Diabetes Mellitus tipo 2 em casos já conhecidos, casos diagnosticados pelo estudo e casos de pré-diabetes; análise da associação entre DM2 e fatores de risco, com descrição da Razão de Prevalência e significância; regressão logística múltipla para fatores de risco, tendo DM2 como desfecho, com descrição dos Odds Ratios e significância; construção da equação de probabilidade de DM2 segundo os diferentes coeficientes de regressão dos fatores de risco, e análise da curva ROC (Receiver Operational Curve), e definição de pontos de corte para Sensibilidade e Especificidade máximas. RESULTADOS: 250 participantes completaram o estudo; destes, 27 casos de Diabetes Mellitus já conhecidos, 15 casos diagnosticados pelo estudo e 20 casos de pré-diabetes. A escala de risco final contou com as variáveis: idade, índice de massa corpórea, antecedente pessoal de hipertensão arterial sistêmica e história familiar de Diabetes Mellitus. A pontuação variou de 0 a 12. A área sob a curva ROC foi de 0,775 e a soma de 8 pontos ou mais na escala foi o melhor ponto de corte, com sensibilidade de 70,7% e especificidade de 71,7% para o diagnóstico de Diabetes Mellitus tipo 2. CONCLUSÃO: O instrumento construído por este estudo é simples, rápido e aplicado facilmente pelo agente comunitário de saúde. É capaz de identificar indivíduos com alto risco de ter a doença e facilitar o diagnóstico precoce / INTRODUCTION: Diabetes Mellitus type 2 is a group of metabolic disorders characterized by hyperglycemia. The condition has an asymptomatic phase that may last for years. Very often the condition is only diagnosed after chronic complications develop. Diabetes mellitus type 2 is a cause of great concern for public health authorities worldwide because of its high prevalence rates that grow progressively and because of the number of undiagnosed cases. It is important to identify these individuals in order to reduce morbidity and mortality, as well as costs, via prevention measures. In Brazil, the Unified National Health System includes community health workers, which are professionals involved in the Family Health Strategy. These workers are considered a great innovation in the health system because they bond with the population through periodic home visits. The purpose of this study was to develop a screening tool for Diabetes Mellitus type 2 and for individuals at risk of developing the condition. The screening is performed by community health workers. METHODS: Participants were selected in the list of patients at the Dr. Carlos Alberto Amorim Family Health Unit, in the city of Sorocaba. Individuals aged >=20 years were selected by raffle from each household. Households were previously selected, also by raffle. Firstly, a questionnaire based on established risk factors was administered; secondly, laboratory samples were collected at the Family Health Unit (fasting glucose and glycated hemoglobin). The 75g Oral Glucose Tolerance Test was requested for individuals whose fasting glucose level ranged between 100-126mg/dl (5,5 - 7 mmol/l) and whose glycated hemoglobin was <6.5% (48 mmol/mol). We carried out the description of sample characteristics, as well as prevalence rates observed for type 2 diabetes (previously identified cases, cases diagnosed in the study, and cases of pre-diabetes); the analysis of the association between type 2 diabetes and risk factors, with the description of Prevalence Rate and significance; the logistic regression for risk factors with type 2 diabetes as outcome, with description of Odds Ratios and significance; the construction of the type 2 diabetes probability equation according to different regression coefficients of risk factors; and the analysis of the ROC (Receiver Operating Characteristic) curve and definition of cut points for maximum Sensibility and Specificity. RESULTS: 250 participants finished the study; 27 were previously diagnosed with type 2 diabetes, 15 were diagnosed in the study, and 20 were pre-diabetic. The final risk scale included the following variables: age, body mass index, personal history of systemic hypertension, and family history of diabetes. Scores ranged from 0 to 12. The area under the ROC curve was 0.775, and the sum of 8 or more was the best cut point, with sensitivity and specificity of 70.7% and 71.7%, respectively. CONCLUSION: The tool developed in this study is simple, fast, and can be easily used by community health workers. It is capable of identifying individuals at high risk, and it facilitates earlier diagnosis

Esta investigação toma como objeto o desenvolvimento de recursos teórico-práticos dos trabalhadores da saúde na atenção básica (AB), particularmente os agentes comunitários de saúde (ACS), para lidar com problemas relativos ao consumo de drogas dos moradores da área de abrangência de Unidades de Saúde da Família (USF). As práticas da AB voltadas para a problemática das drogas constituem preocupação de toda equipe de saúde. Os ACS são particularmente afetados porque se deparam cotidianamente com situações muito próximas diante das quais se sentem despreparados, o que ocasiona frustação e desgaste. A partir da orientação paradigmática da redução de danos e dos pressupostos da educação emancipatória, o objetivo geral desta investigação foi construir um arcabouço teórico-metodológico e operacional para conduzir a formação de trabalhadores sobre drogas da AB. Trata-se de uma pesquisa-ação emancipatória, que contou com 18 ACS de quatro USF do distrito de Sapopemba, município de São Paulo. Foram realizadas 9 oficinas de educação sobre drogas e mais 6, para elaboração de material de apoio. Os dados foram analisados a partir de duas categorias de análise: 1) a unidade objeto-sujeito, conforme tomada pelas práticas em saúde da AB relacionadas ao consumo prejudicial de drogas e 2) o processo de trabalho, que se processa na AB e em que participa o ACS. Os resultados foram organizados em dois temas, que expressam a avaliação do processo educativo realizado: transformação das concepções sobre drogas e usuários de drogas; transformação nas práticas de trabalho do ACS envolvendo o consumo prejudicial de drogas. Pode-se afirmar, a partir dos resultados obtidos, que as concepções sobre drogas e sobre usuários de drogas se transformaram no sentido de agregar elementos sociais na cadeia de determinação do consumo prejudicial de drogas, e de desculpabilizar os usuários e suas famílias. Mecanismos ideológicos, como os que estão na base do processo de construção social de bodes-expiatórios. face ao problema do consumo de drogas, foram descortinados. Coerentemente, as propostas de práticas a serem adotadas no espaço da AB pelos ACS também se modificaram para agregar elementos da dinâmica social nos territórios de atuação da AB e ao mesmo tempo para rever o fardo da frustração frente às práticas adotadas até então. Contradições encontradas no trabalho e na vida dos ACS também foram discutidas na sua essência. Os ACS mostraram que suas práticas são políticas e como tal devem estimular o engajamento sócio-político, o movimento social, e a reflexão acerca dos determinantes sociais do consumo prejudicial de drogas, para que as necessidades de saúde dos diferentes grupos sociais sejam reivindicadas. Para dar fechamento ao processo de pesquisa-ação, elaborou-se o caderno de trabalho do ACS, com a contribuição de todos os participantes. Considera-se que os procedimentos teórico-metodológicos adotados: foram essenciais na transformação das concepções sobre drogas e usuários de drogas e das práticas envolvendo o consumo prejudicial de drogas; compuseram o alicerce para a proposição de práticas críticas na área de drogas na AB. Dessa forma, é possível afirmar que esta é uma formação essencial aos trabalhadores da AB / This investigation takes as its object the development of theoretical and practical resources for health workers in primary health care (PHC), particularly community health workers (CHW), to address drug consumption problems of residents of the catchment areas of Family Health Units (FHU). The health care team is concerned with PHC practices addressing drug consumption. CHW are particularly affected as they are close to daily problematic situations for which they feel unprepared, leading to frustration and debility. Considering the harm reduction paradigm and the emancipatory education prerogatives, this investigation aims to build a theoretical-methodological and operational framework to conduct education on drugs for PHC workers. This is an emancipatory action research, which included 18 CHW from four FHU of Sapopemba, a district of São Paulo. Nine workshops were conducted regarding drug subjects followed by six others, to elaborate a guide for CHW. Data were analyzed through two analytical categories 1) object-subject unity, as taken by PHC practices related to harmful drug consumption and 2) work process, in PHC in which CHW take part. The results were organized in two themes which express the evaluation of the educational process conducted: transformations in the conceptions of drug and drug users; transformations of working practices of CHW involving problematic drug consumption. It can be stated from the results that participants changed their conceptions about drug and drug users by aggregating social elements into the chain of determination of harmful consumption of drugs. They also relieved the responsibility for drug misuse from users and their families. Ideological mechanisms such as those that underlie the process of social construction of \'scapegoats\' to address the problem of drug use were unveiled. Coherently, the proposed practices to be adopted in PHC were transformed as well, to adding elements of social dynamics of the territories where CHW operate. At the same time, they review their frustration considering the practices adopted before the educational process. Perceived contradiction in everyday living and working were discussed in its essence as well. At the end of the process CHW showed that their practices are political, therefore they must stimulate social and political engagement, social movement and reflection on the social determinants of the harmful drug consumption. Health needs of different social groups should be claimed as a result of this political process. To enclose the action research process, we collectively elaborated a CHW working guide, with the contribution of all participants involved. It is considered that the methodological procedures adopted were essential in transforming conceptions about drugs and drug users, as well as the practices involving harmful drug consumption. They composed the foundation for the critical practices propositions in PHC. Thus, we can affirm that this is an essential education for PHC workers