Increased needs for health and social services, along with limits to financial resources, force public sector managers to optimize the allocation of financial resources. In this perspective, this research project is aimed at developing tools to evaluate rehabilitation programs dealing with physical disabilities. More specifically, the objectives are first, to examine relationships between the progression of a physically disabled person's functional profile and the rehabilitation services received, and second, to develop a tool to measure the efficiency of the rehabilitation programs offered. In accordance with the disability creation process conceptual framework, clinical results have been measured by measuring the progression of rehabilitation and efficiency has been defined as the relationship between clinical results obtained and the resources or means employed. A prospective cohort study was done on a sample of 100 users 65 years of age or older enrolled in the visual impairment program. The results of the study tend to show that the hours of service delivery allocated to a user contribute positively to the progress of his or her overall functional profile. They also show that a user's overall functional profile at intake is very strongly related to the consumption of financial resources. This relationship has allowed us to establish a system of classification of homogenous typical functional groups that makes relatively reliable predictions based on a unique measurement. Finally, the efficiency measurement tool developed represents a major innovation in evaluating the performance of rehabilitation programs in that it constitutes a benchmark toward attaining quality objectives for care and services while respecting financial constraints.

Introdução: O presente estudo enquadra-se na dinâmica das relações de trabalho entre profissionais, clientes e instituições no contexto da saúde do adulto e sua temática refere-se à avaliação de políticas públicas e assistenciais de saúde ofertadas às populações indígena e não indígena na região do Alto Rio Negro, Amazonas, Brasil. Objetivo: Avaliar a Atenção Primária à Saúde na perspectiva dos profissionais de saúde dos serviços de saúde ofertados à população pelo Distrito Sanitário Especial Indígena e Secretarias de Saúde. Trata-se de um estudo exploratório, descritivo de corte transversal. Método: A população foi composta por 131 profissionais, correspondendo a 100% dos enfermeiros e médicos que atuavam na APS, sendo que 15 (quinze) encontravam-se afastados para tratamento de saúde e/ou em gozo de férias. Os demais 116 participaram da pesquisa, sendo 84 enfermeiros e 32 médicos. A coleta de dados ocorreu entre junho a agosto de 2015 por meio do instrumento Primary Care Assessment Tool Brasil, versão profissionais. Para avaliação dos escores das variáveis, seguimos as orientações contidas no manual do Ministério da Saúde. Utilizou-se o programa SPSS® para a análise estatística descritiva, distribuição de freqüência absoluta/ relativas com aplicação do teste Qui-quadrado de Pearson (nível de significância p<0,05) para comparação das médias e medianas. Para analisar a associação entre variáveis foram empregados testes estatísticos univariados e adaptação de um modelo de regressão logística. O estudo seguiu a Resolução 466/12 do Conselho Nacional de Saúde. Resultados: Dos profissionais, 72,4 % são enfermeiros e 27,6% médicos; 59,5% do sexo feminino, com médias de idade de 35 anos e 1,5 anos de experiência de trabalho na APS. Uma ONG é a principal contratante (60,3 %), predominantemente pelo regime CLT (80,5%). O ingresso no trabalho é por meio de indicação de amigos, familiares, seleção de currículos. No geral, os participantes avaliaram os atributos com altos escores, em ambos os serviços de saúde. Embora em algumas medianas não tenham sido observados valores adequados, ressalta-se que o escore total essencial (7,1; p<0,002), derivado (7,22; p<0,004) e escore geral (7,2; p<0,003), mostram forte orientação para APS. Quando se observa os atributos isoladamente, por instituição, os profissionais do DSEI qualificaram como de baixo escore (<6,6) a longitudinalidade (6,4) e orientação comunitária (6,1). Já os profissionais da SEMSA os escore acessibilidade (2,6) e a orientação comunitária (5,6). O conjunto das variáveis que interferem na forte orientação da APS corresponde a ser brasileiro, pertencer ao DSEI e ser contratado pela administração direta. Apesar dos serviços ofertados pelo DSEI e a SEMSA terem recebido um alto escore, ainda existem falhas na prestação de serviços, apontando para a necessidade de melhorias em alguns atributos. Isso implica em reformulações de aspectos da estrutura e processo para que futuramente possa ser oferecida uma APS de qualidade. Conclusão: Conclui-se ainda que o PCATool, versão profissional, mostrou-se um importante instrumento para a verificação da presença dos atributos em contextos em que vivem populações indígenas e não indígenas no mesmo território, embora, em alguns casos, suas variáveis estejam distantes da realidade local. Sugerimos estudos mais amplos, para o aprofundamento de questões capazes de captar a realidade dos serviços de APS ofertados às populações amazônicas. / Introduction: The current study fits into the dynamics of work relations among professionals, clients and institutions in the adult health care realm, and its theme refers to the assessment of public, health care policies delivered to indigenous and non-indigenous populations in the Upper Negro River, Amazonas State, Brazil. Objective: It objectifies to assess Primary Health Care (PHC) from health professionals perspectiveof health care services delivered to the population by the Special Indigenous Sanitary District (DSEI, in Portuguese) and Health Secretaries. It is an exploratory, descriptive, cross-cut study. Methods: The population comprised 131 professionals, accounting for 100% nurses and doctors from the Primary Health Care, being 15 (fifteen) of them on sick leave and/or on vacation. The remaining 116 participated in the research, 84 nurses and 32 doctors. Data collection was held between June and August of 2015 by means of the Primary Care Assessment Tool Brazil, professional version. We followed the guidelines from the Manual of the Ministry of Health to assess variable scores. SPSS® Program was used for descriptive statistical analysis, distribution of absolute/relative frequency applying Pearsons chi-square test (significance level p<0.05) in order to compare mean and median values. Univariate statistical tests were used to analyze the association between variables, as well as the adaptation of a logistic regression model. The study complied with Resolution 466/12 of the National Health Council. Results: As for the professionals, 72.4 % are nurses, and 27.6% are doctors; 59.5% are females, average age of 35 years, and 1.5 years of work experience in the PHC. An NGO is the main contractor (60.3%) under the Consolidation of Brazilian Labor Laws (80.5%). Work admission is by means of friends, family members recommendation and resumés selection. In general, participants assessed the attributes with high scores in both health care services. Although proper values have not been attributed to some medians, essential total score (7.1; p<0.002), derivative total score (7.22; p<0.004), and overall score (7.2; p<0.003), are strongly PHC-oriented.When you observe the attributes isolatedly, per institution, low score (<6.6) was attributed to longitudinality (6.4) and community counseling (6.1) by the DSEI professionals. As for the professionals of the Municipal Health Secretary (SEMSA, in Portuguese), the score to accessibility (2.6) and community counseling (5.6). The set of variables, which interfere in strongly PHCoriented, are Brazilian nationality, to join the DSEI, and to be hired by the direct administration. In spite of the services delivered by the DSEI and SEMSA having been attributeda high score, there are still failures in service delivery, pointing to the need for improvement in some attributes. This implies the reformulations of structure and process aspects so that further quality PHC can be rendered to the populations in the studied territory. Conclusion: It can be concluded that the PCATool, professional version, evidenced as a major instrument to verify the attribute presence in contexts where indigenous and non-indigenous populations live in the same territory, although some variables, in some cases, are still away from the local reality. We suggest broader studies, in order to deepen issues able to apprehend the reality of the PHC services rendered to the Amazon populations.

[Truncated abstract] In Australia, asthma is a common chronic illness, which often requires complex treatment regimens. This study used an anthropological perspective to explore the experience of people living with asthma, with the specific aim of contributing to the health care programs offered to people living with asthma. The study was conducted in an Australian city (Perth, Western Australia). The foci of the study were Australian lay people, from the general community, living with asthma, and a small number of non- English speaking Vietnamese-Australian migrants. Some spouses of the Australians and biomedical practitioners were also included. Questionnaires, and particularly indepth interviews, were used to explore the explanatory models of asthma for doctors and lay people with the condition. The explanatory models of the doctors focused primarily on assessing and treating the physiological dimension of asthma, and educating patients. The explanatory models for lay people with asthma reflected their everyday reality: in addition to its impact on their physical health, asthma affected their daily life, social roles and participation, and their personal identity. Placing the experience of asthma in this wider perspective showed that the Australians used practical reasoning to make a trade-off between using medication, such that they felt safe from `attacks? and could `do all they wanted to do?, and minimising their `dependence? on potentially harmful medications. Responding to acute episodes involved a risk assessment in which people weighing the health risk of waiting against the social risk of seeking help unnecessarily. For the Vietnamese- Australians, caring for asthma was strongly shaped by their social position as non- English speaking migrants. They lacked access to information about asthma and to specialist care. They had sufficient medication, but were ill-informed about how to use their medicines effectively and safely: in general, the Vietnamese people were overmedicated but under-serviced in the care of their asthma. Beyond explanatory models, the Australian participants (lay people and doctors) shared a cultural model of asthma as a chronic illness. This Australian cultural model shaped the experience and care of asthma. It included concepts such as framing the past as an adjustment process, and the present as `living normally? with asthma. Taking care of asthma was expressed as `taking control? of asthma, so a person could minimise the illness and still be healthy. The Vietnamese-Australians did not share this cultural model of asthma as a chronic illness, as reflected in their expression of the hardship asthma created in limiting their ability to work hard for their family, and how they expected a cure for their condition from biomedicine. The Australians also shared a cultural model of health that was derived, in part, from the health promotion messages that are targeted at lay people. These promotional messages were the basis of a morality in health: people shared an implicit understanding that a person deserved health, and assistance when ill, when he/she displayed the required self-discipline in performing health behaviours.

Introdução: O presente estudo enquadra-se na dinâmica das relações de trabalho entre profissionais, clientes e instituições no contexto da saúde do adulto e sua temática refere-se à avaliação de políticas públicas e assistenciais de saúde ofertadas às populações indígena e não indígena na região do Alto Rio Negro, Amazonas, Brasil. Objetivo: Avaliar a Atenção Primária à Saúde na perspectiva dos profissionais de saúde dos serviços de saúde ofertados à população pelo Distrito Sanitário Especial Indígena e Secretarias de Saúde. Trata-se de um estudo exploratório, descritivo de corte transversal. Método: A população foi composta por 131 profissionais, correspondendo a 100% dos enfermeiros e médicos que atuavam na APS, sendo que 15 (quinze) encontravam-se afastados para tratamento de saúde e/ou em gozo de férias. Os demais 116 participaram da pesquisa, sendo 84 enfermeiros e 32 médicos. A coleta de dados ocorreu entre junho a agosto de 2015 por meio do instrumento Primary Care Assessment Tool Brasil, versão profissionais. Para avaliação dos escores das variáveis, seguimos as orientações contidas no manual do Ministério da Saúde. Utilizou-se o programa SPSS® para a análise estatística descritiva, distribuição de freqüência absoluta/ relativas com aplicação do teste Qui-quadrado de Pearson (nível de significância p<0,05) para comparação das médias e medianas. Para analisar a associação entre variáveis foram empregados testes estatísticos univariados e adaptação de um modelo de regressão logística. O estudo seguiu a Resolução 466/12 do Conselho Nacional de Saúde. Resultados: Dos profissionais, 72,4 % são enfermeiros e 27,6% médicos; 59,5% do sexo feminino, com médias de idade de 35 anos e 1,5 anos de experiência de trabalho na APS. Uma ONG é a principal contratante (60,3 %), predominantemente pelo regime CLT (80,5%). O ingresso no trabalho é por meio de indicação de amigos, familiares, seleção de currículos. No geral, os participantes avaliaram os atributos com altos escores, em ambos os serviços de saúde. Embora em algumas medianas não tenham sido observados valores adequados, ressalta-se que o escore total essencial (7,1; p<0,002), derivado (7,22; p<0,004) e escore geral (7,2; p<0,003), mostram forte orientação para APS. Quando se observa os atributos isoladamente, por instituição, os profissionais do DSEI qualificaram como de baixo escore (<6,6) a longitudinalidade (6,4) e orientação comunitária (6,1). Já os profissionais da SEMSA os escore acessibilidade (2,6) e a orientação comunitária (5,6). O conjunto das variáveis que interferem na forte orientação da APS corresponde a ser brasileiro, pertencer ao DSEI e ser contratado pela administração direta. Apesar dos serviços ofertados pelo DSEI e a SEMSA terem recebido um alto escore, ainda existem falhas na prestação de serviços, apontando para a necessidade de melhorias em alguns atributos. Isso implica em reformulações de aspectos da estrutura e processo para que futuramente possa ser oferecida uma APS de qualidade. Conclusão: Conclui-se ainda que o PCATool, versão profissional, mostrou-se um importante instrumento para a verificação da presença dos atributos em contextos em que vivem populações indígenas e não indígenas no mesmo território, embora, em alguns casos, suas variáveis estejam distantes da realidade local. Sugerimos estudos mais amplos, para o aprofundamento de questões capazes de captar a realidade dos serviços de APS ofertados às populações amazônicas. / Introduction: The current study fits into the dynamics of work relations among professionals, clients and institutions in the adult health care realm, and its theme refers to the assessment of public, health care policies delivered to indigenous and non-indigenous populations in the Upper Negro River, Amazonas State, Brazil. Objective: It objectifies to assess Primary Health Care (PHC) from health professionals perspectiveof health care services delivered to the population by the Special Indigenous Sanitary District (DSEI, in Portuguese) and Health Secretaries. It is an exploratory, descriptive, cross-cut study. Methods: The population comprised 131 professionals, accounting for 100% nurses and doctors from the Primary Health Care, being 15 (fifteen) of them on sick leave and/or on vacation. The remaining 116 participated in the research, 84 nurses and 32 doctors. Data collection was held between June and August of 2015 by means of the Primary Care Assessment Tool Brazil, professional version. We followed the guidelines from the Manual of the Ministry of Health to assess variable scores. SPSS® Program was used for descriptive statistical analysis, distribution of absolute/relative frequency applying Pearsons chi-square test (significance level p<0.05) in order to compare mean and median values. Univariate statistical tests were used to analyze the association between variables, as well as the adaptation of a logistic regression model. The study complied with Resolution 466/12 of the National Health Council. Results: As for the professionals, 72.4 % are nurses, and 27.6% are doctors; 59.5% are females, average age of 35 years, and 1.5 years of work experience in the PHC. An NGO is the main contractor (60.3%) under the Consolidation of Brazilian Labor Laws (80.5%). Work admission is by means of friends, family members recommendation and resumés selection. In general, participants assessed the attributes with high scores in both health care services. Although proper values have not been attributed to some medians, essential total score (7.1; p<0.002), derivative total score (7.22; p<0.004), and overall score (7.2; p<0.003), are strongly PHC-oriented.When you observe the attributes isolatedly, per institution, low score (<6.6) was attributed to longitudinality (6.4) and community counseling (6.1) by the DSEI professionals. As for the professionals of the Municipal Health Secretary (SEMSA, in Portuguese), the score to accessibility (2.6) and community counseling (5.6). The set of variables, which interfere in strongly PHCoriented, are Brazilian nationality, to join the DSEI, and to be hired by the direct administration. In spite of the services delivered by the DSEI and SEMSA having been attributeda high score, there are still failures in service delivery, pointing to the need for improvement in some attributes. This implies the reformulations of structure and process aspects so that further quality PHC can be rendered to the populations in the studied territory. Conclusion: It can be concluded that the PCATool, professional version, evidenced as a major instrument to verify the attribute presence in contexts where indigenous and non-indigenous populations live in the same territory, although some variables, in some cases, are still away from the local reality. We suggest broader studies, in order to deepen issues able to apprehend the reality of the PHC services rendered to the Amazon populations.

Bakgrund: Denna studie uppmärksammar det komplexa fenomenet Münchhausen by proxy (MBP). MBP innebär att en förälder hittar på eller skapar sjukdomar hos sitt barn. Barnet får genomgå medicinska undersökningar, behandlingar och provtagningar. MBP har sedan början av 2000-talet inkluderats i den definition av barnmisshandel som ska vägleda arbetet med utsatta barn i Sverige. Problemformulering: Då MBP definieras som en form av fysisk barnmisshandel i SOU 2001:72, innebär detta ett delat samhällsansvar. Hälso-och sjukvården har enligt hälso- och sjukvårdslagen (HSL, 2017:30) ansvar för att utreda och behandla den fysiska vården av barnet medan socialtjänsten har ansvar för att utreda barnets skydd och behov. Socialnämnden har enligt socialtjänstlagen (SoL, 2001:453) ansvar för att barn och unga växer upp under trygga och goda förhållanden, Socialnämnden ska även verka för att barn och unga får det skydd och stöd som de behöver. Det delade ansvaret för MBP-utsatta barn mellan hälso- och sjukvård och socialtjänst kan leda till särskilda utmaningar för praktiken, då frågan ligger i skärningspunkten mellan olika politikområden, lagar och professionella verksamhetsområden. Utifrån den begränsade mängd forskning som finns i Sverige kring MBP, får policy i form av lagstiftning, föreskrifter och allmänna råd, riktlinjer och handböcker stor betydelse för hur MBP hanteras i praktiken. Syfte: Syftet med denna studie är att med Sverige som empiriskt case undersöka hur fenomenet MBP konstrueras som problem i policy inom välfärdsområdet med inriktning på utsatta barn. Vidare är syftet med studien även att undersöka konstruktionen av MBP inom nationell och internationell forskning, för att se hur nationell policy förhåller sig till forskningsläget.  Metod och teori: I denna litteraturstudie med abduktiv ansats granskades internationell och nationell forskning, offentliga dokument från statliga myndigheter, statliga offentliga utredningar och riktlinjer för det sociala arbetet och hälso-och sjukvården i Sverige. Dessa har analyserats med utgångspunkt i teori om konstruktionen av sociala problem. Resultat: MBP har konstruerats som problem i olika stor omfattning inom forskning, hälso- och sjukvård samt socialt arbete. De riktlinjer och handböcker som idag finns för socialtjänstens arbete med barnavårdsutredningar är få men omfattande, dock finns inga riktlinjer som beskriver arbetet med MBP. I befintlig svensk lagstiftning går det inte att finna lagrum som uttryckligen nämner MBP. För hälso- och sjukvården i Sverige finns nationella riktlinjer och regionala vårdprogram för arbetet med barn som far illa, som berör MBP. Det finns lagstadgat ansvar för socialt arbete och hälso- och sjukvården vid barn som far illa (SoL och HSL), de två olika verksamhetsfälten har olika arbetssätt vilket gör att det gemensamma arbetet vid barnavårdsutredningar ibland kan bli problematiskt. Diskussion och slutsats: MBP har sedan början av 2000-talet upptäckts och definierats som en form av fysisk barnmisshandel i Sverige. Ansvariga verksamhetsfält och riktlinjer har formulerats kring MBP, dock främst inom hälso- och sjukvården. Eftersom det sociala arbetet inte har några riktlinjer eller förövarbeskrivningar om MBP finns inget organisatoriskt stöd för att socialarbetare ska kunna uppmärksamma fall av MBP. I studien har vi gjort ett försök till att synliggöra konstruktionen av MBP i svensk kontext idag som har resulterat i att vi sett ett tomrum och utvecklingsmöjligheter för det sociala arbetets riktlinjer gällande hur MBP idag konstrueras i dessa. / Background: This study addresses the complex phenomenon of Münchhausen by proxy (MBP). MBP means that a parent finds or creates illnesses with his or her child. The child is allowed to undergo medical examinations, treatments and sampling. MBP has been included in the definition of child abuse since the beginning of the 2000s, a definition which is supposed to guide the work with vulnerable children in Sweden. Problem area: As MBP is defined as a form of physical child abuse in SOU 2001:72, this means shared social responsibility among societal actors. Health care is according to the Health Care Act (HSL, 2017:30) responsible for investigating and treating the physical care of the child, while the social services is responsible for investigating the child's protection and needs. According to the Social Services Act (SoL, 2001:453), the Social Services Board is responsible for securing safe and good conditions for children and young people. The Social Services Board shall also ensure that children and young people receive the protection and support they need. The fact that the health care system and the child welfare system share the responsibility for working with MBP can lead to challenges for practice, as the issue is located at the interface between different policy areas and professional fields of practice. As there is very limited research on MBP in Sweden, policy will play an important role in everyday practice regarding MBP. Aim: The aim of this study was to explore how the phenomenon of MBP is constructed in Swedish welfare policy, specifically in relation to social services and health care. Furthermore, the aim of the study was to investigate the construction of MBP in national and international research, to see how national policy relates to the research situation. Method and theory: A literature study with an abductive approach was carried out, examining national and international research, public documents from government agencies and authorities, Swedish public inquiries and guidelines for social work and health care in Sweden. The analysis is based upon the theory of the construction of social problems. Findings: MBP has been constructed as a problem in research, healthcare and social work in different extent. The guidelines and manuals that exist today for the social services work on child protection are few but extensive, although none of them mentions MBP. In existing Swedish legislation, there is no law available that explicitly mentions MBP, while there are various proposals for legislative changes that mentions MBP. For health care in Sweden there are national guidelines and regional care programs for the work of child abuse, that mentions MBP. There is statutory responsibility for the social work and health care to cooperate in the case of children at risk (SoL and HSL). The two different parts of the welfare system have different working methods, which means that the joint work in child welfare investigations can sometimes be problematic. Discussion and conclusion: Since the late 2000s, MBP has been discovered as a social problem in Sweden, defined as a form of physical child abuse, and fields of responsibility and guidelines have been developed, primarily within health care. Since social work has no guidelines about MBP, there is no organizational support for social workers to pay attention to cases of MBP. In the study we have made an effort to visualize the construction of MBP in Swedish context today, which has resulted in the founding of a gap and development opportunities for the social work guidelines on how MBP is being constructed today.