O presente estudo esta inserido na temática das Desigualdades em Saúde, tendo como objetivo a identificação de desigualdades territoriais em saúde nas 63 regiões de saúde do estado de São Paulo, a partir de indicadores de saúde selecionados segundo a visão dos Articuladores da Atenção Básica que atuam nessas regiões. Trata-se de um estudo descritivo, de natureza quali/quantitativa, que utilizou Grupos Focais para seleção dos indicadores com maior capacidade em identificar desigualdades em saúde num rol de 67 indicadores do Contrato Organizativo da Ação Pública (COAP). A partir de um grupo de dez indicadores escolhidos foram analisadas as tendências da série histórica do período entre 2010 e 2015. Diferenças importantes entre as regiões foram identificadas pelo desempenho desses indicadores e quando interpretadas em relação à estratificação dos municípios estabelecida pelo Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ), com base em critérios sociais, econômicos e demográficos, algumas dessas regiões apresentaram distribuição semelhante àquelas encontradas no PMAQ. O recorte adotado no estudo voltou-se aos indicadores de saúde escolhidos a partir de uma metodologia específica, acreditando em sua capacidade de revelar desigualdades territoriais na saúde, muitas delas iníquas, nos âmbitos estadual e regional, podendo mobilizar profissionais envolvidos na implementação de ações em direção à diminuição das iniquidades na saúde. Os resultados mostraram desigualdades regionais importantes para os indicadores envolvidos no estudo, em especial para a maioria dos indicadores de saúde de algumas regiões do sul e oeste do estado. Dessa forma, acredita-se que o acompanhamento desses indicadores por meio de uma abordagem espaço temporal poderá fornecer subsídios para o planejamento de ações programáticas previstas nas políticas públicas de saúde, levando em consideração as características locoregionais na construção e implementação de medidas que atendam necessidades distintas nos distintos territórios. / This study is inserted in the subject of Health Inequalities, aiming to identify territorial inequalities in health in 63 health regions of São Paulo state, from selected health indicators according to the perception of the of Primary Care Articulators who act in these regions. It is a descriptive study, of qualitative/quantitative nature, which used Focal Groups to select the indicators with higher capacity to identify health inequalities in a list of 67 indicators obtained from the Public Action Organizational Contract (COAP). Starting from a set of ten chosen indicators were analyzed trends in the time series of the period between 2010 to 2015. Important differences between the regions were identified according to the performance of these indicators and when interpreted in relation to the stratification of the municipalities established by the National Program for Improving Access and Quality of Primary Care (PMAQ), which adopts social, economic and demographic criteria, some of these regions showed similar distribution to those found in PMAQ. The outline adopted in the study focused to health indicators chosen from a specific methodology, believing in its ability to show inequalities in health, many of them unfair, on the state and regional levels, and may mobilize professionals involved in implementing actions towards the reduction of health inequities. The results show significant regional differences for the indicators involved in the study, especially for most health indicators in some regions of the south and west of São Paulo state. Thus, it is believed that the monitoring of these indicators through a timeline approach can provide information for planning of programmatic actions envisaged in public health policies, taking into account the local and regional characteristics in the construction and implementation of measures to meet different needs in different territories.

Le travail de cette thèse s’interroge sur les réponses à apporter en terme d’organisation de l’offre médico-technique et de sa juste répartition sur les territoires en particulier pour les patients âgés poly-pathologiques. Il part de l’hypothèse qu’il existe un espace pour des concepts de petits établissements de santé ambulatoires pluridisciplinaires, dotés d’un petit plateau médico-technique, qui permettraient de participer à fluidifier et optimiser les parcours de soins. La méthode a consisté d’une part à étudier des structures plus petites de proximité en Allemagne, les MVZ, avec une expérience plus ancienne que celle dont nous disposons en France avec les MSP ou les Centres de Santé, et d’autre part à analyser les données PMSI pour faire émerger à la fois l’existence de groupes homogènes de co-morbidités et de groupes homogènes de parcours de soins. Les résultats sont constructifs, à la fois dans l’analyse par les sciences des réseaux et par l’automatisation de représentations de parcours de soins complexes. Ils ont permis de faire émerger des patterns représentatifs de groupes, d’en caractériser la consommation de soins, en matière de dispositifs médicaux et de ressources humaines, de quantifier les distances parcourues cumulées et les coûts cumulés par les patients selon leur lieu d’habitation et les institutions de santé auxquelles elles sont adressées. Nous en tirons des éléments pour la définition et la labellisation de nouvelles structures de santé de proximité satellites d’hôpitaux plus importants. Ce travail représente une avancée particulièrement utile, à la fois conceptuelle et pratique, pour les études de données de santé complexes des personnes âgées. / This work questions the answer to be given in terms of organization of the health technical offer and its fair distribution in the territories especially for the elderly patients with multimorbidities. It is based on the assumption that there is space for a concept of small multi-disciplinary outpatient health facilities, with a small health-technical platform, which would help to streamline and optimize care pathways. The method consisted on the one hand to study in Germany smaller community interdisciplinary health care center (the MVZ) in operation for a longer time than the the French multidisciplinary médical care centers. And on the other hand it analyzed the national heath data to reveal both the existence of comorbidités related groups and homogeneous care pathways related groups. The results are positive, both in network science analysis and in the automation of representations of complex care pathways. They made it possible to create representative patterns of groups, to characterize the consumption of care, in terms of medical devices and human resources, to quantify the cumulative distances traveled and the costs accumulated by patients according to their place of residence and the health institutions to which they are sent. We get addition elements for the definition and labeling of small community health centers, satellite of larger hospitals. This work represents a particularly useful step, both conceptual and practical, for complex health data studies of elderly.

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

Societies that foster high quality social environments and integration produce healthier populations. The mechanisms underlying the protective effect of social integration appear to be through various forms of social support. In the Canadian Aboriginal context, few authors have explored the relationship between health and social support. This gap in understanding is significant because Aboriginal frameworks of health point to the salience of larger social structures (i.e., family), yet patterns of population health point to distinctly social causes of morbidity and mortality (e.g., violence, alcoholism). An interesting paradox emerges: patterns of Aboriginal health suggest that social support is not working to promote health. This dissertation explores this paradox through a mixed-methods approach to describe the value of social support for Aboriginal health, and to critically examine the social-structural processes and mechanisms through which social support influences Aboriginal health at the community level. / Principal components analyses of the 2001 Aboriginal Peoples Survey (APS) identified social support as a consistent dimension of Metis and Inuit health, and multivariable logistic regression modelling of the 2001 APS identified social support to be a significant determinant of thriving health among Indigenous men and women (e.g., those reporting their health as excellent/very good versus good/fair/poor). The results also indicate a distinct social gradient in thriving health status and social support among Aboriginal Canadians. / Narrative analyses of 26 interviews with Aboriginal Community Health Representatives point to two key explanations for the health-support paradox: (i) social support is not a widely accessible resource; and (ii) the negative health effects of social support can outweigh the positive ones. The formation of health behaviours and cultural norms - which underpin social supports - are inextricably tied to the poor material circumstances that characterize Canada's Aboriginal communities. The thesis concludes with a critical examination of the processes through which environmental dispossession has influenced the determinants of Aboriginal health, broadly speaking. Effects are most acute within the material and social environments of Aboriginal communities. More research attention should focus on identifying the pathways through which the physical, material and social environments interact to influence the health of Aboriginal Canadians.

The physical, psychological and social development of school children has been neglected - partly because they were seen as healthy "survivors" of the ravages of childhood illnesses, and partly because of the way in which health services are organized (such as the traditional under-five maternal and child health (MCH) services and the curative PHC clinic services). From the age of five years children undergo rapid and profound bio-psycho-social development, to emerge in adolescence as the next generation of leaders and workers. Securing their future growth and development is vital for any society to be economically and socially productive. A substantial body of national and intemational literature has recognised the detrimental impact of helminthic infections and micronutrient deficiencies on the physical and psychological health and development of school children; which requires appropriate nutritional interventions. Concern has been expressed that these adverse biological, physical and social deprivations have a cumulative impact on several dimensions of children's growth. Most important, apart from stunting physical growth, is the inhibition of educational development of school children. Recent evidence strongly suggests a powerful interaction between physical and psychosocial growth and development of children. Inhibition of either component of a child's well-being has adverse implications. Conversely, investments in the physical and psychological development of children are likely to generate substantial health and educational benefits and are a worthy investment to secure a healthy future generation. In summary, there are a number of reasons for, and benefits of, investing in school-based health and nutrition interventions. They are likely to improve learning at school and enhance educational outcomes; create new opportunities to meet unfulfilled needs; redress inequity; build on investments in early child development and promote and protect youth and adolescent development. Health and nutrition interventions such as school feeding programmes, micronutrient supplementation and deworming aim to improve primary outcomes of macro and micro-nutrient deficiencies, parasitic and cognitive status; as well as secondary outcomes of developing integrated comprehensive school health policies and programmes. This rationale served as the conceptual framework for this study. This theoretical framework views improvements of the health, nutritional, cognitive and scholastic development status of school children as the primary focus of policies, strategies and programmes in the health and education sector. This focus constitutes the central core of this thesis. Optimum social development requires investments in both the health and educational development of school children, so as to maximise the synergies inherent in each sector and to operationalise national and international strategies and programmes. As part of the larger RCT study a comprehensive nutritional, health and psychological profile of rural school children was established through a community-based cross-sectional study. Eleven schools were randomly selected from the Vulamehlo Magisterial District in southern KwaZulu-Natal (KZN). Within each school, all Standard 1 pupils, aged between 8 - 10 years, were selected giving a final study sample of 579 children. Some of the observed prevalence's were stunting (7.3%), wasting (0.7%), anaemia (16.5%) (as measured by haemoglobin below 12 g/dl), vitamin A deficiency (34.7%) (as measured by serum retinol below 20 ug/dl) and serum ferritin below 12ng/ml (28.1%). This study established that micronutrient deficiency, parasitic infestations and stunting remain significant public health problems among school-aged children in South Africa. Combining micronutrient supplementation and deworming are likely to produce significant health and educational gains. To determine the impact of single and combined interventions (anthelminthic treatment and micronutrient supplements) on nutritional status and scholastic and cognitive performance of school children, a double-blind randomised placebo controlled trial was undertaken among 579 children 8-10 years of age. There was a significant treatment effect of vitamin A on serum retinol (P<0.01), and the suggestion of an additive effect between vitamin A fortification and deworming. Vitamin A and iron fortification also produced a significant treatment effect on transferrin saturation (P<0.05). Among the dewormed group, anthelminthic treatment produced a significant decrease in the prevalence of helminthic infections (P<0.02), but with no significant between-group treatment effect (P>0.40). Scholastic and cognitive scores and anthropometric indicators were no different among the treated or the untreated children. Fortified biscuits improved micronutrient status among rural primary school children; vitamin A combined with deworming had a greater impact on micronutrient status than vitamin A fortification on its own; while anthelminthic treatment produced a significant reduction in the overall prevalence of parasite infection. The prevalence's of Ascaris lumbricoides, Trichuris trichiura and Schistosoma haematobium declined significantly sixteen weeks post-treatment. The levels of both prevalence and intensity in the untreated group remained constant. The cure rates over the first two weeks of the study were 94.4% for Ascaris lumbricoides, 40% for Trichuris trichiura, and 72.2% for Schistosoma haematobium. The benefits of targeted school-based treatment in reducing the prevalence and intensity of infection supports the South African government's focus of using school-based interventions as part of an integrated parasite control programme. These strategies and programmes were found to be consistent with the recommendations of WHO and UNICEF. The nutritional transition facing developing and middle-income countries also has important implications for preventive strategies to control chronic degenerative diseases (Popkin B, 1994; WHO 1998; Monyeki KO, 1999). This descriptive study, comparing BMI data of school children over three time periods, found a rising prevalence of overweight and obesity among South African school children. Obesity as a public health problem requires to be addressed from a population or community perspective for its prevention and management. Environmental risk factors such as exposure to atmospheric pollution remain significant hazards for children. Lead poisoning is a significant, preventable risk factor affecting cognitive and scholastic development among children. The prevalence of elevated blood lead (PbB) levels in rural and semi-urban areas of KwaZulu-Natal (KZN) as well as the risk factors for elevation of PbB among children in informal settlements were examined. This study investigated over 1200 rural and urban children in two age groups: 3-5 and 8-10 years old. Average PbB level in peri-urban Besters, an informal settlement in the Durban metropolitan region, was 10 ug/dl with 5% of the children showing PbB level of greater than 25 ug/dl. By comparison, average PbB value in Vulamehlo, a rural area located 90-120 km from Durban, was 3.8 ug/dl and 2% of the children's PbB levels were greater than 10 ug/dl. Since the cognitive and scholastic performance of school children was a primary outcome measure in this study, it was important to explore other factors that influenced this variable. The performance scores of all four tests in the battery, among the cohort of a thousand rural and urban children, were in the lower range. The educational deficit identified in this test battery clearly indicates the impact of the inferior "Bantu" educational system that African children have experienced in South Africa. Aspects of the School Health Services that were investigated in this descriptive study included the services provided and their distribution; assessment of health inspection; health education and referral processes undertaken by the School Health Teams; perceptions of managers, providers and recipients of the service; as well as the costs of the provision of the service in KwaZulu-Natal. In KwaZulu-Natal, there were School Health Teams In all the 8 health and education regions in the province. In total, there were 95 teams in the province, consisting of nearly 300 staff members. The School Health Teams were involved in a wide range of activities - 74% of all teams were involved in health inspection and 80% were involved in health education. The total annual cost of delivering School Health Services in the province in 1995 was estimated to be approximately R8 750 000. Given the rise of HIV and AIDS in the province, School Health Services need to play a central role not only in prevention, but also in assisting with the acceptance of HIV-positive children within schools. It is recommended that the current and future draft SHS policy guidelines be approved by the relevant authorities for immediate implementation. Districts should consider developing "Health Promoting Schools", with School Health Teams being a central resource. This thesis has explored several aspects of the epidemiological profile of school children in rural and urban settings in KwaZulu-Natal. It has established that school children are exposed to a range of risk factors ranging from nutritional deficits, parasitic infections, atmospheric lead poisoning and a rising prevalence of overweight. All of these risk factors may compromise their physical, psychological and social development. A number of health interventions have been identified, which have the potential to address these problems. Such investments are essential to secure the health of future generations. / Thesis (M.D.)-University of Natal, Durban, 2001.

Bibliography: leaves 203-219. / 219 leaves : ill. ; 30 cm. / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Concerned with the contribution of commonsense understandings of disease to social differentials in health outcomes. Argues that understandings in part reflect the social circumstances of an individual and mediate preventive activities and use of services, thereby influencing health outcomes. These are examined using the specific health outcomes of tooth loss and tooth decay. / Thesis (Ph.D.)--University of Adelaide, Dept. of Public Health, 2000

[Truncated abstract] The Disability-Adjusted Life Year index, developed by the Global Burden of Disease Study, is used extensively to compare disease burden between locations and over time. While calculation of the fatal component of this measure, Years of Life Lost, is relatively straight-forward, the non-fatal component, Years Lived with Disability, is based on parameters that are challenging to estimate. This thesis pioneers the use of the Western Australian Data Linkage System to enhance epidemiological parameters underpinning Years Lived with Disability, providing, by way of illustration, a robust quantitative profile of burden of stroke in the state of Western Australia at the turn of the 21st century. The principal methodological objective was to utilise data linkage analytic methods for the specific requirements of burden of disease estimation. The principal stroke-related objectives were: 1. To estimate the parameters underpinning the non-fatal burden of stroke (Years Lived with Disability) in Western Australia in 2000. 2. To estimate the total burden of stroke (Disability-Adjusted Life Years) in Western Australia in 2000. 3. To investigate differentials in stroke burden between different sub-populations in Western Australia. 4. To calculate projections of stroke burden for Western Australia in 2016. Years Lived with Disability from stroke were calculated for Western Australia from nonfatal stroke incidence, expected duration and disability (severity) weights. Non-fatal incidence was estimated using linked hospital and death records of first-ever hospitalised stroke 28-day survivors in 2000. This was then adjusted for out-of-hospital cases determined from the population-based Perth Community Stroke Study. iv Analysis of mortality in hospitalised 28-day survivors using linked data revealed that the excess mortality in prevalent, rather than incident cases was the main disease-specific parameter required for modelling stroke duration using DisMod II specialised software. ... Access to data linkage and population-based stroke studies in Western Australia allowed more accurate estimation of non-fatal stroke burden, with previous reports most likely underestimating disability as a contributor to total burden. Although predominantly affecting the growing aged population, stroke also affects a sizable number under the age of 65 years, the age group where differentials in stroke burden are the greatest. The findings highlight the continued need for primary prevention efforts for all ages, targeting especially younger people in disadvantaged groups. The shift to greater disability burden in the future and the needs of disadvantaged groups must be considered when planning stroke services. The multiple studies undertaken for this thesis contribute to ongoing improvement of data quality and methodological refinements underpinning estimates of Years Lived with Disability, specifically for stroke, but applicable also to other diseases. Similar linked data approaches can be used in other Australian states in the future once infrastructure is developed, thereby improving estimates of disease burden for health policy and planning in the future.

[Truncated abstract] The primary aims of this thesis were to investigate health indicators of child maltreatment, as well as pathways into the child protection system using routinely collected government databases, enabling a preventative health approach to child abuse and neglect. This thesis aims to improve understanding of the trends in child maltreatment and the factors, at the child and family level, which increase or reduce vulnerability to child maltreatment so more effective prevention policies and practices can be developed. This project uses longitudinal de-identified population data from the Western Australian Government Departments of Child Protection, Health and Disability Services. These data contained information on demographic, clinical, social and child protection outcomes of children and their families. Record linkage of administrative data was undertaken to: investigate health indicators of abuse and neglect using Hospital Morbidity data to enable the monitoring of population trends in abuse and neglect; compare proportion of cases obtained using health indicators with the Department of Child Protection data, and describe the physical, psychological and social characteristics of abused and/or neglected children and families. Statistical techniques utilised include logistic and Cox regression to investigate risk of adverse child outcomes, taking into account potential confounding and time to event. The main findings include: There has been an increase in assault and maltreatment related hospital admissions over the last 25 years. ... There has been a marked increase in the birth prevalence of Neonatal Withdrawal Syndrome (NWS) in Western Australia over the last 25 years, from 1 per 10,000 live births in 1980, to 31 per 10,000 live births in 2005. Specific maternal characteristics associated with having a child with NWS are identified and these children have an increased risk of child protection involvement. A population level analysis of child and parental factors determined the estimated increase in risk of substantiated child maltreatment for child intellectual disability, parental admissions for mental health, substance use, and assault, as well as greater socio-economic disadvantage. Conclusions This is the first body of research which has extensively used longitudinal, population level linked health and child protection data to investigate health indicators of child abuse and neglect and antecedent causal pathways. Monitoring injuries and conditions associated with child abuse and neglect in routinely collected data and using multiple sources of ascertainment are important initiatives in child maltreatment surveillance. Health indicators of child abuse and neglect are not subject to the same definitional and policy issues as child protection data and therefore provide a more valid comparison over time and between jurisdictions. The identification of factors which increase vulnerability for children and families to child maltreatment is essential in the implementation of prevention strategies including universal public health approaches as well as the identification of at-risk families for targeted intervention.

Diss. (sammanfattning) Stockholm : Karol. inst., 2003. / Härtill 5 uppsatser.

Thesis (Ph.D.)--Pardee Rand Graduate School, 2007. / Title from title screen (viewed on June 13, 2008). This website links to the complete document in PDF format. Includes bibliographical references.