Political science and tobacco policy--Theories of policy change--The global policy context--European countries and the EU--The UK: a case study--The United States--Other advanced industrial countries--Tobacco control policymaking in developing regions--The WHO Framework Convention on Tobacco Control (FCTC) / https://dc.etsu.edu/etsu_books/1104/thumbnail.jpg

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Background: Enhancing the performance of front-line health workers serving vulnerable populations is crucial for redressing inequities. Traditional approaches have focused on introducing technical solutions, such as guidelines and incentives, to modify performance outcomes. Recognition of the complex social nature of health system function draws attention to the intangible software elements that shape performance, including the values, ideas, interests, and norms that guide human behavior and interactions. Insight into the operation of software elements can provide a base for people-focused solutions to support health workers and enable them to confront constraints in low resource settings. This study examines the social environment of the practice of front-line auxiliary nurses (AN) in rural Guatemala, in order to understand the role of health system software elements in enabling their performance and to gain insight into how organizational support can be strengthened through locally-relevant actions. Methods: A mixed methods approach provided a multi-level view of the AN practice environment, situated in the regional health system of the rural department of Alta Verapaz. Interviews with ANs and observations of practice were conducted to understand the values orienting them and how these shaped their relationships with patients and communities. A theory-driven case study of AN supervision was conducted in selected health posts to understand the values orienting supervisors in their role and examine how these shaped their relationships with ANs. The participatory method of concept mapping was used to examine the views of health workers, district and regional managers on actions to strengthen organizational support for the performance of ANs. Results: The values of nursing vocation and community connectedness were prominent in ANs’ interpretations of their work. In relationships, nursing principles oriented them to be attentive to understanding patient needs, and a shared ethnic identity and personal experience of local needs served as a base for engaging with local leaders in community work. The dominant orientation of supervisors in their role was managerial control, and it provided limited support. It contributed to standard-centered relationships with ANs focused on fulfillment of ministry criteria. Supervision oriented by a holistic understanding of ANs’ needs and the goal of improving patient care was more successful in enabling AN motivation. This relationship was characterized as people-centered, based in a shared interpretation of the value of work with patients and the responsive support provided to ANs’ problems. “Organizational climate of support across levels”, where working relationships are characterized by respectful treatment, attention to psycho-social well-being and responsiveness to needs, was identified by health-system actors as a top priority for improving performance. Conclusions: To enable performance, there needs to be a balance between attention to standards and attention to the human dimensions of health worker practice. The dominant approach to supervision did not recognize or build on AN values. Supervision and management should be oriented by a more holistic view of the ANs’ work and their needs, in order to promote a people-centered approach to working relationships. Locally relevant action to strengthen district and regional management’s support for AN performance should focus on operationalizing performance goals that go beyond standards to encompass care that responds to patient and community needs.

Made available in DSpace on 2014-06-11T19:26:17Z (GMT). No. of bitstreams: 0 Previous issue date: 2009-06-29Bitstream added on 2014-06-13T18:06:38Z : No. of bitstreams: 1 paveloski_em_me_bauru.pdf: 828753 bytes, checksum: b443cc0b09bd4dc5570267c14288216d (MD5) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Este trabalho aborda como tema principal a situação da geração, segregação e disposição final dos Resíduos de Serviços de Saúde na região do Coder (Conselho de Desenvolvimento Econômico Regional) que tem como sede o município Bauru. O objetivo foi levantar dados, avaliar a situação atual da questão dos RSS e propor soluções para uma melhor gestão deste tipo específico de lixo urbano. Ao cumprir tais objetivos, as considerações expostas pelo autor levam a um retrato da situação atual dos resíduos de serviços de saúde na região, trazendo também um panorama do tema no Brasil e no Estado de São Paulo, expondo as fragilidades das leis que contemplam mais os grandes geradores e a baixa qualificação da mão de obra, o que diminui o processo de segregação e, no destino final, problemas ambientais. / The theme of this work is about generation, segregation and final disposal of Health Services Residues (RSS) in the region of CODER (Regional Economic Developing Council), which is based in Bauru. The aims of this research are to improve the management of this specific type of urban waste. In order to accomplish such objectives, considerations made by the author of this dissertation show a portrait of the actual situation of the RSS in the region researched and a panorama of the theme in Brazil and in São Paulo state. It possible to observe in this work the weaknesses of the laws that serve mostly big generators of waste and the low qualified work force, which diminishes the quality of segregation process and environment problems during the final disposal of the waste.

O estudo analisou a sustentabilidade da estratégia DOTS na visão de coordenadores de Programa de Controle Tuberculose (PCT) em sete municípios do interior do estado de São Paulo, prioritários para o controle da Tuberculose (TB). O quadro teórico está sustentado nas dimensões operacional, organizacional e política da gerência e sua articulação no contexto atual das políticas e serviços de saúde. A partir de uma abordagem quantitativa, de estudo epidemiológico descritivo por meio de levantamento de fontes secundárias, foram analisados os indicadores epidemiológicos do PCT: cura, abandono e óbito de casos novos com baciloscopia de escarro positiva, cobertura de Tratamento Supervisionado (DOT/TS) e de detecção de casos. Também optou-se pela abordagem qualitativa, análise de conteúdo-modalidade temática que utilizou como fonte a entrevista semi-estruturada com coordenadores de PCT. A Unidade Temática central foi a sustentabilidade da estratégia DOTS como um desafio para coordenadores de PCT, contendo dois sub-temas: A organização da estratégia DOTS diante da necessidade de captar/otimizar recursos e definir estratégias e A operacionalização das ações de controle da TB: raciocínio estratégico e negociação como ferramentas gerenciais. Os resultados quantitativos mostraram um coeficiente angular positivo para cura, mas a maioria não atingiu a meta de 85%; declínio no percentual de abandono, ainda aquém do esperado. A cobertura de DOT/TS apresentou aumento em todos os municípios, contudo, apenas um atingiu 95%. Nenhum município atingiu a meta de 70% de detecção de casos. Os temas que emergiram neste estudo apontaram nós críticos na captação e manutenção de incentivos financeiros; recursos humanos (RH) insuficientes e despreparados; rotatividade de pessoal; desconhecimento do destino da verba da TB e falta de autonomia para gerenciar os recursos; dificuldades de comunicação e integração com gestores; falta de priorização da doença na agenda política; priorização de agravos com repercussão política e necessidade de parcerias. Sobre a operacionalização do DOTS, o estudo apontou a cooperação de pessoas de fora do serviço como ferramenta gerencial estratégica, quando estimula a coresponsabilização da família e da comunidade como cuidadores ou multiplicadores. A avaliação, pautada em indicadores epidemiológicos, é utilizada prioritariamente para alcançar recursos, ao invés de subsidiar o planejamento. A gerência do PCT parece ser uma gerência burocrática, fundamentada no planejamento normativo. Acredita-se que a efetividade das ações gerenciais para sustentar a estratégia DOTS dependa de atores com conhecimento técnico, habilidades políticas e organizacionais, além de raciocínio estratégico para estimular e envolver todos os atores que lidam com a TB. Habilidades estas que, dificilmente são adquiridas na formação profissional. Conclui-se que os coordenadores trabalham em meio a pressões de cima e de baixo, ocupando dupla posição de transmissão, no plano hierárquico e das relações. Neste sentido, a sustentabilidade da estratégia DOTS representa desafios importantes para estes atores que utilizam poucos instrumentos gerenciais, têm pouca autonomia no processo decisório, lidam com recursos escassos e, muitas vezes, sem preparo para esta função, reforçando a necessidade de investimento na formação e capacitação contínua tanto para estes atores como para aqueles que lidam com a TB / This study analyzed the sustainability of the DOTS (Directly Observed Treatment Strategy). It shows the point of view of the TCP (Tubercolosis Control Program) coordinators of seven priority municipalities in the Sao Paulo State. The theorical framework is based on operational, organizational and political levels of the management and on its articulation in the current context of health policies and services. We carried out an epidemiological-descriptive study, using secondary sources, and through a quantitative approach. The following epidemiological TCP indicators were analyzed: cure, abandonment and death of new cases with positive sputum bacilloscopy, Supervised Treatment (DOTS/ST) and case detection coverage. We also chose to apply a qualitative approach, through a semi-structured interview with TCP Coordinators, and with the application of content analysis in the thematic modality. The main thematic unity is the sustainability of the DOTS strategy as a challenge to the TBP coordinators. It contains two sub-themes: The organization of the DOTS strategy faced with the need for resource captation/optimization and for clearly outlined strategies, and The operationalization of TB control actions: strategic thinking and the negociation as key management skills. Quantititive results show a positive angular coefficient for cure. Nonetheless, the majority did not achieve the 85% goal and the decline in the abandonment rate is still lower than expected. The ST coverage rose in all municipalities. However, only one municipality achieved coverage of 95%. None of the municipalities achieved the goal of 70% case detection rate. The themes analyzed in this study pointed to critical knots in the collection and maintenance of financial incentives; insuficient and unprepared Human Resources (HR); staff turnover; lack of knowledge concerning the destination of the TB funds, as well as lack of autonomy to manage resources; difficulties in the communication and in the integration with other managers; failure in making the disease a priority on the political agenda; priorization of aggravations with political repercussion and the need for partnerships. Concerning the DOTS operationalization, the study pointed to the cooperation of people outside the job as an important strategic management tool. It encourages family and community to take co-responsibility as caretakers and multipliers. The evaluation, which is based on epidemiological indicators, is especially used to achieve resources, instead of subsidizing the planning process. TCP management seems to be exceedingly bureaucratic and based on normative planning. We believe that the effectiveness of management actions to support the DOTS strategy needs characters with technical knowledge, political and organizational skills and strategic thinking. These skilss are important in order to encourage and get involved all those who deal with TB. These skills are hardly achieved in the professional training. We conclude that the coordinators work under pressure from the top and from the bottom of the hierarchy, and occupy a double transmission position: in the hierarchic level and in the relationship level. Thus, the sustainability of the DOTS strategy represents an important challenge for these characters, who use few management tools, have little authonomy in the decisionmaking process, have to work with scarce resources and are usually unprepared for the position they occupy. These findings highlight the need for more investments in continuing education and capacitation not only for coordinators but also for all those who have to deal with TB

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Objectives: Women with substance use disorders often experience unique challenges to obtaining contraception and adhering to user-dependent methods. As a result, this at-risk population of women tends to have higher than average rates of unintended pregnancy. The objective of this study was to describe contraceptive use, pregnancy intentions, and adequacy of access to reproductive healthcare among women receiving opioid agonist therapy in northeast Tennessee. Methods: A cross-sectional survey was piloted among female patients aged 18 to 55 years from two opioid agonist therapy clinics. Descriptive analyses were conducted using logistic regression to evaluate the statistical significance of bivariate associations. Results: Of 91 participants, 84% reported having health insurance, with 70% perceiving having adequate access to health care. More than half had a history of unwanted pregnancy (53%), among whom few (23.1%) reported the consistent use of contraception at time of conception. Although most desired to avoid pregnancy (90%), only 59% of women reported the current use of regular contraception. Most of those not using regular contraception believed that they were not at risk for pregnancy (54.3%). Conclusions: Although most participants reported adequate access to health care and a desire to avoid pregnancy, few reported the consistent use of regular contraception. Furthermore, misperceptions regarding pregnancy risk were common among participants. Research is needed to identify barriers to contraceptive acceptance and causes of pregnancy risk misperceptions in this population of women at increased risk of unintended pregnancy.

Introduction: Long–standing disparities in colorectal cancer (CRC) outcomes and survival between Whites and Blacks have been observed. A person–centered approach using latent class analysis (LCA) is a novel methodology to assess and address CRC health disparities. LCA can overcome statistical challenges from subgroup analyses that would normally impede variable–centered analyses like regression. Aim was to identify risk profiles and differences in malignant CRC survivorship outcomes. Methods: We conducted an LCA on the Surveillance, Epidemiology, and End Results data from 1975 to 2016 for adults ≥18 (N = 525,245). Sociodemographics used were age, sex/gender, marital status, race, and ethnicity (Hispanic/Latinos) and stage at diagnosis. To select the best fitting model, we employed a comparative approach comparing sample-size adjusted BIC and entropy; which indicates a good separation of classes. Results: A four–class solution with an entropy of 0.72 was identified as: lowest survivorship, medium-low, medium-high, and highest survivorship. The lowest survivorship class (26% of sample) with a mean survival rate of 53 months had the highest conditional probabilities of being 76–85 years–old at diagnosis, female, widowed, and non-Hispanic White, with a high likelihood with localized staging. The highest survivorship class (53% of sample) with a mean survival rate of 92 months had the highest likelihood of being married, male with localized staging, and a high likelihood of being non-Hispanic White. Conclusion: The use of a person–centered measure with population-based cancer registries data can help better detect cancer risk subgroups that may otherwise be overlooked.

Background: Social media (Facebook, WhatsApp, Instagram, Twitter) as communication channels have great potential to deliver Human papillomavirus self‐test (HPVST) intervention to medically underserved women (MUW) such as women of low income. However, little is known about MUW’s willingness to participate in HPVST intervention delivered through social media. We evaluated factors that contribute to MUW’s intention to participate in the social media‐related intervention for HPVST. Methods: A 21‐item survey was administered among women receiving food from a local food pantry in a U.S. southern state. Independent variables were social media usage facilitators (including confidentiality, social support, cost, and convenience), and barriers (including misinformation, time‐consuming, inefficient, and privacy concerns). Dependent variables included the likelihood of participating in social‐driven intervention for HPVST. Both variables were measured on a 5‐point scale. We used multinomial logistic regression to analyze the data. Results: A total of 254 women (mean age 48.9 ± 10.7 years) comprising Whites (40%), Hispanics (29%), Blacks (27%), and Other (4%) participated in the study. We found that over 44% of the women were overdue for their pap smears for the past three years, 12% had never had a pap smear, and 34% were not sure if they had had a pap smear. Over 82% reported frequent social media (e.g., Facebook) usage, and 52% reported willingness to participate in social media‐driven intervention for HPVST. Women who reported that social media provide privacy (Adjusted Odds Ratio (AOR) = 6.23, 95% CI: 3.56, 10.92), provide social support (AOR = 7.18, 95% CI: 4.03, 12.80), are less costly (AOR = 6.71, 95% CI: 3.80, 11.85), and are convenient (AOR = 6.17, 95% CI: 3.49, 10.92) had significantly increased odds of participating in social media intervention for HPVST. Conclusions: The findings underscore that the majority of the MUW are overdue for cervical cancer screening, regularly use social media, and are willing to participate in social media‐driven intervention. Social media could be used to promote HPV self‐testing among MUW.