Residents of rural communities have poorer health status than people living in more populated areas. For example, The Urban and Rural Health Chartbook notes that the age-adjusted death rate among younger (1-24 years of age) persons who live in the most rural counties is 31 percent higher than those who live in the most urban counties and 65 percent higher for those who live in suburban counties (Eberhardt, Ingram, Makuc et al., 2001). Explanation for the health disparity experienced by rural residents is complex due to the influence of both community factors and the socioeconomic and behavior patterns of individuals. Access to health care, including preventive care, as well as substantial challenges with health literacy, higher instances of smoking, and lack of health insurance among rural residents, are some of the main causes of this disparity. Rural health networks have been touted by many involved with rural health issues as an effective way to address the health disparity experienced by rural areas. The last fifteen years have seen a growth in the development of rural health networks, with a growing number of grantors, e.g. the Health Resources and Services Administration, The Robert Woods Johnson Foundation and states such as New York, Florida, and West Virginia, funding their development. However, little research has been done on the effectiveness of rural health care networks. While some have evaluated rural health networks, Wellever explains that many questions are left unanswered with "the most fundamental question — whether rural health networks benefit either their members or the rural residents they serve" (1999, p. 133). Thus, it needs to be determined if health networks are in fact a viable means for improving the disparity in rural health and, more importantly, what can be done to make them more effective. This research provides insight into the correlates of effectiveness for a type of health network, vertically integrated rural health networks. Provan and Milward's (2001) framework for evaluating the effectiveness of public-sector organizational networks, which proposes three levels of analysis, i.e., the community, network, and organization/participant, was adapted to analyze the effectiveness of vertically integrated rural health networks. One-on-one interviews, questionnaires, and archival data were used to collect data on the networks sampled. Primarily, data was collected from four networks that were chosen from a larger sample of twenty-one networks to serve as best practices. Analysis of the data collected revealed a few significant predictors for the effectiveness of vertically integrated rural health networks. Financing was found to be the most important predictor, as it was significant at both the community and network levels. Both cohesiveness and the number of problems in the rural environment were also found to be significant predictors but only at the network level. No significant predictors were found at the organizational level; however, organizational and network-level effectiveness were found to be strongly correlated with each other. Overall, networks were found to be more favorable about their effectiveness at the network and organizational levels. / Ph. D.

No description available.

La recherche porte sur l’analyse des relations entre l’hôpital et la ville dans la prise en charge des malades atteints de cancer et sur les enjeux d’une formalisation de la coordination des interventions au sein de réseaux de santé. Il s’agit d’élucider le processus de formalisation de la coordination dans le système de prise en charge des patients atteints de cancer, à travers l’identification des objectifs des acteurs et des facteurs de convergence de leurs discours. Pour cela, on retrace dans un premier temps la problématisation de la coordination dans la politique de lutte contre le cancer : depuis la définition d’un « problème » de coordination dans le champ de la lutte contre le cancer, sa mise sur agenda, jusqu’à l’ « instrumentation » de l’action publique. Dans un second temps, une méthodologie qualitative et quantitative permet de cerner le jeu des acteurs autour de cet enjeu de coordination. On décrit les pratiques et les représentations des malades, des médecins généralistes et des professionnels et les conditions de leur adhésion à une formalisation de la coordination au sein de réseaux de santé. Il apparaît finalement que leur adhésion repose sur des variables symboliques et stratégiques. / This work deals with the relationships between hospital and general practice, while caring for people suffering from cancer. It focuses on what is at stake in the coordination of these healthcare network actors. In order to clarify the process of formalization of coordination in cancer’s care system, we identified actor’s goals and causes of the convergence of their concerns. Firstly, we described the process of definition of coordination as a problem in the policy of fight against cancer and the selection of an instrument to solve this problem. Secondly, thanks to a qualitative and quantitative methodology, we understood the way “social actors” play with the coordination issue. We described perceptions and practices of patients, General Practitioners and Hospital Doctors and the conditions of subscription to formal health networks. The study showed that their subscription depends on symbolic and strategic variables.

As reinternações psiquiátricas são consequência de uma complexa combinação de situações que vão além da severidade do próprio transtorno mental. Vários fatores relacionados ao paciente, comunidade e ao sistema de saúde têm sido associados com admissões psiquiátricas recorrentes. A Reforma Psiquiátrica determinou uma mudança da base assistencial fortalecendo modalidades de tratamento comunitário. Neste contexto, a análise das readmissões assumiu um papel de destaque para a organização das redes de saúde mental, pois a dinâmica das re-internações poderá ser um indicador de qualidade dos serviços hospitalares e comunitários possibilitando a compreensão das relações entre estes serviços. Como a região de Ribeirão Preto passou a enfrentar problemas pelo aumento do número de internações e pela falta de leitos psiquiátricos disponíveis para admissão de novos pacientes, organizamos esta pesquisa objetivando verificar eventuais mudanças nas características clínicas e sócio-demográficas dos pacientes admitidos pela primeira vez além de analisar possíveis fatores preditores de re-internações psiquiátricas. Nesse estudo, todos os pacientes admitidos nos serviços de internação entre os anos de 2000 e 2007 foram analisados utilizando banco de dados único criado para a pesquisa de modo que todas as admissões e readmissões do período pudessem ser estudadas. A análise dos pacientes internados no decorrer dos anos foi realizada utilizando a razão dos pacientes em relação ao ano índice para cada variável e com análise bivariada utilizando o teste do qui-quadrado. Para analisar o risco de readmissão, foi utilizada regressão logística para estimar as razões de risco relativo com seus respectivos intervalos de confiança. A análise do tempo entre a primeira e a segunda internação (readmissão) foi executada com curvas de sobrevivência. Durante o período estudado, 6.261 pacientes foram admitidos sendo verificado aumento na proporção de pacientes com algumas características sócio-demográficas (jovens, idosos e inativos profissionalmente) e clínicas (internações breves e com diagnósticos de transtornos depressivos, transtornos de personalidade e os transtornos relacionados ao uso de substâncias psicoativas). Cerca de 1/3 dos pacientes admitidos sofreram readmissões durante o estudo e os principais preditores para re-internação foram faixas etárias menores, internações prolongadas e diagnósticos transtornos psicóticos e afetivos bipolares. O risco de re-internação precoce esteve relacionado com fatores de desproteção social (menor faixa etária e ausência de vínculos conjugais e ocupacionais) e de gravidade clínica (diagnósticos mais severos, tempo de permanência prolongado e internação nas enfermarias do hospital geral e do hospital psiquiátrico). Nossos dados alcançaram os objetivos propostos e novas pesquisas são necessárias para definição de preditores pera re-internações, pois usuários frequentes do sistema hospitalar geram custos para a rede de saúde. Portanto, as políticas de saúde mental devem priorizar estes pacientes. / Psychiatric readmissions are mainly due to a complex combination of factors which go beyond the mental illness itself. Several factors associated to the patient, community and health care system have been associated to recurrent psychiatric admissions. The Psychiatric Reform has determined a shift in the basic services strengthening community treatment modalities. In this context, re-admission analyses have taken a major role in organizing mental health networks, because the dynamics of re-admissions could be an indicator of the quality of the hospital and community-based services offered allowing a better understanding of the relations between these services. As the Ribeirão Preto region has suffered from the increase of admissions and the lack of beds in psychiatric wards, we organized this research aiming at verifying possible changes in the socio-demographic and clinical characteristics of patients admitted for the first time besides analyzing possible factors for re-admissions. In this study, all patients admitted to psychiatric wards between 2000 and 2007 were analyzed using a single data base created for this research so that all admissions and re-admissions during the period could be studied. The hospitalized patients analysis along the years was accomplished using the ratio patient/index year for each variable and through a bivariant analysis using the chi-square test. In order to analyze the re-admission risk, logistic regression was used to evaluate the relative risk reasons with their respective confidence interval. Analysis of the time between first and second admission (re-admission) was made according to survival curves. During the time under study, 6.261 patients were admitted. It occurred an increase in the proportion of patients with some socio-demographic (young and elderly people clinically affected as well as professionally inactive) and clinical characteristics (short stays due to depressive, personality and psychoactive substance abuse diagnostics). About 1/3 of admitted patients went through a re-admission during the research and the main predictors for re-admission were: younger age group, prolonged length of stay in hospitals and psychotic or bipolar affective disorder diagnoses. Precocious re-admission risk was related to a lack of social protection (younger age group and absence of occupational and marital bonds) as well as the clinical seriousness (more severe dignoses, longer stay in hospital (general or psychiatric). Our data has reached the proposed goals but new researches are needed in order to define better the re-admission predictors, because frequent users of the health care system entail higher costs. Therefore, mental health policies must prioritize these patients.

La légitimation scientifique et institutionnelle des bénéfices de l’activité physique (AP) régulière sur la prévention du surpoids et de l’obésité a rendu possible le développement de nouvelles dynamiques professionnelles autour de l’AP dans les Réseaux de prévention et de prise en charge de l’obésité en pédiatrie (Réppop). La création d’une nouvelle offre de service en AP destinée à soutenir un engagement des jeunes patients dans une pratique physique régulière, mobilise la profession médicale (médecins généralistes, pédiatres, médecins du sport), les professions paramédicales (diététiciens, kinésithérapeutes) et les professionnels du sport et de l’activité physique (professeurs d’Activité Physique Adaptée et Santé (APAS), éducateurs sportifs). A l’interface de la sociologie des groupes professionnels et de la sociologie du sport, la thèse a pour objectif d’étudier la construction d’un territoire Activité Physique Adaptée et Santé (APAS) dans les Répop. Ces dispositifs présentent la particularité d’être en cours de construction et de mobiliser des groupes professionnels dans un projet global à partir de leurs compétences spécifiques et de compétences transversales. A côté des groupes établis dans le champ médical, le groupe émergent de l’APAS s’appuie sur cet espace transversal pour construire son territoire spécifique, dans une situation de collaboration qui suscite paradoxalement des concurrences directes avec les autres groupes en présence. La dynamique est étudiée au carrefour des perspectives des professions, de celles des jeunes patients et de leur famille ainsi que de celles de l’Etat, en cohérence avec l’approche théorique d’Andrew Abbott (2003). / Scientific and academic recognition of the benefits of regular physical activity (PA) in the prevention of overweight and obesity has made possible the development of new professional dynamics around PA in childhood obesity prevention and management networks—known as REPOPs—in France. The creation of a new offer of PA services intended to encourage young patients in their commitment to regularly engage in physical activity rallies together the medical profession (general practitioners, paediatricians, sports medicine physicians), other healthcare professions (dieticians, physiotherapists), and sports and physical activity professionals (Adapted Physical Activity and Health (APAH) teachers, sport teachers). Lying at the interface between the sociology of professional groups and the sociology of sport, this paper aims to study the creation of a jurisdiction of Adapted Physical Activity and Health (APAH) in REPOPs. These systems have the distinctive feature of being under construction and bringing together the specific and interdisciplinary competencies of professional groups around a common project. Alongside the groups already established in the medical field, the emerging APAH group is using this multidisciplinary arena to build its own jurisdiction in a collaborative manner that, paradoxically, is giving rise to direct competition with the other groups. Using Andrew Abbott’s theoretical approach (2003), this dynamic is explored at the point where the perspectives of the professions, those of young patients and their families, and those of the government, converge.

As reinternações psiquiátricas são consequência de uma complexa combinação de situações que vão além da severidade do próprio transtorno mental. Vários fatores relacionados ao paciente, comunidade e ao sistema de saúde têm sido associados com admissões psiquiátricas recorrentes. A Reforma Psiquiátrica determinou uma mudança da base assistencial fortalecendo modalidades de tratamento comunitário. Neste contexto, a análise das readmissões assumiu um papel de destaque para a organização das redes de saúde mental, pois a dinâmica das re-internações poderá ser um indicador de qualidade dos serviços hospitalares e comunitários possibilitando a compreensão das relações entre estes serviços. Como a região de Ribeirão Preto passou a enfrentar problemas pelo aumento do número de internações e pela falta de leitos psiquiátricos disponíveis para admissão de novos pacientes, organizamos esta pesquisa objetivando verificar eventuais mudanças nas características clínicas e sócio-demográficas dos pacientes admitidos pela primeira vez além de analisar possíveis fatores preditores de re-internações psiquiátricas. Nesse estudo, todos os pacientes admitidos nos serviços de internação entre os anos de 2000 e 2007 foram analisados utilizando banco de dados único criado para a pesquisa de modo que todas as admissões e readmissões do período pudessem ser estudadas. A análise dos pacientes internados no decorrer dos anos foi realizada utilizando a razão dos pacientes em relação ao ano índice para cada variável e com análise bivariada utilizando o teste do qui-quadrado. Para analisar o risco de readmissão, foi utilizada regressão logística para estimar as razões de risco relativo com seus respectivos intervalos de confiança. A análise do tempo entre a primeira e a segunda internação (readmissão) foi executada com curvas de sobrevivência. Durante o período estudado, 6.261 pacientes foram admitidos sendo verificado aumento na proporção de pacientes com algumas características sócio-demográficas (jovens, idosos e inativos profissionalmente) e clínicas (internações breves e com diagnósticos de transtornos depressivos, transtornos de personalidade e os transtornos relacionados ao uso de substâncias psicoativas). Cerca de 1/3 dos pacientes admitidos sofreram readmissões durante o estudo e os principais preditores para re-internação foram faixas etárias menores, internações prolongadas e diagnósticos transtornos psicóticos e afetivos bipolares. O risco de re-internação precoce esteve relacionado com fatores de desproteção social (menor faixa etária e ausência de vínculos conjugais e ocupacionais) e de gravidade clínica (diagnósticos mais severos, tempo de permanência prolongado e internação nas enfermarias do hospital geral e do hospital psiquiátrico). Nossos dados alcançaram os objetivos propostos e novas pesquisas são necessárias para definição de preditores pera re-internações, pois usuários frequentes do sistema hospitalar geram custos para a rede de saúde. Portanto, as políticas de saúde mental devem priorizar estes pacientes. / Psychiatric readmissions are mainly due to a complex combination of factors which go beyond the mental illness itself. Several factors associated to the patient, community and health care system have been associated to recurrent psychiatric admissions. The Psychiatric Reform has determined a shift in the basic services strengthening community treatment modalities. In this context, re-admission analyses have taken a major role in organizing mental health networks, because the dynamics of re-admissions could be an indicator of the quality of the hospital and community-based services offered allowing a better understanding of the relations between these services. As the Ribeirão Preto region has suffered from the increase of admissions and the lack of beds in psychiatric wards, we organized this research aiming at verifying possible changes in the socio-demographic and clinical characteristics of patients admitted for the first time besides analyzing possible factors for re-admissions. In this study, all patients admitted to psychiatric wards between 2000 and 2007 were analyzed using a single data base created for this research so that all admissions and re-admissions during the period could be studied. The hospitalized patients analysis along the years was accomplished using the ratio patient/index year for each variable and through a bivariant analysis using the chi-square test. In order to analyze the re-admission risk, logistic regression was used to evaluate the relative risk reasons with their respective confidence interval. Analysis of the time between first and second admission (re-admission) was made according to survival curves. During the time under study, 6.261 patients were admitted. It occurred an increase in the proportion of patients with some socio-demographic (young and elderly people clinically affected as well as professionally inactive) and clinical characteristics (short stays due to depressive, personality and psychoactive substance abuse diagnostics). About 1/3 of admitted patients went through a re-admission during the research and the main predictors for re-admission were: younger age group, prolonged length of stay in hospitals and psychotic or bipolar affective disorder diagnoses. Precocious re-admission risk was related to a lack of social protection (younger age group and absence of occupational and marital bonds) as well as the clinical seriousness (more severe dignoses, longer stay in hospital (general or psychiatric). Our data has reached the proposed goals but new researches are needed in order to define better the re-admission predictors, because frequent users of the health care system entail higher costs. Therefore, mental health policies must prioritize these patients.

Abstract Black women are disproportionately affected by adverse health conditions, such as obesity and heart disease. For example, more black women currently die from complications associated with diabetes, obesity and high blood pressure than any other ethnic group in the United States (Gourdine 2011). There are however, increasing numbers of everyday black women who defy these statistics and are positive role models for all women. One such group of women is the New Orleans chapter of Sistas On The Move (SOTM), an all-female running group that emphasizes the importance of black women’s health and builds community around physical activity. Through field interviews and participant observation, I examine the following questions: What motivates these women to run, walk and lead healthy lifestyles in New Orleans? How do SOTM members claim and utilize space in New Orleans for their physical health and social activities?

O estudo proposto nesta tese aborda o processo de regionalização do SUS a partir de duas vertentes dinamizadoras. Uma orientada pela diretriz da descentralização político-administrativa e outra pela diretriz de regionalização e hierarquização da rede de saúde com foco na integração de atividades e serviços em regiões. Tal processo pode ter como resultado a mitigação ou o aprofundamento das desigualdades regionais. O processo de regionalização assim considerado foi analisado segundo duas dimensões do desenvolvimento capitalista, a territorial e a da saúde pública. Em relação à dimensão territorial, a divisão inter-regional do trabalho foi considerada elementar para a diferenciação das regiões segundo suas funções na organização da produção. É nessa perspectiva que recorremos à rede urbana como síntese da divisão inter-regional do trabalho. Em relação à dimensão da saúde pública, o norteamento para a compreensão da sua inserção no desenvolvimento capitalista foi dado por dois conceitos dicotômicos de saúde, saúde como ausência de doença e saúde como bem-estar social. É por meio deles que se torna possível identificar as diferentes funções sociais da saúde pública e, a partir daí, desvelar seu papel no aprofundamento do movimento desigual da acumulação do capital ou, ao contrário, como elemento de transformação social. Devido à importância do financiamento na elucidação do processo de regionalização, a tese evidenciou as transferências de recursos da esfera federal para os governos municípios no âmbito do bloco de financiamento da Média e Alta Complexidade Ambulatorial e Hospitalar (Bloco MAC) com foco nas estratégias vinculadas às redes temáticas. Foram observadas as transformações na concentração/desconcentração territorial dos recursos do Fundo Nacional de Saúde (FNS) para os Fundos Municipais de Saúde (FMS) paulistas no período 2009-2014, considerando as condições de urbanização das 63 Regiões de Saúde do estado de São Paulo (Metropolitana, Alta urbanização, Média urbanização e Baixa urbanização) propostas pela tese. A análise assim fundamentada tornou possível verificar que o processo recente de regionalização do SUS no estado de São Paulo, dinamizado pelo financiamento das ações e estratégias vinculadas às redes temáticas, aprofunda as características de distribuição espacial desigual no território paulista. / The study proposed in this thesis discusses the SUS regionalization process from two aspects dynamizing. A guided by the policy of political and administrative decentralization and the other by the regionalization policy and hierarchical health network focused on integration activities in the regions. This process may result in the mitigation or the deepening of regional inequalities. The regionalization process thus considered was analyzed according to two dimensions of capitalist development, territorial and public health. In relation to the territorial dimension, the inter-regional division of labor was considered elementary for the differentiation of the regions according to their roles in the organization of production. It is in this perspective that we used the urban network as a synthesis of the inter-regional division of labor. In relation to the public health, the guideline for understanding of its insertion in capitalist development was given by two dichotomous concepts of health, health as absence of disease and health as welfare. It is through them that it is possible to identify the different social functions of public health and reveal its role in deepening unequal accumulation of capital or as social transformation element.

O estudo proposto nesta tese aborda o processo de regionalização do SUS a partir de duas vertentes dinamizadoras. Uma orientada pela diretriz da descentralização político-administrativa e outra pela diretriz de regionalização e hierarquização da rede de saúde com foco na integração de atividades e serviços em regiões. Tal processo pode ter como resultado a mitigação ou o aprofundamento das desigualdades regionais. O processo de regionalização assim considerado foi analisado segundo duas dimensões do desenvolvimento capitalista, a territorial e a da saúde pública. Em relação à dimensão territorial, a divisão inter-regional do trabalho foi considerada elementar para a diferenciação das regiões segundo suas funções na organização da produção. É nessa perspectiva que recorremos à rede urbana como síntese da divisão inter-regional do trabalho. Em relação à dimensão da saúde pública, o norteamento para a compreensão da sua inserção no desenvolvimento capitalista foi dado por dois conceitos dicotômicos de saúde, saúde como ausência de doença e saúde como bem-estar social. É por meio deles que se torna possível identificar as diferentes funções sociais da saúde pública e, a partir daí, desvelar seu papel no aprofundamento do movimento desigual da acumulação do capital ou, ao contrário, como elemento de transformação social. Devido à importância do financiamento na elucidação do processo de regionalização, a tese evidenciou as transferências de recursos da esfera federal para os governos municípios no âmbito do bloco de financiamento da Média e Alta Complexidade Ambulatorial e Hospitalar (Bloco MAC) com foco nas estratégias vinculadas às redes temáticas. Foram observadas as transformações na concentração/desconcentração territorial dos recursos do Fundo Nacional de Saúde (FNS) para os Fundos Municipais de Saúde (FMS) paulistas no período 2009-2014, considerando as condições de urbanização das 63 Regiões de Saúde do estado de São Paulo (Metropolitana, Alta urbanização, Média urbanização e Baixa urbanização) propostas pela tese. A análise assim fundamentada tornou possível verificar que o processo recente de regionalização do SUS no estado de São Paulo, dinamizado pelo financiamento das ações e estratégias vinculadas às redes temáticas, aprofunda as características de distribuição espacial desigual no território paulista. / The study proposed in this thesis discusses the SUS regionalization process from two aspects dynamizing. A guided by the policy of political and administrative decentralization and the other by the regionalization policy and hierarchical health network focused on integration activities in the regions. This process may result in the mitigation or the deepening of regional inequalities. The regionalization process thus considered was analyzed according to two dimensions of capitalist development, territorial and public health. In relation to the territorial dimension, the inter-regional division of labor was considered elementary for the differentiation of the regions according to their roles in the organization of production. It is in this perspective that we used the urban network as a synthesis of the inter-regional division of labor. In relation to the public health, the guideline for understanding of its insertion in capitalist development was given by two dichotomous concepts of health, health as absence of disease and health as welfare. It is through them that it is possible to identify the different social functions of public health and reveal its role in deepening unequal accumulation of capital or as social transformation element.

Rural hospitals in America hold a critical position within their communities because they possess the duty and responsibility of not only providing adequate healthcare services for the population, but also bearing the heavy burden of functioning as one of the main socio-economic engines within the area. These factors, along with drastically inadequate operating budgets, often create programmatic and operational challenges for these entities to confront as they fight to provide the technologically current facilities and services needed to adequately care for their community. All of this must be done in the most cost effective way possible. This thesis will look at current trends being administered within the widespread replacement effort of these facilities, and propose several alternative strategies aimed at facilitating feasible solutions to these and other issues that are not currently being addressed. Design resolution strategies will be formulated and tested. These will then be directly implemented through a specific project design exercise that will then be evaluated.