O diagnóstico precoce da tuberculose é uma das prioridades do Plano Nacional de Controle da Tuberculose, sendo que nas visitas domiciliares dos Agentes Comunitários de Saúde (ACS) está prevista a detecção de casos entre sintomáticos respiratórios e contatos. Dada a importância deste ator no controle da doença, este estudo teve como objetivo analisar o desempenho do ACS no controle da tuberculose em duas modalidades de Atenção Primária à Saúde (APS). Trata-se de um estudo descritivo exploratório de corte transversal realizado no período de junho de 2009 a janeiro de 2010 com 39 ACS da Estratégia Saúde da Família (ESF) e 69 ACS da Unidade Básicas de Saúde (UBS) do município de Ribeirão Preto/SP. A coleta de dados ocorreu mediante a observação da estrutura das unidades de saúde investigadas (roteiro observacional) e por meio de entrevistas direcionadas aos ACS (instrumento com escala Likert de resposta). O plano analítico se deu em dois momentos, inicialmente procedeu à análise descritiva e bivariada, e posteriormente a Análise de Correspondência Múltipla (ACM). Os escores médios das respostas dos entrevistados aos itens do instrumento que continham escala Likert, foram analisados como insatisfatório (valores próximos de 1 e 2), regular (próximo de 3) e satisfatório (próximos de 4 e 5). De acordo com a observação, as modalidades de APS apresentaram fragilidades em relação à estrutura para consecução das ações de controle da tuberculose pelo ACS como ausência de insumos para detecção dos casos da doença, falta de rotina sistematizada e de profissionais responsáveis pelas ações de controle da tuberculose. No julgamento dos ACS, identificaram-se escores satisfatórios relacionados à capacitação e ao preparo dos mesmos para a realização de tais ações. Com relação ao desempenho do ACS, notou-se diferença com significância estatística na investigação dos comunicantes no domicílio, sendo que os ACS inseridos nas UBS questionam mais a presença de tosse entre os comunicantes quando comparados àqueles inscritos nas ESF. Observou-se em ambas as modalidades de APS, escores satisfatórios em relação à identificação de sintomáticos respiratórios na visita domiciliar, a participação dos ACS em discussões sobre a tuberculose na equipe e ao apoio institucional ofertado frente a uma situação de suspeita da doença, e escores insatisfatórios relacionados às ações desenvolvidas pelo ACS na comunidade. Na ACM identificou-se a correspondência entre as ações de controle da tuberculose e a interação dos ACS com a equipe, independente da modalidade de APS, na qual eles se inserem. Ao se cotejarem os resultados obtidos, aponta-se para a necessidade de mudanças no processo de trabalho, consubstanciadas pela qualificação, valorização e motivação do ACS. No que tange às fragilidades que fogem à sua governabilidade, cabe à gestão municipal apoiar dispositivos institucionais para produção em saúde condizente com a complexidade epidemiológica e social da tuberculose. / The early diagnosis of tuberculosis is one of the priorities in the National Tuberculosis Control Plan. Home visits by Community Health Workers (CHW) are expected to include case detection among respiratory symptomatics and contacts. Given the importance of these agents in disease control, this study was aimed at analyzing the performance of CHW in tuberculosis control in two Primary Health Care (PHC) modalities. A descriptive and exploratory cross-sectional study was carried out between June 2009 and January 2010, involving 39 CHW from the Family Health Strategy (FHS) and 69 CHW from Primary Health Care Units in Ribeirão Preto, a city in São Paulo State, Brazil. Data were collected by observing the structure of the health units under analysis (observational script) and through interviews with the CHW (instrument with a Likert-type response scale). Analysis involved two phases. Initially, descriptive and bivariate analysis was applied, followed by Multiple Correspondence Analysis (MCA). The interviewees\' mean answer scores to the instrument items that contained a Likert scale were analyzed as unsatisfactory (scores close to 1 and 2), regular (close to 3) and satisfactory (close to 4 and 5). According to the observation, the PHC modalities revealed weaknesses in their structure to allow the CHW to practice tuberculosis control actions, such as lack of inputs to detect cases of the disease, lack of a systemized routine and of professionals responsible for tuberculosis control actions. According to the CHW, satisfactory scores were identified regarding their training and preparation to accomplish these actions. Concerning the CHW\' performance, a statistically significant difference was observed in the investigation of communicants at home, with the CHW working at Primary Health Care Units inquiring further about the presence of cough among communicants when compared to those working in FHS. In both PHC modalities, satisfactory scores were observed for the identification of respiratory symptomatics during home visits, the CHW\' participation in tuberculosis discussions in the team and the institutional support offered when the presence of the disease was suspected, against unsatisfactory scores for the CHW\' actions in the community. In the MCA, correspondence was identified between tuberculosis control actions and the CHW\' interaction with the team, independently of the PHC modality. The comparison of the results obtained reveals the need for changes in the work process, in the form of qualification, valuation and motivation of the CHW. Regarding the weaknesses they have no control over, municipal managers are responsible for supporting institutional devices to produce health in accordance with the epidemiological and social complexity of tuberculosis.

South Africa is a country with a high mortality rate because of tuberculosis and increasing cases of multidrug-resistant tuberculosis makes it a global health problem. Tuberculosis is curable and preventable but without proper treatment many of the infected have no chance of survival. Nurses has an essential role as team leaders for the community health workers in the tuberculosis care. The aim of this study is to investigate nurses' experiences of being team leaders for the community health workers in the care of tuberculosis patients. This study is based on semi-structured interviews with seven nurses working as team leaders in the tuberculosis care in different suburbs in Western Cape, South Africa. The nurses experienced that their leadership gets affected by many obstacles in their daily work. A nurse team leadership have a major effect on the quality of care and the community health workers have an essential role by reaching out to the patients in the communities. To develop the cooperation between the nurses and the community health workers, more resources are needed. Therefore a good cooperation is the key to compete against tuberculosis. This study was sponsored by the Swedish Development Cooperation Agency as a Minor Field Study

O diagnóstico precoce da tuberculose é uma das prioridades do Plano Nacional de Controle da Tuberculose, sendo que nas visitas domiciliares dos Agentes Comunitários de Saúde (ACS) está prevista a detecção de casos entre sintomáticos respiratórios e contatos. Dada a importância deste ator no controle da doença, este estudo teve como objetivo analisar o desempenho do ACS no controle da tuberculose em duas modalidades de Atenção Primária à Saúde (APS). Trata-se de um estudo descritivo exploratório de corte transversal realizado no período de junho de 2009 a janeiro de 2010 com 39 ACS da Estratégia Saúde da Família (ESF) e 69 ACS da Unidade Básicas de Saúde (UBS) do município de Ribeirão Preto/SP. A coleta de dados ocorreu mediante a observação da estrutura das unidades de saúde investigadas (roteiro observacional) e por meio de entrevistas direcionadas aos ACS (instrumento com escala Likert de resposta). O plano analítico se deu em dois momentos, inicialmente procedeu à análise descritiva e bivariada, e posteriormente a Análise de Correspondência Múltipla (ACM). Os escores médios das respostas dos entrevistados aos itens do instrumento que continham escala Likert, foram analisados como insatisfatório (valores próximos de 1 e 2), regular (próximo de 3) e satisfatório (próximos de 4 e 5). De acordo com a observação, as modalidades de APS apresentaram fragilidades em relação à estrutura para consecução das ações de controle da tuberculose pelo ACS como ausência de insumos para detecção dos casos da doença, falta de rotina sistematizada e de profissionais responsáveis pelas ações de controle da tuberculose. No julgamento dos ACS, identificaram-se escores satisfatórios relacionados à capacitação e ao preparo dos mesmos para a realização de tais ações. Com relação ao desempenho do ACS, notou-se diferença com significância estatística na investigação dos comunicantes no domicílio, sendo que os ACS inseridos nas UBS questionam mais a presença de tosse entre os comunicantes quando comparados àqueles inscritos nas ESF. Observou-se em ambas as modalidades de APS, escores satisfatórios em relação à identificação de sintomáticos respiratórios na visita domiciliar, a participação dos ACS em discussões sobre a tuberculose na equipe e ao apoio institucional ofertado frente a uma situação de suspeita da doença, e escores insatisfatórios relacionados às ações desenvolvidas pelo ACS na comunidade. Na ACM identificou-se a correspondência entre as ações de controle da tuberculose e a interação dos ACS com a equipe, independente da modalidade de APS, na qual eles se inserem. Ao se cotejarem os resultados obtidos, aponta-se para a necessidade de mudanças no processo de trabalho, consubstanciadas pela qualificação, valorização e motivação do ACS. No que tange às fragilidades que fogem à sua governabilidade, cabe à gestão municipal apoiar dispositivos institucionais para produção em saúde condizente com a complexidade epidemiológica e social da tuberculose. / The early diagnosis of tuberculosis is one of the priorities in the National Tuberculosis Control Plan. Home visits by Community Health Workers (CHW) are expected to include case detection among respiratory symptomatics and contacts. Given the importance of these agents in disease control, this study was aimed at analyzing the performance of CHW in tuberculosis control in two Primary Health Care (PHC) modalities. A descriptive and exploratory cross-sectional study was carried out between June 2009 and January 2010, involving 39 CHW from the Family Health Strategy (FHS) and 69 CHW from Primary Health Care Units in Ribeirão Preto, a city in São Paulo State, Brazil. Data were collected by observing the structure of the health units under analysis (observational script) and through interviews with the CHW (instrument with a Likert-type response scale). Analysis involved two phases. Initially, descriptive and bivariate analysis was applied, followed by Multiple Correspondence Analysis (MCA). The interviewees\' mean answer scores to the instrument items that contained a Likert scale were analyzed as unsatisfactory (scores close to 1 and 2), regular (close to 3) and satisfactory (close to 4 and 5). According to the observation, the PHC modalities revealed weaknesses in their structure to allow the CHW to practice tuberculosis control actions, such as lack of inputs to detect cases of the disease, lack of a systemized routine and of professionals responsible for tuberculosis control actions. According to the CHW, satisfactory scores were identified regarding their training and preparation to accomplish these actions. Concerning the CHW\' performance, a statistically significant difference was observed in the investigation of communicants at home, with the CHW working at Primary Health Care Units inquiring further about the presence of cough among communicants when compared to those working in FHS. In both PHC modalities, satisfactory scores were observed for the identification of respiratory symptomatics during home visits, the CHW\' participation in tuberculosis discussions in the team and the institutional support offered when the presence of the disease was suspected, against unsatisfactory scores for the CHW\' actions in the community. In the MCA, correspondence was identified between tuberculosis control actions and the CHW\' interaction with the team, independently of the PHC modality. The comparison of the results obtained reveals the need for changes in the work process, in the form of qualification, valuation and motivation of the CHW. Regarding the weaknesses they have no control over, municipal managers are responsible for supporting institutional devices to produce health in accordance with the epidemiological and social complexity of tuberculosis.

Malaria is the main cause of mortality for children under the age of 5 in Burundi. The access to malaria diagnostics and treatment is hampered not only because of logistical issues, but also due to the lack of qualified human resources and their inequitable distribution across the country. To mitigate the lack of human resources for health, the government of Burundi, along with its partners, shifted some tasks to community health workers (CHWs) to cover unmet healthcare needs for selected diseases such as malaria, diarrhea, and pneumonia. The purpose of this study was to determine whether the social support provided to CHWs had an impact on morbidity due to malaria for children under the age of 5. The social networks and social support theoretical framework was used to explore the type of social support received by CHWs and its impact on the number of children treated. The 88 CHWs who participated in this cross sectional survey, were randomly selected from a pool of 719 CHWs who were part of a pilot project that was implemented in the districts of Gahombo, Gashoho, and Mabayi, from 2011 to 2014. The study findings showed mixed results with a positive correlation between the instrumental support received and the number of children under the age of 5 treated. However, a statistically significant correlation was not established between the emotional, informational, and appraisal support received and the number of children under the age of 5 treated. The positive social change implications of the study include providing evidence to build and enhance human resource capacity for improving the health of children living in Burundi, an under-resourced country, through the development of a support package that can be offered to CHWs to help them perform their duties in a more effective way.

Asthma prevalence continues to increase across the United States of America, affecting more than 43.1 million people and projected to affect over 50 million people by 2025. Asthma prevalence differs by demographic characteristics, such as race, ethnicity, socio-economic status, education, age and gender. Poor quality of life is common among people who suffer from asthma, in addition to school and work absenteeism. In 2008, children 5-17 years old with at least one reported asthma attack missed 10.5 million school days in the past year (CDC, 2010). Healthcare use for asthma is high and disparities remain in asthma healthcare use and reimbursement. In community settings, reimbursement for asthma education and prevention has been problematic due to current reimbursement mechanisms (Bodenheimer et al. (2003); Halterman (2010); CDC (2011) and Laster et al. 2010) that do not go far enough in assisting low-income communities manage their asthma medically nor have uniform standards for billable services associated with asthma management provided by both healthcare professionals and public health workers. A change in reimbursement policy is advocated and the evidence for the effectiveness of community health workers in asthma management is examined.

South Africa recently changed infant feeding policy within Prevention of Mother to Child Transmission (PMTCT) of HIV from free formula to recommendation of breastfeeding for all. The country is evaluating the role of Community Health Workers (CHWs) in supporting mothers and newborns. The aim of this thesis is to explore perceptions of household members on the value given to and the social forces behind formula feeding in light of the recent policy change, and to assess the effect of a community-based package of maternal and newborn care delivered by CHWs on HIV-free survival and exclusive and appropriate infant feeding up to 12 weeks of age. Studies were conducted in a high HIV prevalence township. Focus group discussions were performed (grandmothers, fathers and teenage mothers) and in-depth interviews with HIV-positive and HIV-negative mothers. Perceptions of household members on the formula policy change were explored and the value household members place on formula feeding and circumstances that drive it. In a cluster-randomized trial (15 intervention, 15 control clusters) CHWs provided two antenatal and five post-natal home visits to support and promote PMTCT activities. There were misunderstandings by community members on the free formula policy change. Mothers transferred the motherhood role to their mothers while partners provided inadequate financial support, leading to risky mixed feeding. Teenage mothers rarely breastfed their infants due to perceived constraints including embarrassment, sagging breasts and loss of freedom and boyfriends. At 12 weeks of age the intervention had doubled exclusive breastfeeding (EBF) (28% vs. 14%) and slightly increased infant weight and length. No difference was seen between study arms in HIV-free survival. The effect on EBF at12 weeks did not differ with maternal education or wealth levels, but was higher among HIV-negative mothers.  Focusing on teenage mothers breastfeeding challenges, involvement of grandmothers and fathers in infant feeding decision-making, improving communication strategies on policy change and breastfeeding to the community and health workers and CHWs home visits supporting PMTCT activities are important for infant feeding and child health.

Submitted by Maria Creuza Silva (mariakreuza@yahoo.com.br) on 2015-04-06T18:38:32Z No. of bitstreams: 1 Diss MP Marina Garcia C. Aquino. 2014.pdf: 1332307 bytes, checksum: c73c2bf77b6307c194608d4eb8d4726d (MD5) / Approved for entry into archive by Maria Creuza Silva (mariakreuza@yahoo.com.br) on 2015-04-15T14:33:58Z (GMT) No. of bitstreams: 1 Diss MP Marina Garcia C. Aquino. 2014.pdf: 1332307 bytes, checksum: c73c2bf77b6307c194608d4eb8d4726d (MD5) / Made available in DSpace on 2015-04-15T14:33:58Z (GMT). No. of bitstreams: 1 Diss MP Marina Garcia C. Aquino. 2014.pdf: 1332307 bytes, checksum: c73c2bf77b6307c194608d4eb8d4726d (MD5) / A atuação do Agente Comunitário de Saúde (ACS) possui potencial para promover melhorias na assistência prestada à população, contudo, precisa ser guiada pela educação permanente. O curso de atualização na atenção á saúde da mulher no ciclo gravídico puerperal, é uma estratégia de educação permanente proposta pela Escola de Formação Técnica em Saúde, do estado da Bahia, que tem como objetivo a melhoria da atenção à gestante e à puérpera, mediante o trabalho e a qualificação das ações dos ACS, junto à população e aos serviços de saúde. O objetivo do trabalho foi analisar os efeitos do curso de atualização nas práticas dos ACS em uma USF do município de Salvador, Ba. A partir de documentos normativos foi construído um modelo lógico do Curso do qual derivou uma matriz de análise, utilizada para analisar as práticas dos ACS. Foram realizadas entrevistas semi estruturadas com os ACS e enfermeiros e usuárias gestantes ou puérperas. Constatou-se que o curso em questão foi uma estratégia que se mostrou capaz de provocar reflexão nos Agentes Comunitários de Saúde sobre as práticas relacionadas com a saúde da gestante e da puérpera, porém, as ações desenvolvidas ainda mostraram-se frágeis diante das atividades sugeridas pelo Curso.

A pesquisa tem como objetivo caracterizar o perfil dos Agentes Comunitários de Saúde (ACS), identificando as ações realizadas e analisando-as à luz do paradigma da Promoção da saúde. Para isso optou-se por uma pesquisa exploratória do tipo quanti-qualitativa, realizada com todos os ACS das 15 equipes de PACS, num total de 241 ACS, do município de São Bernardo do Campo (SP). A coleta de dados foi pela aplicação de um questionário para a caracterização dos ACS e um formulário baseado nas competências preconizadas pelo Ministério da Saúde (MS), que buscou identificar as ações que este profissional realiza, bem como a freqüência com a qual executa essas ações. O conteúdo dos instrumentos de coleta foi organizado e analisado no programa computacional SPSS. Como resultado da análise evidenciou-se que a maioria dos ACS é constituída de mulheres, com idade média de 33 anos, com união conjugal, de raça branca e parda, nascidas na região Sudeste, zona urbana, com ensino médio completo e curso profissionalizante, com participação em um trabalho formal antes de ser ACS e que vivem com média de 3 salários mínimos. Em média, moram há 15 anos no bairro onde trabalham, sendo que há 4 anos trabalham como ACS. A forma de participação comunitária na vida pessoal que mais se destaca é a ligada a grupos religiosos. As competências preconizadas pelo MS: \"Integração da equipe com a população local\"; \"Prevenção e monitoramento de risco ambiental e sanitário\" e \"Prevenção e monitoramento a grupos específicos e morbidades\" são em sua maioria realizadas pelos ACS, enquanto que as de \"Planejamento e avaliação das ações de saúde\" e \"Promoção da saúde\" são realizadas de forma heterogênea pelo Município. Partindo-se do princípio que as estratégias de Promoção da saúde necessitam, entre outros fatores, das políticas públicas para concretizar suas ações, concluiu-se pela necessidade de se realizar um planejamento das ações do ACS que seja comum a todo o Município, pela importância de se fortalecer a competência do ACS para a Promoção da saúde, de forma que esta possa encaminhar para o empowerment da comunidade e para a intersetorialidade. / The research has as objective to characterize the profile of the Communitarian Agents of Heath (CAH), identifying the carried through actions and analyzing them in the way of the paradigm of the Health Promotion. For this it was opted to an exploring research of the quanti-qualitative kind, carried through with 241 CAH of the city of São Bernardo do Campo (SP). Collection of data was made through application of questionnaire for characterization of CAH and form based in abilities praised for Ministry of Health (MH), that it searched to identify the actions that this professional carries through, as well as the frequency which executes these actions with. The content of the collection instruments was organized and analyzed in the computational program SPSS. As result of the analysis, it was evidenced that the majority is constituted of women, with average age of 33 years, conjugal union, of white and medium brown race, born in the southeastern region, urban zone, with complete high school education and professionalizing course, with participation in a formal job before being CAH and that they live with average of 3 minimum wages. In average, they live has 15 years in the neighborhood where they work, and it has 4 years they work as CAH. The form of communitarian participation that is more distinguished is bound to religious groups. The abilities praised for the MH: Integration of the team with the local population; Prevention and monitoring of ambiental risk and sanitary; Prevention and monitoring the specific groups and morbidities are in its majority carried through by the CAH while that of planning and the evaluation of the actions of health and promotion of the health they are carried through of heterogeneous form in the city. Considering the strategies of health promotion need, among others factors, of the public politics to materialize its action, it\'s concluded for the necessity to carry through a planning of the actions of the CAH to the health promotion, such that it\'s able to direct to the empowerment of the community and to the action between sectors.

A detecção de casos de tuberculose é uma das prioridades do Plano Nacional de Controle da Tuberculose, sendo que a Busca de Sintomáticos Respiratórios (BSR) precisa ser uma atitude permanente e incorporada à rotina de atividades dos membros das equipes de saúde, principalmente dos Agentes Comunitários de Saúde (ACS). Este estudo teve como objetivo analisar a BSR na percepção do ACS, em dois municípios prioritários para o controle da tuberculose. Trata-se de um estudo descritivo e exploratório, do tipo inquérito realizado em 2009 através de dados secundários, roteiro observacional e formulário estruturado aplicado a 210 ACS (105 do município de Natal - RN e 105 de Ribeirão Preto - SP). Criou-se indicadores de estrutura, processo e resultado a partir das proporções dos itens observados e colhidos através de fontes secundárias, e dos escores médios das respostas dos entrevistados aos itens do formulário que continham escala Likert de resposta, sendo avaliados como insatisfatório (valores próximos de 1 e 2), regular (próximos de 3) e satisfatório (próximos 4 e 5). De acordo com a observação, os municípios apresentaram algumas fragilidades em relação à estrutura dos serviços de saúde para a BSR: ausência de pote de escarro (21%), ausência de geladeira para acondicionamento das baciloscopia (63,2%) e a falta de laboratórios responsáveis pelo recolhimento das baciloscopias (31,6%) nas unidades de saúde de Natal. Em Ribeirão Preto, verificou-se ausência de livro de registro de sintomáticos respiratórios (42,6%), de profissionais responsáveis pelo cuidado do paciente com tuberculose (30,7%) e de rotina sistematizada para o atendimento do suspeito de tuberculose (38,5%). No julgamento dos ACS, identificaram-se escores satisfatórios relacionados ao treinamento e ao preparo dos mesmos para o controle da tuberculose. Observou-se fragilidades na ação de investigação da tosse nas visitas domiciliares e na oferta de pote de escarro, embora escores satisfatórios tenham sido encontrados na identificação de sintomáticos respiratórios na comunidade e nos serviços de saúde, bem como na investigação de casos suspeitos a partir dos casos índice. Identificou-se fragilidades no estabelecimento de parcerias com a comunidade para a BSR e para discussões sobre tuberculose, contudo verificou-se escore razoável em relação à educação em saúde sobre a doença na comunidade. Verificaram-se ainda escores satisfatórios em relação à participação dos ACS em discussões sobre a tuberculose no serviço e ao apoio institucional ofertado frente a uma situação de suspeita da doença. Dos sintomáticos respiratórios estimados no território circunscrito às unidades dos ACS de Natal e Ribeirão Preto, observou-se que, respectivamente, apenas 11,2% e 6,2% desta população foi examinada com baciloscopia de escarro. O processo de trabalho do ACS no território possibilita refletir sobre seu protagonismo como parceiro no controle da tuberculose. Fragilidades foram encontradas na estrutura dos serviços de saúde em ambos os municípios, as quais podem ter resultado no desempenho deficiente dos ACS para a BSR. O trabalho ressaltou ainda a necessidade de um novo processo de trabalho capaz de intervir sobre os reais problemas de saúde da comunidade, com avanços na educação permanente e na articulação intersetorial visando o incremento na detecção de casos da doença. / Detection of tuberculosis is one of the National Tuberculosis Control Policy priorities, which consider active case finding (ACF) as a permanent action, incorporated into the routine activities of all health teams members, especially for Community Health Workers (CHW). This study aimed to analyze the ACF according to CHW perspective in two priority cities for tuberculosis control. Descriptive study conducted in 2009 using secondary data and an observational and structured questionnaire applied to 210 CHW (105 in Natal - RN and 105 in Ribeirão Preto - SP). Indicators of structure, process and result were developed from the proportions of the items observed and collected from secondary sources and from the mean scores of respondents\' answers to items which contained Likert scale response - assessed as insatisfactory (values close to 1 and 2), regular (near 3) and satisfactory (near 4 and 5). According to observation forms, some weaknesses in structure of health services for the RS\' search were identified: lack of sputum pot (21%), lack of refrigerator for storing the smear (63.2%) and lack of laboratories responsible for collecting the sputum (31.6%) in health facilities in Natal. In Ribeirão Preto, there was no form register of TB suspects (42.6%), neither professionals for tuberculosis patients care (30.7%) and for systematic search and routine assistance for suspected tuberculosis cases (38 5%). In the CHW inquiry, satisfactory scores have been identified related to training and self-prepare for tuberculosis control. There are weaknesses in detection of cough during home visits and the provision of sputum pot in the territory, although scores have been found satisfactory in the ACF in the community and health services, as well as in the investigation of suspected cases from the index cases. We identified weaknesses in partnerships with the community to the ACF and to discussions on tuberculosis, but there was a reasonable score for health education about the disease in the community. There were also satisfactory scores for participation of CHW in discussions about TB inside the health services and institutional support offered when a suspected case was identified by CHW. The analysis of estimated RS in the CHW area in Natal and Ribeirão Preto, showed that, respectively, only 11.2% and 6.2% of this population was examined with sputum smear microscopy. The CHW work process bring out a reflection on their role as partners in tuberculosis control. Weaknesses were found in the structure of health services in both cities, which may have resulted in poor performance of the CHW for the ACF. The work also highlighted the need for a new work process capable of intervention on the real health problems of the community, improving permanent education actions and intersectoral coordination to increase case detection.

Philosophiae Doctor - PhD / The epidemiological interconnectedness of tuberculosis (TB) and human immunodeficiency virus (HIV) epidemics is well documented. Although international agencies such as the World Health Organisation (WHO) have been advocating for the implementation of collaborative TB/HIV activities at all levels in order to mitigate the impact of the dual epidemic on communities, health care delivery and programme management, its implementation has been very slow, particularly in countries highly burdened with TB/HIV infection, such as South Africa. Provision of integrated TB/HIV services has been partial and sub-optimal at community level. This requires innovative interventions that go beyond health facility boundaries such as engaging community care workers (CCWs). This thesis presents ways of engaging community members such as CCWs in collaborative TB/HIV activities including prevention of mother-to-child transmission of HIV (PMTCT). Methods: Both action research and health systems strengthening research were used as theoretical frameworks. The study was conducted in three phases which consisted of: a situational analysis; design and implementation of the intervention; and evaluation of the intervention. Mixed method research using both quantitative and qualitative research methods in one study was conducted, and various research designs were used depending on the research questions and the study phases. Results: The findings of Phase I of this study highlight partial integration of TB/HIV/PMTCT services at facility and community levels, and sub-optimal provision of integrated services, particularly at community level where only 10% of TB and HIV patients needing care at community level were supported by CCWs. Most TB-HIV co-infected patients were managed at the primary health care (PHC) clinic level of care, compared to other levels (p<0.05), and less than 50% of PHC clinic staff were trained in TB and HIV management. This phase also indicates poor linkage between facility and CCWs through the nongovernmental organizations (NGOs) managing CCWs. In addition, it identifies various health systems barriers that impede the implementation of collaborative TB/HIV/PMTCT activities and involvement of CCWs in the mainstream of the primary health care system. The findings of Phase II and III show that integrating different CCW cadres into one cadre and expanding their scope of practice to provide a comprehensive package of care for TB/HIV/PMTCT is a feasible and an effective intervention to accelerate the implementation of collaborative TB/HIV activities, including PMTCT, at community level. In addition, the findings suggest that up-skilled CCWs contribute significantly to bridging the current service delivery gaps in vertical TB, HIV and PMTCT services by increasing coverage for case finding of TB (38%) and sexually transmitted infections (STIs) (40%), PMTCT services (infant feeding, referral for PCR and AZT adherence support) (30%), and TB and antiretroviral treatment (ART) adherence (30%, 28%). The increase in uptake of TB/HIV/PMTCT services was statistically significant (p<0.05). Provision of home-based HIV counseling and testing by CCWs proved to be acceptable and feasible. Of 684 people offered home based HCT, 634 (82%) accepted to be tested and 45 (7%) tested HIV positive. However, other PHC care services such as integrated management of childhood illnesses (IMCI) and referrals to social welfare were poorly provided. Conclusion and Recommendations: The findings indicated that up-skilling CCWs resulted in improvement of CCW's performance in provision of integrated TB/HIV/PMTCT services, particularly for TB and STI symptom screening, HCT, infant feeding counselling and AZT treatment support for PMTCT, and treatment adherence support for TB and ART. However, this study emphasised the need for addressing contextual and health systems issues such as structural, organisational and managerial constraints. There is a need to reorganise the PHC system to ensure that CCWs are integrated as part of the PHC system. Systematic skills building and consistent CCW supervision, with reliable referral and monitoring and evaluation (M&E) systems are required for efficiency and sustainability of any community based intervention. It is also necessary to ensure that other PHC activities, such as referral for social welfare and IMCI, are not compromised when additional activities are added to the CCW care package. / This research was made financially possible by the, African Doctoral Dissertation Research Fellowship (ADDRF) of the African Population and Health Research Centre, in partnership with the International Development Research Centre and Ford Foundation. South African Tuberculosis AIDS Training (SATBAT): a South African/US research training collaboration funded by Fogarty International Center Grant 1U2RTW007370-01A1).