Buscamos neste trabalho, refletir a partir da experiência de profissionais, sobre a relação entre as práticas da Atenção Básica desenvolvidas em uma UBS e as diretrizes políticas do SUS a que elas se referemr. Realizamos uma breve retomada histórica das práticas de atenção em saúde, uma contextualização da Atenção Básica e de sua situação atual no Brasil, de modo a problematizar como esse contexto atravessa a prática diária. A partir da fala dos trabalhadores e de observações realizadas na UBS, identificamos um distanciamento, que nomeamos como lacunas, entre o trabalho que se prescreve a partir de diretrizes políticas e o trabalho efetivamente realizado. Na análise, identificamos contradições referentes a essas diretrizes e programas derivados para a Atenção Básica: poucos recursos e investimentos em um trabalho que demanda estudo de alta complexidade técnica e profundo conhecimento empírico da realidade para lidar com demandas da população. A complexidade desse setor se expressa entre os trabalhadores através de sentimentos ambíguos e contraditórios em relação à própria atuação profissional e à relação estabelecida com os usuários do sistema de saúde. As ressonâncias na subjetividade desses profissionais são diversas e temas como medo, carência e sentimento de impotência ganham destaque frente à dificuldade de compreensão das próprias práticas e das lacunas entre o que se prescreve e o que se implanta e implementa / We´vesought in this work, based on the health professionals´ experiences, to reflect on primary care practices developed in a UBS (Basic Health Unit) located in the state of São Paulo referred to SUS (Unified Heath System) policy guidelines. We conducted a brief historical research on health care practices, a contextualization of primary care and its current situation in Brazil, in order to discuss how that context goes through daily practice. Based on the spoken comments of workers and observations made in UBS, we identified a kind of distance, which we named as gaps between the work that is prescribed by policy guidelines and the work that is actually performed. In the analysis, we identified contradictions regarding these guidelines and related programs for primary care: few resources and investments in a job that requires studies of high technical complexity, as well as deep empirical knowledge of the reality to deal with demands of the population. The complexity of this sector is expressed by workers through ambiguous and contradictory feelings about their own professional performance, as well as in relationships established among them and the users of the health system. Resonances in the subjectivity of these professionals are several and themes, such as fear, lack of affection and a sense of powerlessness, gethighlighted by the difficult understanding of the practices themselves and the gaps between what is prescribed and what is implanted and implemented

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.

Problems concerning the planning and practicing of health care currently exist. Countries are spending more funds on medical care without making a discernible dent in the health status of their citizens. This lack of success in obtaining health is obviously a problem for everyone experiencing ill health or the effects thereof It also creates a personal problem for all health workers, because a halt is being called to profligate spending on health that will affect all. The problems underlying tl:e health care crisis are rising costs, unequal distribution, low productivity, poor heali..ii status, and a lack in sensitivity towards the communities it serves. The multi-disciplinary, complex nature of these problems in health care, their magnitude and their inter-relatedness indicate that traditional approaches to health care planning and management have been inadequate or have failed. An alternative approach to solve these problems is to adopt a holistic view, i.e., to see all parts (components) which contribute to the problem as parts of the whole. By viewing the problem as a whole, more enduring solutions may be formulated. The aim of this study was to employ and evaluate the adoption of a systems approach to solve "real life" problems. The Soft Systems Methodology of Peter Checkland was utilized to assess the situation within the Oral Health Service of the SAMS and to identify relevant systems to improve the situation. The need for a Preventive System and a Performance Measurement System was established. These two systems were planned, developed and implemented using and obeying systems rules and techniques. Both these systems were evaluated and found to be highly efficient, effective, cost-effective and made a positive net contribution to the Oral Health Service of the SAMS. It is finally concluded that the adoption of a systems approach to identify and solve "real life" problems was effective and efficient. It is therefore recommended that a systems approach to the management of oral health, and probably health too, should be embraced by the encumbered health industry. / Dissertation (MChD)--University of Pretoria, 1993. / gm2013 / Community Dentistry / unrestricted

Magister Public Health - MPH / From 2004 the Eastern Cape Department of Health (ECDoH) started implementing the new community health worker (CHW) programme in all its clinics, but so far little is known about its implementation process, its successes and challenges. The aim of this study was to assess the implementation of the new government funded CHW programme at three clinics of the Eastern Cape Province. / South Africa

Magister Public Health - MPH / The prevalence of obesity is reported to be high among health workers both in high-income and low-income countries. This is alarming, as health workers not only serve the community’s health needs, but should also serve as role models for a healthy lifestyle. Health workers are instrumental in delivering quality health care to patients and the entire population at large and if they are unable to take care of their own health, staff shortages may become severe, resulting in deteriorating health service delivery. It is therefore important that obesity among health workers is reduced before it gets worse. It has been noted that there is an increasing prevalence of obesity among health workers, which in turn is a common risk factor in all non-communicable diseases. The current study explored perceptions and attitudes about obesity amongst health workers in Pietermaritzburg, KwaZulu-Natal province. This was an explorative and descriptive qualitative study utilizing in-depth interviews for data collection. A total of 18 health workers from the three selected hospitals in Pietermaritzburg medical metropolitan were interviewed. Thematic analysis was done, using. a priori themes from the health belief model. The current study found that all health workers were aware of the negative consequences of being overweight or obese. However, only a few of the participating health workers chose to adopt a healthy lifestyle as a result of their weight. Some of the positive motivators were improving their public image, improving their health status and becoming more flexible, while negative motivators were finding it difficult to fit into old clothes, fear of suffering from obesity related conditions and reducing the risk of suffering from NCDs. The health worker participants reported that African cultural beliefs, limited operational times of physical activity facilities and unavailability of healthy food were barriers to adopting a healthy lifestyle. The African cultural belief of considering people who are overweight to be healthy, progressive and prosperous prevents people from changing their behaviour on weight control. In addition, participating hospitals do not have independent physical exercising facilities as such the available physiotherapy departments give priority to patients, resulting in staff members having only limited hours for exercising. Lastly, the participating hospitals did not sell healthy food options in the cafeterias resulting in health workers buying what is available. Public health care facilities need to invest in their work force. This may include giving health workers access to physical exercise facilities and affordable healthy food within the hospital. The infrastructure and system should enable them to pursue a healthy lifestyle. Institutions should introduce health-behaviour change programmes on obesity and other NCDs in order to combat established cultural norms, which advocate for overweight body sizes to be desirable because of positive cultural connotation afforded to them. / The National Research Foundation (NRF)

Magister Scientiae Dentium - MSc(Dent) / BACKGROUND: The scourge of HIV and AIDS on the people of Lesotho is a huge public health problem faced by the country’s Ministry of Health and in 2005 the national adult HIV prevalence rate was 23% (WHO, 2009). It is estimated the one in every four adults in the country is HIV positive and in 2012, new HIV infection per year was estimated to be 18,000 (MoH Lesotho, 2014). The 2014 health reform by the Ministry of Health, Lesotho plans to capacitate village health workers (VHWs) to play an important role in addressing Lesotho's most urgent health crises which are: to reduce child mortality, to improve maternal health, to combat HIV/AIDS and other diseases. This is because VHWs and primary health care nurses (PHC nurses) are in vital positions to identify, manage or refer such patients for appropriate care. Studies have shown that between 74.4% - 90% of HIV infected people present with at least one oral lesions in the course of the disease. Health care workers need to have adequate knowledge of these conditions for effective management thereof. AIM: To determine the knowledge, attitudes and practices of nurses and VHW in Butha-Buthe district with respect to oral HIV/AIDS manifestations. METHODOLOGY: A descriptive cross-sectional survey was conducted on one hundred and forty-one Village health workers and nurses in Butha-Buthe district of Lesotho. A self– administered questionnaire was used to gather information on demographic characteristics of the participants and their knowledge, attitudes and practices regarding the management of oral lesions associated with HIV. Analysis was done using the SPSS statistical software package. Descriptive statistics such as frequency distributions and cross tabulations was generated and the results were summarized in tables and figures. RESULTS: The ages of the participants ranged between 21 and over 50 years. There majority were female (83.7%). And two thirds had a secondary school education. The healthcare providers that had ten years or less of service accounted for 59.6% of the respondents and 0.7% had more than 30 years of service. Most of the respondents (97.9%) had previous knowledge on oral lesions related to HIV/AIDS but only (8.2 %) reported having received knowledge through training institutions. The majority (79.3%) identified oral candidiasis (OC) as the most common lesion found in people living with HIV/AIDS while lesions of NOMA, aphthous ulceration, Kaposi’s sarcoma and herpes zoster were the least identified lesions by the respondents. The findings showed that 67.4% of the participants washed their hands routinely with water only whereas 66.7% routinely washed their hands with antiseptics. However, a majority of them (96.5%) said that they washed their hands with water and soap routinely. CONCLUSION: There are however gaps in the knowledge, attitude and practices of nurses and VHWs in Butha-Buthe district to oral HIV/AIDS manifestations. Improvement in the knowledge and ability of these cadres of health care providers to recognize and manage such lesions can be done through an introduction of such training in their school curriculum. It may also be necessary to continuously have seminars aimed at training and retraining these cadres of health workers on this topic. It is also worrisome that a high number of the participants indicated they didn’t strictly adhere to standard precautions as stipulated by WHO. It may be necessary to conduct studies to assess reasons for their infection control practices.

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).

To tackle one of the world’s worst maternal, neonatal and child health outcomes and a chronic shortage of human resources for health, the Afghan Ministry of Public Health deployed volunteer Community Health Workers (CHW) in rural areas of Afghanistan in 2003. This thesis documents the Afghan CHW program, exploring organizational and community contexts. The research design in this study is a mixed methods case study. The actual Afghan CHW program was situated with an Afghan complex adapative health system, mainly guided by the policy of the health system but was also largely influenced by the power and gender dynamics of the community context in which it was implemented. The tasks of CHWs were numerous but CHWs role was more than just the sum of their tasks; they occupied a unique location juxtaposed between formal and informal HRH systems. It is important to acknowledge the assembly of so many national and international organizations in achieving a shared goal of providing health services to a large population in an unstable and partially insecure environment. The shared goal in the Afghan context may have been interpreted only in terms availability of services, though the goal carries with it, either explicitly or implicitly, the values of effectiveness, efficiency, timeliness, and costliness – known as quality by some participants of this study. The community component was another layer of the complex adaptive system that made up the Afghan CHW program. Political-ethnic power in the community and legal-rational authority of the health system influenced the way communities were mapped in an inequitable manner, in turn, contributed to the unfair distribution of resources to the populations. Finally, the intersection of the gender equity approach and the gendered nature of the work as a cross-cutting layer added to the complexity of the Afghan health system.

This thesis, 'Living with HIV/AIDS: An ethnography of care in Western Kenya', is based upon 18 months of ethnographic fieldwork carried out in Central Nyanza, Kenya, between 2005-2007. It studies practices of care against the backdrop of the HIV/AIDS epidemic, which has impacted the region severely. The thesis explores how home and hospital are established as domains of care through practice. It draws upon ethnographic material collected from within a District Hospital, a Community-Based Organisation and people's homes. The thesis follows practices of care across divergent domains of social life to consider how practices of care within Luo networks of kinship and relatedness intersect with governmental interventions to manage HIV/AIDS. The thesis describes two governmental projects introduced to administer HIV/AIDS care in this region. It considers Home-Based Care, an HIV/AIDS response in which Community Health Workers are trained to support particular aspects of care at home, focusing on the practices of care employed by Community Health Workers as they visit sick people at home and attend organisational meetings. The thesis also describes the landscape of HIV care in the District Hospital, including the delivery of antiretroviral therapy. The focus here is on the relationships between caring practices in the hospital and at home, and the divergent responsibilities to care experienced by hospital staff and family members. The main argument of the thesis is that care is a particularly useful analytical tool for anthropology because practices of care take place across many different domains of social life, cutting across the boundaries that have formed the traditional focus of anthropological study. Studying practices of care illuminates the production of bounded domains of social life whilst simultaneously drawing attention to similarities of practice across different domains. Care provides a way of understanding the complex social landscape that has developed as people in Western Kenya endeavour to live with HIV/AIDS.

Orientador: Ana Maria Aparecida Guaraldo / Tese (doutorado) - Universidade Estadual de Campinas, Instituto de Biologia / Made available in DSpace on 2018-08-22T08:35:35Z (GMT). No. of bitstreams: 1 Ferreira_GlaucoRogerio_D.pdf: 2964649 bytes, checksum: 7665afd2ae49a0524acb8e13d66e8985 (MD5) Previous issue date: 2013 / Resumo: A Organização das Nações Unidas (ONU) no ano 2000 definiu oito Objetivos do Milênio; dentre eles pode-se destacar o sexto que é Combater o HIV/AIDS, a malária e outras doenças. As doenças parasitárias constituem ainda um sério problema de saúde pública. A erradicação ou controle desses parasitas requer melhorias das condições sócio-econômicas, do saneamento básico e educação. O presente trabalho teve como objetivo avaliar o Ensino a Distância como ferramenta de ensino para agentes de saúde, sobre as temáticas Doenças parasitárias; Criar conteúdo e disseminar conhecimento para capacitar agentes municipais de saúde em medidas profiláticas, transmissão e prevenção de parasitoses intestinais, através do preparo e aplicação de curso a distância (EAD); Analisar a Plataforma TelEduc para difundir essa capacitação a outros agentes. O curso foi montado e realizado em Plataforma TeldEduc, hospedada no Instituto IPES (Instituto de Projetos Especiais), com duração de 180 horas, sendo 148 horas por EAD e 32 presenciais. A maioria das aulas presenciais foi realizada na Faculdade Municipal "Professor Franco Montoro", no município de Mogi Guaçu-SP. O público alvo foi constituído pelos agentes de saúde e profissionais da saúde; 158 alunos se inscreveram no curso e a taxa de evasão foi de 24,8%. As aulas presenciais eram constituídas por aulas práticas, visitas técnicas ou revisão de conteúdo. Foi aplicado um questionário no início e outro no término para avaliar os conhecimentos pré existentes sobre a temática e os adquiridos pelo curso. Foi empregado o teste Qui-Quadrado para avaliar o nível de significância entre as respostas dos questionários. Concluiu-se que o EAD pode e deve ser utilizado, como uma alternativa de educação em doenças parasitárias, como mais uma ferramenta útil para acesso e ampliação do conhecimento / Abstract: The Organization of the United Nations (ONU) in 2000 set eight Millennium Development Goals; among them we can highlight which is the sixth: Combat HIV / AIDS, malaria and other diseases. Parasitic diseases are still a serious public health problem. The eradication or control these parasites requires improvements in socioeconomic conditions, sanitation and education. This study aimed to evaluate the Distance Learning as a teaching tool for health workers, concerning parasitic diseases. Create content and disseminate knowledge to empower local health agents in prophylactic measures, transmission and prevention of intestinal parasites, through the preparation and application of distance learning course (DLC); Analyze Platform TelEduc to disseminate this training to other agents. The course was set up and held in TeldEduc Platform, hosted at the Institute IPES, lasting 180 hours, with 148 hours of classroom and 32 DLC. Most regular classes were held in the Faculty Franco Montoro. The course was facing health workers and health professionals, 158 people enrolled in the course and 115 completed, which generated a dropout rate of 24,8%. The classroom consisted of practical sessions, technical visits or content review. A questionnaire was applied at the beginning and another at the end to assess the pre-existing knowledge on the subject and acquired by the course. It was employed a chi-square test to assess the level of significance between the answers of questionnaire. It was concluded that the DLC can and should be used as an alternative education on parasitic diseases and means a very useful tool to improve the access and knowledge / Doutorado / Relações Antrópicas, Meio Ambiente e Parasitologia / Doutor em Biologia Animal