Orientadora: Heloisa Pait / Banca: Andreas Hofbauer / Banca: César Gomes da Silva / Resumo: A Organização Mundial de Saúde (2001) reconhece a dependência química como doença, porque há grave alteração da estrutura e do funcionamento normal do indivíduo, sendo-lhe altamente prejudicial. Não existe causa isolada, mas é resultado de uma série de fatores (físicos, emocionais, psíquicos, espirituais e sociais) que atuam ao mesmo tempo, podendo ser um mais predominante que o outro. Até pouco tempo, o tratamento destinado ao dependente químico era basicamente de contenção e com métodos hospitalar bastante repressivo. Ao passar dos anos, outras formas de abordagem foram ganhando atenção no cenário das políticas públicas, com ênfase na prevenção, tratamento e reinserção social. As Comunidades Terapêuticas surgem nesse cenário como uma das alternativas de tratamento e orientação. Atualmente a reinserção social torna-se um novo desafio para a continuidade desse modelo, para o dependente químico, que se submeteu de forma voluntária ao programa terapêutico, a reinserção dá continuidade ao processo de transformação de vida, oportunidade em que serão restabelecidos os vínculos com a família, escola, trabalho e a sociedade. Ainda se conhece muito pouco sobre esse modelo, cada vez mais procurado por usuários, bem como sobre a sua metodologia de trabalho, especialmente no campo das Ciências Sociais. Por esse motivo, há uma grande carência bibliográfica na área, o que nos motivou a desenvolver essa pesquisa intitulada "A reinserção do dependente químico no mercado de trabalho: o caso ... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The World Health Organization (2001) recognizes chemical dependency as a disease, because there is a serious alteration in the structure and normal functioning of the individual, and it is highly harmful to the one. There is no single cause, but it is the result of a series of factors (physical, emotional, psychic, spiritual and social) that act at the same time, being more prevalent than the other. Until just recently, the treatment for the chemical dependent was basically of containment and with repressive hospital methods. Over the years, other approaches have been gaining attention in the public policy scenario, with emphasis on prevention, treatment and social reintegration. The Therapeutic Communities appear in this scenario as one of the alternatives of treatment and orientation. Currently, social reintegration becomes a new challenge for continuities of that model and for the chemical dependent, who voluntarily submitted to the therapeutic program. Reinsertion gives continuity to the process of life transformation, an opportunity to reestablish links with the family, school, work and society. This model is not so well known, which is increasingly sought after by users, as well as its methodology, especially in the field of Social Sciences. For this reason, there is a great bibliography lack in the area, which motivated us to develop this research entitled "The reinsertion of chemical dependents in the labor market: the case of Ave Cristo therapeutic community." For th... (Complete abstract click electronic access below) / Mestre

There is a paucity of scientific evidence into the lived experience of people who have a history of injecting drug use and are living with leg ulceration. Portraying the true voice of injecting drug users (IDUs) through narrative means is a novelty in contemporary literature. The representation of the life and the person behind the leg ulcer, having experienced addiction, is original from a purist narrative perspective. This study, led from the perspective of a nurse-researcher leading in the field of wound management, offers a unique opportunity to gain a rare glimpse into the daily life of IDUs, as reported in their own words. The aim of this study was to explore the experience of injecting drug users living with leg ulceration using qualitative methodology. A naturalistic paradigm framed the design by allowing participants to control the data in an unrestricted an open manner without direct intrusion form the researcher. Qualitative methodology was central to collecting data on life experience and feelings. The ethics process detailed a rigorous application to explore the professional, ethical virtues from the perspective of an insider-outsider working with sensitive data in a marginalised population. Diaries were kept and recorded by participants over four weeks in their routine daily life; this was followed by semi-structured interviews. The diaries allowed a unique insight into the past, present and future of IDUs and how their ulcer affected their lives. The diaries also facilitated a means of reflection on themselves and their wounded body. The interviews offered an opportunity to explore in detail the diary entries and other stories participants wished to share. The study recruited twelve participants from leg ulcer clinics set in London; three women and nine men older than 18 years of age (median age of 52 years; range 35 - 62 years). Ten completed the data collection process; two of the participants, aged 61 and 62 years, were married. Gatekeepers working with IDUs with leg ulceration were central to the process of engagement and recruitment. Participants welcomed the design as an opportunity to voice and share their journey of living with an open wound. The findings revealed the detailed suffering participants endured living with their ulcer: pain, shame and stigma were clearly voiced in their narratives. The majority of participants had experienced some form of stigma during their life and this was exacerbated as they were drug users. The self-blame and punishment triggered by this felt stigma was a detriment to the health of participants. Those in contact with specialist wound care services saw a significant improvement in wound healing and this had a positive impact on their wellbeing and their overall outlook on life. Participants also voiced enacted-stigma experienced from encounters in health practice. These negative experiences exacerbated the self-stigma. Findings also portrayed the multiple characteristics and talents of participants including humour, art and resilience. This research contributes to science and practice by understanding the lives of IDUs living with leg ulceration. It provides a platform from which to engage both generalists and specialists who care for these patients and has the potential to influence medical and social policy-making and clinical practice in this field. By means of narrative inquiry, this study may challenge the conventional social stereotypes, the taboos and the stigma still experienced by this patient group in health care.

Hepatitis C virus (HCV) infection is the most common blood-borne infection in the United States (U.S.). The largest increases of incidence for HCV infection are reported in the Appalachian region. This study aimed to 1) examine the prevalence and trends of HCV infection in the U.S. from 1999 to 2012; 2) investigate barriers to HCV infection treatment in Northeast Tennessee and the U.S.; and 3) study characteristics and risk factors for HIV-infection and HCV-infection in Northeast Tennessee. In the U.S., data were obtained from the National Health and Nutrition Examination Survey (NHANES) 1999-2012 to study the prevalence of HCV infection and barriers to treatment. In Northeast Tennessee, hepatitis C and HIV/AIDS data were obtained from National Electronic Disease Surveillance System (NEDSS) and enhanced HIV/AIDS Reporting System (eHARS). Descriptive statistics and multiple logistic regression models were used for analysis. Odds ratios (OR) and 95% confidence intervals (CI) were reported. There was an estimated 3.8 million people having HCV antibody in the U.S. in 2012. No significant change was found in the prevalence of HCV infection during 1999 – 2012. The leading barrier to the treatment was cost issues in the U.S. (50.0%) and Northeast Tennessee (25.0%), respectively. HCV patients without symptoms in Northeast Tennessee were more likely to be untreated (OR: 3.08, 95% CI: 1.10-8.60) and patients without health insurance in the U.S. were more likely to be untreated than their counterparts (OR: 3.38, 95% CI: 1.14-10.05). The incidence of acute hepatitis C peaked in 2012-2013 in Northeast Tennessee, while the incidence of HIV/AIDS increased by 100% from 2013 to 2015. More injection drug users (IDUs) and less men who have sex with men (MSM) were observed in patients with HCV infection than in those with HIV infection (IDUs: 50.63% vs.16.38% p

The applicant's research has led to a substantial body of published work and 17 pieces from this work are submitted here. Of these, eight are in peer refereed journals testifying to the importance of the body of work submitted. The work has attracted external funding of £73,000 from North West Thames Regional Health Authority which attests further to the quality of the work undertaken. In addition the applicant's expertise in the area has been recognised internationally by her appointments as World Health Organisation Advisor (Guidelines on Counselling of HIV Infected and AIDS Patients; Intravenous Drug Use and Risk of HIV Infection) and as UK representative to the Commission of the European Communities (Prevention of AIDS for Intravenous Drug Users) and she has presented evidence to a Home Office Working Party (Advisory Council on the Misuse of Drugs) and acted as academic referee for several academic journals including AIDS, AIDS Care, and Addiction. The submitted research publications are based upon five studies drawing upon 623 injecting drug users (idus) surveyed between 1985 and October 1992. The demographic characteristics of the clients included in each of the studies did not vary substantially between studies. Three of the studies involved evaluation of interventions for harm minimisation and two of those included designs of innovative interventions. The remaining two were aimed at identifying trends in risk - related behaviours and risk reduction. The body of work with its regular data collection over a seven year period from one location in the UK charts the behavioural changes and service responses from a point in time when AIDS awareness among idus was virtually non-existent through the response to the awareness of risks of sharing injecting equipment, followed by the introduction of needle exchange schemes and their evaluation, awareness of sexual transmission risks and need for sexual counselling, provides a unique perspective. The first and the final study had longitudinal components but the over all behavioural and attitudinal trends are identified from cross-sectional data. The approach taken by the research was to place risk-related behaviours within a context of the idus' social lifestyles rather than isolating behaviours from the contexts in which they occur. This approach contrasts with the individualistic social-cognitive models that have been used by others rather unsuccessfully to try to account for health related risk behaviours. The aims of the research were to obtain accurate information about the behaviours of idus with specific reference to HIV transmission related behaviours especially injecting practices and sexual behaviours by (1) identifying the characteristics of idus attending a drug dependency unit and/or syringe exchange unit in Central London (2) examining the sexual and drug-related behaviours of clients attending those services and their risks for HIV infections.

Background: To curb the transmission of HIV/AIDS and other infectious diseases several studies indicate the need for improved access to medical care for injection drug users (IDUs) including those already linked to syringe exchange programs (SEPs). However, availability and access to services remains a problem for many IDUs. This study seeks to examine perceptions of medical care access among a pharmacy-based sample of IDUs, utilization of medical services among IDUs and, identify barriers to accessing health care services to help ensure that IDUs receive appropriate care when needed and reduce the transmission of diseases. Methods: Data was obtained from the Pharmacists As Resources Making Links to Community Services (PHARM-Link) study. Dependent variables: health care access to the same provider and receiving care a usual source, health care utilization of services including the emergency room, clinic, medical office, medical mobile unit and hospital; and health care barriers categorized as personal or structural. Independent variables were insurance status, homelessness in the prior six months, case management, drug treatment and socio-demographic characteristics such as age, sex, income, education and employment status. Descriptive statistics analysis and logistic regression were performed using SAS version 9.4 (2013) with significance set at p<0.05. Results: Our sample included 615 IDUs participating in the PHARM-Link study. Overall, IDUs accessed health services and having the same provider remained statistically higher among those with legal income above $5,000 OR: 1.60 (95% CI: 1.03- 2.48), the insured OR: 4.11 (95% CI: 2.48-6.79), and those with positive HIV status OR: 7.64 (95% CI: 3.18 – 18.36), while those who were homeless reported lower access to the same provider OR: 0.63 (95% CI: 0.43 – 0.92). Only the older age group OR: 2.85 (95% CI: 1.42-5.73) and the insured OR: 3.42 (95% CI: 1.81-6.46) remained significantly associated with more access to receiving health needs at the same location. Those with some college education had less frequent visits to the clinic OR: 0.59 (95% CI: 0.38-0.92) and medical office OR: 0.64 (95% CI: 0.41-0.99), while the homeless were more likely to visit the emergency room OR: 1.49 (95% CI: 1.06-2.11). Females were less likely to go to a mobile unit OR; 0.52 (95% CI: 0.33-0.83) and married people were more likely OR: 1.95 (95% CI: 0.28-0.91). Visit to the hospital were less likely among females OR: 0.54 (95% CI: 0.36-0.81) and among those with some college education OR: 0.63 (95% CI: 0.41-0.96). Those with legal income above $5,000 were less likely to have any personal barriers OR: 0.64 (95% CI: 0.45 – 0.92). Structural barriers remained more likely among those who were homeless OR: 1.62 (95% CI: 1.13-2.39), but less likely among those 44 years and older OR: 0.58 (95% CI: 0.40-0.85), the insured OR: 0.60 (95% CI: 0.38-0.94), those with positive HIV status OR: 0.53 (95% CI: 0.28-0.99), as well as Non-Hispanic Blacks OR: 0.47 (95% CI: 0.14-0.83) and Latinos OR: 0.47 (95% CI: 0.25-0.86). Conclusion: Our results suggest that most IDUs linked to care through pharmacy-based SEP programs established to expand health services and improve health, did access available health services. However, some continue to experience difficulties such as structural barriers among the homeless as well as few reported visits to the clinic, medical office and the hospital among the employed believed to have resources to pay for such services. These services may have been underutilized because the participants were unsatisfied with the services provided. Therefore, interventions should target structural barriers such as homelessness among IDUs as well as health insurance coverage to help increase access to and utilization of health services.

Orientador: Francisco Hashimoto / Banca: Paula Ione Costa Quinterno Fiochi / Banca: Guilherme Elias da Silva / Banca: Ana Maria Rodrigues de Carvalho / Banca: Liamar Aparecida dos Santos / Resumo: Este trabalho se configura como proposta de problematização das questões relacionadas aos fenômenos de uso e abuso de drogas em nossa sociedade atual. Objetiva, em última análise, discorrer acerca do atual modelo de atenção aos usuários de drogas, cujas diretrizes se encontram traçadas na relação com o modo de atenção psicossocial em saúde mental. O lugar do sujeito usuário de drogas em meio à configuração deste modelo constitui o cerne das análises consideradas, com destaque para as tensões presentes no esboço de transposição do paradigma proibicionista no tocante às drogas. Metodologicamente, este trabalho entende que as produções de conhecimento sobre as drogas estão em constantes transformações e sujeitas a diversificados condicionantes, fortemente presentes na conformação do proibicionismo como uma de suas características centrais. Para a finalidade de compreensão de tais condicionantes, o trabalho elegeu o raciocínio de escavação genealógica dos conceitos e arranjos conformadores desse paradigma, através do olhar da hermenêutica da profundidade como veio de análise. A problematização dos conceitos e sua relação com o eventos de formação do proibicionismo são apresentadas, assim como suas transformações e desdobramentos para o arranjo legal-institucional de regulação das drogas nas políticas públicas no Brasil. A tese busca discutir e inquirir em que medida e proporção o atual modelo de atenção aos usuários de drogas poderia ser considerado de transposição e superação do... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: This work is configured as questioning of issues related to the phenomena of use and abuse drugs in our society. Objective, ultimately, discuss about the current model of care for drug users, whose guidelines are drawn in relation to psychosocial care in mental health. The place of the drug user through the configuration of this model is the core of the analysis considered, highlighting the tensions present in the transposition draft prohibitionist paradigm with regard to drugs. Methodologically, this paper considers that the production of knowledge about drugs are in constant transformation and subject to diverse conditions, strongly present in the formation of prohibition as one of its central features. For the purpose of understanding of such constraints, the work elected genealogical digging reasoning concepts and conformers arrangements of this paradigm through the depth hermeneutics look like it came from analysis. The questioning of the concepts and their relation to the prohibition of the training events are presented, as well as their changes and developments for the legal-institutional arrangement for the regulation of drugs in public policies in Brazil. The thesis aims to discuss and inquire in what extent and proportion the current model of care to drug users could be considered for implementation and overcoming of prohibition in terms of care practices and implementation of care devices. As regards the composition structure, the thesis has as its starting point t... (Complete abstract click electronic access below) / Résumé: Il s'agit dans ce travail de poser des problèmes liés aux phénomènes de l'usage et de l'abus des drogues dans notre société actuelle. Il vise, en fin de compte, produire des réflexions sur le actuel modèle de soins pour les usagers de drogues, dont les lignes directrices sont établies par rapport aux modes des soins psychosociaux en santé mentale. La place du sujet l'usager de drogues au milieu de la configuration de ce modèle est le cœur des analyses considérées, sourtout les tensions présentes dans le projet de la transposition du paradigme prohibitionniste dans ce qui concerne les drogues. Méthodologiquement, ce travail considère la production de connaissances sur les drogues comme toujours en transformation ainsi que soumis à diverses contraintes qui sont fortement présents dans l'établissement du prohibitionnisme comme l'une des caractéristiques essentielles. Pour comprendre ces contraintes, ce travail a élu le raisonnement de creusement généalogique des concepts et arrangements conformées de ce paradigme, par le regard de l'herméneutique de profondeur comme axe de l'analyse. La remise en question des concepts et leur relation avec des événements de formation du prohibitionnisme, sont présentés, ainsi que leurs changements et les développements de l'arrangement juridique et institutionnel de la réglementation des drogues dans la politique publique au Brésil. La thèse vise à discuter et se demander dans quelle mesure et proportion du modèle actuel des soins aux usagers de... (Résumé complet accès életronique ci-dessous) / Doutor

No Brasil, políticas de saúde que incluem o cuidado aos usuários de álcool e outras drogas são recentes. Apesar da existência de serviços comunitários, a internação dos usuários é algo muito frequente. Nos últimos anos, as modalidades de internação compulsória e involuntária passaram a ser aplicadas em larga escala, principalmente, por meio de solicitações dos familiares de pessoas com problemas relacionados ao uso de drogas. Estudos demonstram que há poucas evidências científicas acerca da efetividade de tais internações. O objetivo deste estudo foi compreender como os sentidos sobre a internação involuntária e/ou compulsória da pessoa que usa álcool e outras drogas foram construídos com seus familiares. Para tanto, foi realizado um estudo qualitativo, com referencial teórico construcionista social. O corpus foi composto por 15 entrevistas semiestruturadas feitas com familiares de usuário de drogas que foram, anteriormente, internados involuntariamente e/ou compulsoriamente. A técnica utilizada para a seleção destes participantes foi a bola de neve. O projeto foi aprovado pelo Comitê de Ética em Pesquisa da FFCLRP-USP. Em primeiro lugar, foi realizada análise temática das entrevistas, considerando a construção dos sentidos dentro do contexto histórico-cultural, as experiências de vida e as interações sociais. A seguir, foi realizado um estudo de caso de uma das entrevistas realizadas, com o objetivo de analisar discursos envolvidos no processo de busca de internações involuntárias e compulsórias. Para isto, foi selecionada a entrevista de uma participante que havia solicitado 23 internações involuntárias e cinco compulsórias para seu filho. O corpus dessa análise consistiu na entrevista semiestruturada e notas de campo que foram elaboradas a partir das conversas com a participante. A partir da análise temática foram construídos quatro temas: (1) Sentidos sobre internações involuntárias e compulsórias, em que as internações foram construídas como formas de educar, cuidar e proteger o usuário dos perigos da rua, dos traficantes, de ser preso e de morrer, alcançar abstinência e alívio principalmente para os familiares. (2) Consequências do uso problemático de drogas, como relatos de mudanças negativas no comportamento do usuário, acúmulo de perdas na vida do usuário e a percepção de estigma. (3) Sentimentos da família, envolvendo culpa, desespero, frustração, vergonha, medo e desesperança diante do problema. (4) Tentativas mal sucedidas de resolver o problema, diante do desconhecimento de serviços ambulatoriais e do foco apenas na abstinência. A partir do estudo de caso, foram construídas três narrativas: (1) discurso individualista e discurso do déficit sobre seu filho que ao ser posicionado como alguém que é definido pelas suas falhas passa a ser internado repetidamente; (2) Discurso individualista e culpabilização da mãe uma vez que ela é descrita como superprotetora, inadequada e impotente; (3) Discurso alternativo baseado na perspectiva relacional que convidaria mãe e filho a se engajar em uma conversa colaborativa, criando um contexto onde novas formas de entendimento poderão surgir. Considera-se que para reduzir o número de reinternações dos usuários de drogas é necessário apoiar seus familiares por meio da ampliação da rede de cuidados, orientação sobre tratamentos ambulatoriais e acolhimento dos sentimentos e angústias da família. / In Brazil, the health policies that include care for alcohol and other drug users are recent. Despite the existence of community services, the drug users hospitalization is very frequent. Over the last years, compulsory and involuntary hospitalization has been applied on a large scale, especially, requested by families of people who consume alcohol and drugs. Studies shown few scientific evidences of the efficiency of those hospitalizations. This study aims to understand how the meanings about the compulsory or involuntary hospitalization of the person that uses alcohol and other drugs were constructed with the families. To achieve this, it has been a qualitative study, with social constructionist referential. The corpus consisted in 15 semistructured interviews conducted with the families of drug users that were previously taken by involuntary or compulsory hospitalization. The selection participant technique was made through snowball selection. The project was approved in the Ethical Committee of FCLRPUSP. In first place, it was made thematic analysis of interviews, considering the construction of meanings inside the historic-cultural context, their experiences of life, and their social interactions. In second place, a case study was made through one of the interviews conducted in order to analyze discourses involved in the seeking process of involuntary and compulsory hospitalizations. To achieve this, it was selected an interview with a participant who had requested 23 involuntary and five compulsory hospitalizations for her son. The corpus of analysis consisted by the full transcription of this interview and the field notes referring to it. Through the thematic analysis was constructed four themes: (1) Meanings about involuntary and compulsory hospitalization, in which the hospitalizations were construed such as education, care, abstinence, relief mainly for family members, protection from the dangers of the street, from drug dealers, police, and death. (2) Problematic drug uses consequences, such as reports of changes in the user behaviors, accumulation of losses in the drug users life, and the perceived stigma. (3) Feelings of the family, involving guilt, despair, frustration, shame and hopelessness in the face of this problem. (4) Attempts to help the family member, due to not knowing the community services for drug treatment and to focus only on abstinence. Through the discourses analysis, it were constructed three narratives: (1) individualistic discourse and deficit discourse that helped to position her son as somebody who is defined by his failures, and resulting in new hospitalizations. (2) Individualistic discourse and blaming the mother since she was described as overprotective, flawed, and powerless. (3) Alternative discourse based on the relational perspective that invited the mother and son to engage in a collaborative conversation, creating a context where new forms of understanding can emerge. In order to reduce the number of hospitalizations of drug users, it is necessary to support their relatives by publicizing services for community treatment, and helping the family to deal with distress.

Aims - This thesis describes an open drug market and its suspected drug users in a Swedish city. This drug market is located at the local bus hub called Navet, in the city of Sundsvall, which has a reputation of being a place to avoid because of the substance abuse and accompanied crime. The aim was to disclose what happens at Navet that is associated with drug related activities. Method - two observers visited Navet from November 2016 to March 2017 at different times of the day with an ethnographic approach to take notes of the daily life at Navet, using their own experiences as basis for the description and analysis. No interactions with the actors at Navet were initiated by the observers. Results - Navet is more than just adrug market, it also provides a meaningful social aspect for the actors by spending time at Navet granting a feeling of belonging to a group. Four different groups of people were identified, the traveling citizens using Navet for transportation, people using navet as their meeting place without taking part of the drug activities, the suspected drug users and the young suspected drug users. The most frequent and openly used substances was alcohol followed by unspecified pills, other types of illegal substances were suspected to be common at Navet but never witnessed to be consumed. Conclusion - As rumored, Navet is a place where drugs and suspected drug users are present during almost all hours of the day. However, the generally perceived feeling of hostility and danger is exaggerated, contributing to a worse reputation of Navet compared to what can be supported through this study. / <p>2017-06-01</p>

京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第18465号 / 社医博第55号 / 新制||社医||8(附属図書館) / 31343 / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 中山 健夫, 教授 中原 俊隆, 教授 髙折 晃史 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

Background: Aftercare services with an aftercare program in the Czech Republic significantly help to integrate persons with addictological problems into the majority society. However, according to the National Monitoring Center for Drugs and Drug Addiction, more than 50 % of users of these services are unsuccessful in their aftercare. Objective: The aim of the research is to find out the needs of clients in the area of housing at selected after-treatment centers. Identify whether these needs are met and whether clients' success in aftercare programs is not affected by unmet housing needs. Methodology: The theoretical and practical part of the thesis delimits the research findings. The theoretical part deals with aftercare services with aftercare program and the effect of relapse and relapse in aftercare for addiction.The practical part defines the area of research and with the use of quantitative methods of research comes up with statistical data, which are subsequently interpreted. Results: 7 residential facilities with a capacity of 85 beds participated in the research. The research sample consisted of 76 respondents. The research sample found that a significant proportion of clients did not meet the housing needs and in 44,7 % would use the sociohealth services only for housing. In the research...