The well-being of employees is an important issue. Researchers, policy makers and organisations are directing more resource into this field as the link between the health of people and their performance in the workplace becomes increasingly understood. This research programme examines how employee well-being can be measured. Having the right tools to successfully appraise well-being at the outset is judged to be imperative where any research or organisational programme to bring about change is under consideration. A review of existing methods indicates that the current provision of scales to assess the well-being of workers is limited and the construction techniques used in their development may be improved upon. At the core of this study is the testing of a new measurement framework which seeks to address these deficiencies. This innovative approach is taken from one established practice used to assess the well-being of patients using health related quality of life instruments. Three organisations participated in the study; a call centre operation, a police force and a county-based library service. Using qualitative and quantitative methodologies, three pilot questionnaires were constructed using Impact Analysis; an established procedure deployed in health related quality of life settings. Basic findings from each case study were analysed against conventional construction methods and against existing employee well-being scales. Results were also examined in respect of how they compared with the wider literature on employee well-being. ii The Impact Analysis method was critically appraised. Although weaknesses in respect of some of the qualitative phases of analyes were noted, the overall notion of transferring the practice of Impact Analysis to an occupational setting was assessed as cautiously encouraging. While this scale construction method lacks the statistical elegance of factor analytical methods, provisional indications suggest potential benefits in content validity over extant occupational scales where the assessment of a study population’s own experiences are critical to any well-being evaluation strategy. Based on the findings, a new operational definition for employee well-being is posited. A new, working model is also proposed. This emphasises for the first time, the need for specificity when researchers and organisations are seeking to evaluate a multi-dimensional, subjective construct that is employee well-being. Limitations regarding the study are noted. This means that the findings should be treated as tentative rather than conclusive. Nevertheless, it is hoped that this study will inject new thinking on how employee well-being may be evaluated using an alternative approach. By doing so, it is ventured that research communities and employers alike may take up the methods described in this study to conduct assessment programmes that could benefit not just the study teams or the employers, but importantly, the workers themselves.

Trata-se de um estudo longitudinal, prospectivo, de abordagem quantitativa, cujo objetivo foi conhecer a trajetória da fadiga e da depressão em mulheres com câncer de mama em tratamento radioterápico. Participaram do estudo 58 mulheres em tratamento radioterápico para câncer de mama não-metastático, atendidas em um serviço de radioterapia de um hospital terciário do interior de São Paulo, após aprovação do comitê de ética em pesquisa, no período de janeiro a setembro de 2016. Os instrumentos de coleta de dados utilizados foram a Ficha de Identificação com dados sociodemográficos e clínicos; a Escala de Performance de status de Karnofsky, a Escala de Fadiga de Piper Revisada e o Inventário de depressão de Beck. Na análise de dados, adotou-se a análise descritiva, o teste de Mann-Whitney e a análise de regressão pelo modelo linear generalizado misto (Generalized Linear Mixed Models). Quanto aos resultados, a idade média das participantes foi 55 anos, as quais eram em sua maioria casadas (29,31%), brancas (65,5 %), com média de 8 anos de estudo e possuíam como diagnóstico o carcinoma ductal invasivo (94,8%). Constatou-se que no início mostravam-se fatigadas (T1:24,1%) e essa proporção ampliou-se ao longo da radioterapia (T2: 30,7%; T3: 40,3%). Em relação a intensidade da fadiga, o nível moderado teve predomínio (T1: 13,8%; T2 e T3: 23,08%). A maioria não desenvolveu depressão (T1: 74%, T2: 80,4%, T3: 88,4%). Verificou-se que a fadiga e a depressão possuem uma relação de significância estatística do início ao fim desse tratamento (T1: p=0,0021; T2: p=0,0001; T3 p= 0,0003). A dor e o transtorno de sono apresentaram uma relação significante com a fadiga, assim pode-se inferir que as participantes com dor tinham 7,54 vezes mais chance de apresentar fadiga do que as que não referiram esse sintoma. As mulheres com transtorno de sono tinham 9,31 vezes mais chance de se mostrar fatigadas do que as que negaram tal transtorno; pacientes ao final do tratamento radioterápico tiveram quatro vezes mais chance de apresentar fadiga. O ajuste do modelo da depressão assinalou que às variáveis T3 (final da radioterapia; p=0,0002), sono (p=0,0276) e dose da radioterapia recebida (p=0,0339) apresentaram uma relação estatisticamente significativa com a depressão. Quanto à depressão, os achados apontaram que, para cada unidade de dose de radioterapia recebida, esperava-se uma redução relativa média de 0,01% no escore da escala de depressão. As pacientes que apresentaram transtorno de sono tiveram um aumento relativo médio de 19,51% no escore da depressão quando comparadas às pacientes que não tiveram esse problema. Conclui-se que a fadiga aumentou ao longo do tempo ao contrário da depressão, porém esses dois sintomas neuropsicológicos apresentaram uma relação estatisticamente significante. Os profissionais de saúde precisam estar atentos ao perfil de risco para fadiga e depressão, exercendo um papel atuante na identificação e no gerenciamento desses sintomas / This is a longitudinal, prospective research, with a quantitative approach, which goal was to knor the trajectory of fatigue and depression in women with breast csncer under radiotherapy. Fifty-eight women participated in the radiotherapeutic treatment for non-metastatic breast cancer attended at the radiotherapeutic service of terciary hospital at the interior of São Paulo State, after the institutional review board approval, from january to september of 2016. As data collect tools, were used the identification form, with clinical and sociodemographic data, the Karnofsky Status Performance Scale, the Revised Fatigue Scale of Piper, and the Beck Depression Inventory. In the data analysis, we adopted the descriptive analysis, the Mann Whitney test,and the regression analysis by generalized mixed linear models. The average age of the participants was 55 years old, mostly married (29,31%), caucasian (65,5%), within 8 years of education average, who had invasive ductal carcinoma (94,8%) diagnosis. It was found at the outset, that the women were fatigued (T1:24,1%), this scrutiny depicted that the proportion has increased throughout the radiotherapy (T2:30,7%; T3: 40,3%). In relation of fatigue\'s intensity, the moderated level had predominated (T1:13,8%; T2 and T3: 23,08%).The majority of the sample do not developed depression (T1: 74%, T2:80,4% T3: 88,4%). It was verified that fatigue and depression had a meaningfulness statistic relationship, from the beginning to the end of the treatment (T1: p=0,0021; T2: p=0,0001; T3 p=0,0003).Pain and sleep disorders had presented a significant relationship regarding fatigue, thus it could be infered that participants with pain were 7,54 times more likely to present fatigue than those who did not have such symptom. Women with sleep disorder had 9,31 times more chances of presenting fatiguated, than those who denied it.Patients at the end of the radiation therapy, werefour times more likely of showing fatigue. The model adjustment of depression indicates that the variables T3 (ending of the radiation therapy; p=0,0002), sleep (p=0,0276) and radiotherapy dose (p=0,0339) received had a statisticaly meaningful link with depression. As for depression, the findings indicate that,for each dose unities of radiotheraphy received, it was expected a relative average reduction of 0,01% in the depression\'s scale score. The patients who presented sleep disorder, had a fairly average increasing of 19,51% in the depression score in comparison with the patients who did not have this issue. So we concluded that fatigue increased throughout the time, conversely regarding depression, nevertheless both showed a meaningful statisticaly connection. Healthy professionals should be aware of the risk profile to the fatigue and depression, playing an active role in the identification and managing of those symptoms

O aprimoramento do processo de avaliação e monitoramento da Atenção Básica vem sendo almejado pelos gestores das diversas esferas no contexto do Sistema Único de Saúde - SUS. Nesse sentido, buscou-se identificar alguns aspectos da assistência à saúde no município de Araraquara, SP, a partir das características particulares presentes nas áreas de adscrição de cada unidade de saúde. A adoção de um indicador composto permitiu contemplar a emergência de fenômenos a partir de uma visão mais abrangente. Valeu-se da metodologia desenvolvida no Índice de Saúde de Drumond Jr, cujo valor final do Índice é obtido pela média dos valores dos componentes de cada Distrito de Saúde. Aos componentes adotados originalmente- Coeficiente de Mortalidade Infantil, Coeficiente de Incidência de Tuberculose, Coeficiente de Mortalidade por Causas Externas e Coeficiente de Mortalidade Precoce por Doenças Crônicas, agregou-se ainda nesse estudo, a Taxa de Alfabetização e o Rendimento Médio Nominal Mensal de Pessoas Responsáveis pelos Domicílios. As 24 Unidades de Saúde foram classificadas segundo os valores obtidos na relação entre seus componentes. Os resultados apontam diferenciais intra-urbanos para a maioria dos componentes e menores valores das Unidades de Saúde da periferia do município. / The improvement of the process of evaluation and monitoring of the Primary Care Attention has been yearned by the managers of the different spheres in the context of the Unified System Health - UHS. Thus, in the order to identify the conditions of the health assistance in the city of Araraquara, SP, based on the particular features presented in the inscribe areas of each unit of health. It was adopted by means of a composed indicator aiming to favor a broader view which comtemplates the emergency of phenomena from a more including vision. It was used the methodology developed in the Index of Health of Drumond Jr, whose final value of the Index is gotten by the average of the values of the components of each health district. To the components originally adopted - Coefficient of Infant Mortality, Coefficient of Tuberculosis Incidence of, Coefficient of Mortality by External Causes and Coefficient of Precocious Mortality by Chronic Diseases - was still added in this study, the Tax of Alfabetization and the Monthly Nominal Average Income of Responsible People for the Domiciles. The 24 Units of Health had been classified according to values obtained in the relation among its components. The results point intraurban differentials in relation to the majority of the components and minors values of the Health Units at the periphery of the city.

As políticas públicas de atenção à criança no Brasil têm se aprimorado com vistas à qualidade do cuidado integral. Este estudo objetivou avaliar a presença e extensão dos atributos da Atenção Primária à Saúde (APS) e o grau de afiliação do usuário na Estratégia Saúde da Família (ESF), a partir da ótica dos cuidadores com a assistência prestada a crianças menores de um ano de idade. Trata-se de uma pesquisa quantitativa, transversal com dados coletados mediante uso do Instrumento de Avaliação da Atenção Primária (PCATool - infantil). Foram entrevistados 271 cuidadores cujas crianças pertenciam às áreas de abrangência das 13 equipes de saúde da família da zona urbana de Vitória da Conquista - BA. Os escores foram atribuídos para 10 dimensões da APS. Os resultados revelaram escores elevados para apenas quatro dimensões: grau de afiliação, acesso de primeiro contato (utilização), longitudinalidade e coordenação (sistema de informação). As outras dimensões apresentaram baixos valores de escore, tais como: o acesso de primeiro contato (acessibilidade), a coordenação (integração de cuidados), a integralidade (serviços disponíveis e prestados), a orientação familiar e a orientação comunitária. Ao avaliar as dimensões em conjunto encontramos os escores essencial e geral com baixos valores. Concluímos que a ESF, apesar de ser um cenário preferencial para as ações de promoção e prevenção à saúde e se constituir como porta de entrada para os serviços, não tem alcançado uma assistência à criança com ênfase no cuidado integral. / Public policies on childcare in Brazil have been enhanced to promote quality on comprehensive care. This study aimed to evaluate the presence and extent of the attributes of the Primary Health Care (PHC) and the degree of user affiliation in Family Health Strategy (FHS) from the perspective of caregivers with the care provided to children under one year of age. This is a quantitative, cross-sectional study which data were collected using Primary Care Assessment Tool (PCATool). We interviewed 271 caregivers whose children belong to the areas of 13 family health teams in the urban area of Vitoria da Conquista - BA. The scores were assigned to 10 dimensions of APS. The results revealed high scores for only four dimensions: degree of affiliation, first contact access (use of service), longitudinality and coordination (information system). Other dimensions had low score values such as: first contact access (accessibility), coordination (integrated care), comprehensiveness (services available and services provided), and family and community orientation. By assessing the dimensions together we found low values for the essential and general scores. We conclude that despite FHS has being a preferred scenario for the actions of health promotion and disease prevention and gateway to health services FHS has not been attained the child care with emphasis on comprehensive care

A fase inicial dos transtornos psicóticos tem recebido atenção crescente nas últimas décadas, principalmente por tratar-se de um momento de grandes mudanças e perturbações para os indivíduos acometidos e seus familiares. Entre as ferramentas disponíveis para garantir um melhor prognóstico dos indivíduos que vivenciam a fase inicial da psicose destaca-se a intervenção precoce que engloba medidas desenvolvidas com o indivíduo e seus familiares. Para efetivação das propostas de intervenção direcionadas a essa clientela é fundamental o desenvolvimento de estudos de avaliação. Desse modo, o presente estudo tem como objetivo compreender o atendimento familiar individual e o grupo de ação multifamiliar desenvolvidos no Ambulatório de Primeiro Episódio Psicótico (APEP) na perspectiva dos familiares e pacientes. Estudo de abordagem qualitativa a luz do referencial teórico do paradigma da complexidade de Edgar Morin. Participaram do estudo oito díades, pacientes em seguimento no ambulatório de Primeiro Episódio Psicótico do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (APEP/HC-FMRP-USP) e seus familiares que participam de atividades propostas para eles no serviço. Para coleta dos dados foram utilizadas as seguintes questões norteadoras: Você tem tido oportunidade de discutir o que te interessa ou incomoda durante os grupos/atendimentos? Você tem alguma sugestão do que seria interessante conversar e faltou nos grupos/atendimentos? Para você se sentir melhor existe mais alguma coisa que você gostaria de saber? Os dados foram submetidos à análise temática proposta por Braun & Clark. A análise possibilitou a construção de três categorias temáticas e subcategorias: 1) intervenções aos familiares como troca de experiência; 2) envolvimento com as intervenções familiares e 3) reconhecimento do conteúdo abordado nas intervenções familiares. Os resultados reforçam a importância da oferta de intervenções que envolvam pacientes na fase inicial da psicose e seus familiares / The initial phase of psychotic disorders has received increasing attention in the last decades, mainly because it is a time of great changes and disturbances for the affected individuals and their relatives. Among the tools available to guarantee a better prognosis of the individuals who experience the initial phase of psychosis is the early intervention that includes measures developed with the individual and their relatives. The development of evaluation studies is fundamental for the effectiveness of the intervention proposals directed to this clientele. Thus, the present study aims to understand individual family care and the multifamily action group developed in the Psychotic First Episode Outpatient Clinic (APEP) from the perspective of family members and patients. Study of qualitative approach in the light of the theoretical reference of the paradigm of the complexity of Edgar Morin. Participants in the study were eight dyads, patients in the Psychotic First Episode Clinic of the Hospital das Clínicas of the University of São Paulo at Ribeirão Preto Medical School (APEP / HC-FMRP-USP) and their families participating in activities proposed for them in service. The following guiding questions were used to collect the data: Have you had an opportunity to discuss what interests you or bothers you during the groups / services? Do you have any suggestions of what would be interesting to talk about and missed in the groups / services? Do you feel better if there is something else you would like to know? The data were submitted to the thematic analysis proposed by Braun & Clark. The analysis allowed the construction of three thematic categories and subcategories: 1) interventions to family members as an exchange of experience; 2) involvement with family interventions and 3) recognition of the content addressed in family interventions. The results reinforce the importance of offering interventions that involve patients in the initial phase of psychosis and their relatives

Thesis (MTech(Environmental Health)--Cape Technikon, Cape Town,1997 / The study project researched the quality of the investigations and the institutional transfer of data regarding notifiable food poisoning outbreaks reflected in "the study region", that is to say North-, East- and Western Cape Provinces. In comparing the data of the central-, provincial- and local governments' total notifiable food poisoning outbreaks notifications for specific local areas, problems relating to incomplete and poor data, poorly completed reports and ignorance of health workers re notifiable medical conditions were identified. Various conclusions and recommendations were made for "the purpose of future improvements.

A tuberculose (TB) é um grave problema de saúde pública no Brasil e no mundo, necessitando ainda de pesquisas que considerem aspectos operacionais de tratamento e controle de sua disseminação, de forma a contemplar questões econômicas; especialmente no que tange à avaliação de tecnologias em saúde. Objetivo: Conduzir uma análise custo-efetividade de tratamento diretamente observado (TDO) da tuberculose, comparando estratégias de tratamento sob perspectiva da sociedade. Materiais e métodos: Avaliação econômica completa do tratamento de pacientes com tuberculose via administração de medicamentos com acompanhamento de visitador sanitário (VS), contemplando microcusteio parcial por meio de coleta de dados em prontuários de amostra de 92 pacientes e entrevistas com profissionais de saúde do Programa de Controle de Tuberculose no Centro de Saúde Escola da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, seguida de análise custo-efetividade baseada em inquérito aplicado na forma de entrevistas a 92 pacientes nos cinco distritos sanitários de saúde de Ribeirão Preto (SP). Resultados: Os custos estimados para TDO realizado com visitadores sanitários (TDO-VS) foram US$1.642,93 ao sistema de saúde e US$942,35 aos pacientes e familiares. O custo global societário foi US$2.585,28. Em comparação com TDO realizado por supervisores domiciliares (TDO-SD), cujo custo médio por paciente foi US$430,03 em estudo recentemente publicado, o custo médio por paciente em TDO-VS foi US$363,12; sendo que ambos apresentaram efetividade similar. Conclusão: O TDOVS apresentou menor custo em relação ao mesmo grau de efetividade no que tange à cura de tuberculose em comparação com TDO-SD. Os resultados obtidos apresentam subsídios à adoção de uma alternativa de tratamento de TB aos gestores em saúde no processo de tomada de decisão no contexto do Programa de Controle da Tuberculose. / Tuberculosis (TB) is a serious public health problem in Brazil and worldwide, requiring further research to consider operational aspects of treatment and control its spread, in order to cover economic issues; especially with regard to the evaluation of health technologies. Objective: Conduct a cost-effectiveness of directly observed treatment (DOTS) tuberculosis, comparing treatment strategies in perspective of society. Methods: Full Economic evaluation of the treatment of tuberculosis patients via administration of drugs with accompanying health visitor (HV), covering partial microcusteio through data collection sample of medical records of 92 patients and interviews with Program health professionals Tuberculosis Control in the health Center of Ribeirão Preto Medical School, University of São Paulo, followed by cost-effectiveness analysis based on survey conducted in the form of interviews with 92 patients in five health districts Ribeirão Preto health, estate of São Paulo. Results: The estimated costs for DOT conducted with health visitors (DOT-HV) were US$ 1,642.93 to the health system and US$ 942.35 to patients and families. The corporate overall cost was US $ 2,585.28. Compared with DOT done by home supervisors (DOT-HS), the average cost per patient was US $ 430.03 in a recent study, the average cost per patient in DOT-HV was US $ 363.12; both of which showed similar effectiveness. Conclusion: DOT-HV had lower cost compared to the same degree of effectiveness with regard to tuberculosis cure compared with DOT-HS. The results obtained are subsidies to the adoption of an alternative TB treatment to health management in the decision-making process in the context of the Tuberculosis Control Program.

O acompanhamento dos casos de Tuberculose (TB) envolve planejar ações assistenciais e gerenciais, as quais preveem a utilização de diferentes instrumentos de registro e sistemas de informação. Dessa forma, desenvolveu-se um sistema de informação para acompanhamento dos doentes de TB (SISTB), sendo que o presente estudo teve como objetivo analisar a implantação e utilização de tal sistema em um Ambulatório de Referência (AR) para o tratamento da TB de Ribeirão Preto - SP no período de 2013 à 2016. Trata-se de um estudo epidemiológico descritivo-analítico, do tipo intervenção, com abordagem quantitativa. Para análise do processo de implantação do SISTB, foi realizada observação com roteiro. O banco de dados do SISTB foi consultado para analisar a utilização e completude de preenchimento dos dados. Resultados: adaptações foram realizadas no SISTB para atender as necessidades dos profissionais de saúde. O cadastro dos doentes no sistema ocorreu em média 7 dias após o início do tratamento. O cadastro das supervisões medicamentosas e a edição de dados foram as ações mais realizadas. Fragilidades na completude dos dados foram identificadas no preenchimento do CPF, número do SINAN e na data do exame de cultura de escarro. Apresentaram 100% de completude o número do prontuário, endereço, município, data de nascimento, serviço que descobriu o caso, data de notificação, unidade de atendimento médico, unidade de supervisão medicamentosa, data de início do tratamento, tipo de tratamento, realizou tratamento anterior, data da alta e desfecho do tratamento. Conclusão: a utilização do SISTB possibilitou a geração automática da Ficha de Registro do Tratamento Diretamente Observado (TDO) e Boletim de Acompanhamento Mensal. Apesar da incompletude no preenchimento de alguns dados, outros foram completamente preenchidos. Foram identificados problemas que dificultavam o uso do SISTB, os quais foram corrigidos. O SISTB permitiu agrupar diferentes registros em um único local com acesso online, facilitando o compartilhamento e visualização de informações entre os profissionais e serviços de saúde / The monitoring of tuberculosis (TB) cases involves planning care and management actions, which provide the use of different instruments registration and information systems. Thus, it was developed an information system for monitoring TB patients (SISTB), and the present study analyzed the implementation and use of this system in a reference outpatient clinic (AR) for TB treatment in Ribeirão Preto - SP from 2013 to 2016. This is a descriptive and analytical epidemiological study of type intervention with a quantitative approach. For analysis of SISTB deployment process, script with observation was performed. The SISTB database was consulted to analyze the data use, data fill completeness. Results: Improvements were made in SISTB to meet the needs of healthcare professionals. The registration system of the patients was on average 7 days after initiation of treatment. Registration of drug supervision and editing of data was the most performed actions. Weaknesses in the completeness of data were identified for completion of the CPF, SINAN number and date of sputum culture test. Showed 100% completion of the medical record number, address, city, date of birth, service that discovered the case, notification, medical care unit, drug supervision unit, starting date of treatment, type of treatment, being treated earlier, date of discharge and treatment outcome. Conclusion: The use of SISTB enabled the automatic generation of Treatment Registration Form Directly Observed (TDO) and Monthly Monitoring Bulletin. Despite the incompleteness in filling some data, others were completely filled. Problems were identified that hindered the use of SISTB, which were corrected. The SISTB allowed group different records in a single location with online access, facilitating the sharing and visualization of information between professionals and health services

Introdução/Objetivos: A avaliação em saúde no Brasil apresenta-se em um contexto em que os processos ainda são incipientes, pouco incorporados às práticas e possuem caráter mais prescritivo, burocrático e punitivo que subsidiário do planejamento e da gestão. Além disso, os instrumentos existentes ainda não se constituem ferramentas de suporte ao processo decisório nem de formação das pessoas nele envolvidas. Esta tese tem o objetivo de analisar as concepções de avaliação presentes nas práticas avaliativas na formação de sujeitos interessados e de interesse para a institucionalização da avaliação em saúde no Sistema Único de Saúde. Metodologia: Esta tese será apresentada na forma de quatro manuscritos de artigos científicos e o capítulo de um livro. O capítulo do livro descreve a reflexão sobre o tema da avaliação em saúde no contexto da atenção básica, tomando como referência a elaboração e realização do curso de especialização à distância ofertado aos avaliadores da qualidade e supervisores que realizaram a avaliação externa do PMAQ-AB, vinculados à Rede Governo Colaborativo em Saúde (Rede). O segundo manuscrito é um artigo que trata de uma revisão documental do arcabouço jurídico que regulamenta o Sistema de Saúde e implementa o PMAQ-AB como um dispositivo de institucionalização da avaliação relacionada com a teoria avaliativa focada no valor. O terceiro manuscrito analisa o perfil dos alunos ingressantes e concluintes do referido curso de especialização, analisando as características de avaliadores externos formados em seis estados do Brasil. O quarto manuscrito analisa o desempenho dos alunos relacionando o conhecimento relativo ao conteúdo trabalhado durante o curso. O quinto manuscrito apresenta a experiência de implementação da avaliação educacional dentro de um curso de graduação inovador em Odontologia. Resultados: O capítulo do livro além de expor a estrutura curricular, pondera sobre os desafios que a ousadia proposta no curso de Especialização em Avaliação de Serviços de Saúde colocou para todos os envolvidos. Os artigos apresentam uma análise da institucionalização da avaliação no Sistema Único de Saúde que abrange a legislação que regulamenta o sistema sob a ótica dos autores que centram seus estudos no valor, a descrição do perfil e análise do desempenho dos alunos na formação de avaliadores para o desenvolvimento de práticas avaliativas dentro de um programa de melhoria ao acesso e qualidade e a utilização da avaliação formativa na formação de profissionais de saúde conforme as Diretrizes Curriculares para os cursos de Odontologia preconizam. Conclusão: A partir dos resultados apresentados nos estudos, é possível concluir que o caminho trilhado pelo Sistema Único de Saúde tem demonstrado uma tendência e uma necessidade de qualificação das práticas avaliativas em todos os seus níveis. Se formarmos avaliadores e, na graduação, profissionais de saúde que, por serem avaliados numa perspectiva emancipatória, desenvolvam uma relação mais participativa e uma visão menos punitiva das práticas avaliativas, estaremos mais próximos de implementar a mudança inerente aos processos relacionados com a avaliação. Assim, seremos capazes de transformar os serviços e por consequência a própria formação em saúde, afinal, a avaliação é um investimento em pessoas e no desenvolvimento. / Introduction / Objectives: Health evaluation in Brazil comes in a context in which processes are still incipient, not incorporated to practices and with a prescriptive, bureaucratic character. Furthermore, the existing evaluation tools do not constitute additional support to decision-making process or training of people involved. This thesis aims to analyze the conceptions of evaluation present in assessment practices during the training of individuals of interest and interested in the institutionalization of health evaluation in the Unified Health System. Methodology: This thesis will be presented in the form of four manuscripts and chapter of a book. The later describes the reflection on health evaluation in the context of primary care, with reference to the provision of a distance learning specialization course to quality evaluators and the supervisors who carried out the external evaluation of PMAQ-AB. The second manuscript reviews the legal framework that regulates the health system and implements the PMAQ-AB as institutionalization proposition related to the evaluation theory focused on value. The third manuscript analyzes the profile of students of the referred specialization course, analyzing the characteristics of external evaluators trained in six states of Brazil. The fourth manuscript reviews the performance of students in knowledge related to the contents developed during the course. The fifth manuscript presents the implementation of educational assessment within an innovative graduation course in dentistry. Results: The book chapter reports on the curriculum proposal and ponders the challenges faced by the course. The articles present an assessment of the institutionalization of Health Evaluation in the National Health System that covers the laws governing the system from the perspective of authors who focus their studies on the value, the profile description and analysis of student performance in the training of evaluators for development of assessment practices within an program of improvement of access and quality and the use of formative assessment in the training of health professionals in an Undergraduate System. Conclusion: We conclude that the path taken by the Unified Health System has shown a trend and a need for qualification of assessment practices at all levels. Evaluation based on an emancipatory perspective, develop a more participatory relationship and a less punitive view of assessment practices which may result in better implementation of the changes inherent in the processes related to the assessment which is able to transform services and therefore the formation of health professionals. After all, evaluation is an investment in people and their development.

Background and Significance: Severe childhood obesity, the fastest growing subcategory of childhood obesity, affects 4-6% of youth. Children from racial/ethnic minority groups and low income households are disproportionately affected. Severe obesity increases risk for metabolic syndrome, cardiovascular disease, non-alcoholic fatty liver disease, musculoskeletal problems, poor health-related quality of life, bullying, low self-worth, absenteeism, and adult obesity. One method of addressing childhood obesity is through school-based interventions. School nurses may be well-suited to lead obesity interventions because of their healthcare expertise, long-term relationships with students and families, and availability to students without financial burden. Purpose: The overarching aim of this mixed methods dissertation was to evaluate the implementation and efficacy of the Healthy Options and Physical Activity Program, a school nurse-led intervention for children with severe obesity attending New York City schools. This evaluation focused on the 2012/2013 school year, the first full year of program implementation. Methods: Aims 1 and 2 were conducted to prepare for the Healthy Options and Physical Activity Program evaluation. Aim 1 included conduct of a systematic review and meta-analysis of existing literature to examine the role and impact of nurses in school-based obesity interventions. Aim 2 studied application of 3 propensity score methods to the observational Healthy Options and Physical Activity Program data set to determine which best removed significant differences in 11 potential confounders between the 1,054 kindergarten through fifth grade children who participated in the program in 2012/2013 and the 19,464 children who were eligible but did not participate. Aims 3-6 comprised the Healthy Options and Physical Activity Program evaluation. Aims 3, 4, and 5, utilized a retrospective cohort design to examine program implementation and its one year impact on body mass index percentile, school absences, and walk-in school nurse visits. Analytic methods included descriptive statistics, Wilcoxon signed rank tests, McNemar’s test, and logistic regression. Aim 6 qualitatively explored perceived barriers to and facilitators of implementing the Healthy Options and Physical Activity Program from the perspective of school nurses, using individual semi-structured interviews. Interview data were analyzed using content analysis. Results/findings: Of 11 studies eligible for systematic review, 8 met inclusion for meta-analysis. Pooled findings suggest that school nurse led interventions decreased BMI percentile by -0.41 (95%CI: -0.60, -0.21; I2=0, Cochrane Q=2.0). The comparison of propensity score methods demonstrated that only propensity score matching removed all significant differences between children who received the Healthy Options and Physical Activity Program and children who were eligible for but did not receive the program. The program evaluation demonstrated that the program had limited reach (5% of eligible children) and low intensity (median 1 session/year, parent attendance at 3.2% of sessions). Factors associated with selection for program enrollment included attending a school with low school nurse workload (OR 2.4, 95%CI 2.0-2.8), low school poverty (OR 1.6, 95%CI 1.3-1.9), and lack of chronic illness comorbidity (OR 0.5, 95%CI 0.5-0.6). After propensity score matching, program participants failed to decrease body measures, school absences, or school nurse visits at 1 year. Themes of interviews with 19 school nurses suggest that nurses encountered barriers to program implementation: parental and administrative resistance, heavy workload, and obesogenic environments. Despite barriers, nurses implemented the program to the best of their ability using creativity and teamwork. Conclusion: As implemented, the Healthy Options and Physical Activity Program was not effective in reducing body mass index percentile, absences or school nurse visits in youth with severe obesity. Barriers such as limited time and lack of parental and administrative support prevented nurses from fully implementing the program. However, school nurses with their clinical knowledge base, cost-free accessibility to children and families, and long-term relationship with students may be able to successfully employ other school-based obesity interventions. Therefore future research should use rigorous methods to develop and test school-based interventions implemented by school nurses, with a focus on intervention feasibility and sustainability. Implications for the Profession: This dissertation has implications for nursing practice, health policy, and nursing science. Findings of this mixed methods evaluation suggests that nurses may not have the resources necessary to implement intensive school-based obesity interventions. Nurses who are planning to implement such an intervention may want to carefully consider program intensity and feasibility. In addition, careful attention to increasing parent buy-in and ensuring administrator support are key. In addition, policy that supports adequate school nurse staffing can support appropriate nursing workload and may allow nurses time to implement health promotion programs and obesity interventions. During the qualitative portion of this dissertation, nurses reported the obesogenic environment as a barrier to healthful living that impacted the program’s effectiveness; obesogenic environmental factors (e.g., unhealthy school meals) will need to be addressed via legislation. Lastly, nurse scientists can work to increase the literature surrounding school-based obesity interventions, particularly with randomized controlled trials of interventions and qualitative work with nurses, parents, school administrators, and children. In addition, school-based obesity interventions must be developed and tested that consider the challenges faced by vulnerable children such as children living and attending school in high poverty neighborhoods.