Made available in DSpace on 2015-04-22T22:06:47Z (GMT). No. of bitstreams: 1 luciana pires.pdf: 2003195 bytes, checksum: 33993ef44c4bf520a768616be73034f1 (MD5) Previous issue date: 2008-02-29 / This paper results from the data analysis of the oral health epidemiological survey of the Yanomami indigenous community based on Xitei indigenous area and Ketaa indigenous sub-area. It was followed the SB Brasil 2003 Project and WHO methodology rules. The variable observed were: Decay, Missed and Filled Tooth index (DMF-T); treatment necessity; use and necessity of prosthesis; community periodontal index (CPI); periodontal attachment loss index (PALI). In this study, 823 indigenous of a total of 1220 resident indigenous in this region, being 50.6% of masculine sex and 49.4% of the feminine sex, had been examined. The age of this sample approaches to the total population above of 2 years. The tooth attacked by caries average in the examined population was 0,23 ± 0,60; 0,33± 0,75; 1,43± 1,39 in age bands 12, 15-19 and more than 60 years, respectively. The values found for index DMF-T had been very low, near to zero in all the age bands except for people above of 50 years (DMF-T = 1.21). It was observed that 82.3% of the total of the sample were presented free of caries. Differences between men and women in the prevalence of caries had gotten no statistical significance. The results found for the periodontal condition had demonstrated a bigger prevalence of bleed, calculus and 4-5 mm pockets when compared to the data in the same age bands of the Brazilian population and North Brazilian Region population. Rare dental losses had been registered between the investigated population and no patient was identified who needed prótese removable or total prosthesis. The condition of very low prevalence of caries found between the Yanomami of Xitei makes to assume that the distance of the places of food commercialization allies to the strategy of systematization in the relations of exchange between indigenous and non-indigenous in the region, that do not include strange item to the traditional feeding, probably have influenced the maintenance of a good condition of oral health / Esse trabalho é o resultado da análise dos dados produzidos a partir de um levantamento epidemiológico em saúde bucal realizado em comunidades indígenas Yanomami na região do Pólo- Base Xitei e sub-pólo Ketaa. Foram seguidos os critérios preconizados pelo Projeto SB Brasil 2003 e pela OMS. As variáveis observadas foram: Índice de Dentes Cariados, Perdidos e Obturados (CPO-D e ceo-d); Necessidade de Tratamento; Uso e Necessidade de Prótese; Índice Comunitário Periodontal (CPI) e Perda de Inserção Periodontal (PIP). Nesse estudo, foram examinados 823 indígenas de um total de 1220 indígenas residentes nessa região, sendo 50,6% do sexo masculino e 49,4% do sexo feminino. A composição etária dessa amostra de conveniência se aproxima a da população total acima de 2 anos. A média de dentes atacados pela cárie, na população examinada foi 0,23 ± 0,60; 0,33± 0,75; 1,43± 1,39 nas faixas etárias 12, 15-19 e mais de 60 anos, respectivamente. Os valores encontrados para o índice CPO-D foram muito baixos, próximos de zero em todas as faixas-etárias exceto para pessoas acima de 50 anos (CPO-D = 1,21). Observou-se que 82,3% do total da amostra apresentou-se livre de cárie. Diferenças entre homens e mulheres na prevalência de cárie não obtiveram significância estatística. Os resultados encontrados para a condição periodontal demonstraram uma prevalência maior de sangramento, cálculo e bolsas de 4-5 mm quando comparados aos dados nas mesmas faixas-etárias da população brasileira e da Região Norte. Raras perdas dentárias foram registradas entre a população investigada e não foi identificado nenhum paciente que necessitasse de prótese removível ou total. A condição de prevalência de cárie muito baixa encontrada entre os Yanomami do Pólo-Base Xitei fazem supor que a distância dos locais de comercialização de alimentos aliados a estratégia de sistematização nas relações de troca entre indígenas e não-indígenas na região, que não incluem itens estranhos à alimentação tradicional, provavelmente têm influenciado a manutenção de uma boa condição de saúde bucal.

Introdução - Desde a criação do Sistema Único de Saúde (SUS), muitas mudanças ocorreram nas políticas públicas voltadas aos povos indígenas. A intensa luta dos movimentos indígenas subsidiou a proposta da criação e organização do Subsistema de Atenção à Saúde Indígena em 1999, sendo a Fundação Nacional de Saúde (FUNASA) designada como gestora e executora das ações de saúde indígena no país, no período de 1999 a 2010. Após 2010, a responsabilidade pela saúde indígena foi atribuída a Secretaria Especial de Saúde Indígena (SESAI). Em 2011, a Política Nacional de Saúde Bucal definiu a reorganização do modelo de atenção em saúde bucal para os povos indígenas, propondo-se que seja planejada a partir de um diagnóstico das condições de saúde-doença e subsidiada pela epidemiologia e informações sobre o território indígena, além de acompanhar o impacto das ações por meio de indicadores adequados. Objetivo - Analisar componentes de saúde bucal da Política Nacional de Saúde Indígena com foco na atenção à saúde bucal das comunidades do Xingu, considerando as tendências da cárie dentária entre crianças e jovens e as ações implementadas no período de 2004 a 2013. Método - Pesquisa com abordagem qualiquantitativa, do tipo estudo de caso, com o uso de dados secundários do Distrito Sanitário Especial Indígena Xingu e do Projeto Xingu, da Universidade Federal de São Paulo, a partir dos quais foram gerados indicadores de avaliação. Foi analisada a evolução, nesse período, dos indicadores de cobertura de primeira consulta odontológica programática, tratamento odontológico básico concluído, proporção de exodontia em relação aos procedimentos, média da ação coletiva de escovação dental supervisionada do Baixo, Médio e Leste Xingu. Foram utilizados os índices de experiência de cárie dentária (CPO-D e ceo-d) para as idades de 5 e 12 anos e no grupo etário de 15 a 19 anos, a partir de inquéritos epidemiológicos, realizados em 2007 e 2013, utilizando a padronização preconizada pela Organização Mundial da Saúde (OMS). Para contextualizar os indicadores, foi realizada uma revisão da produção científica sobre saúde bucal dos povos indígenas no Brasil no período de 1999 a 2014, bem como a análise de propostas relacionadas à saúde bucal dos povos indígenas nas cinco Conferências Nacionais de Saúde Indígena (1986 a 2013), na 3ª Conferência Nacional de Saúde Bucal (2004) e nas 13ª e 14ª Conferências Nacionais de Saúde (2007 e 2011). Resultados - Observou-se uma cobertura de primeira consulta odontológica programática maior que 60 por cento em todos os anos analisados, exceto nos anos de 2009 e 2010 com uma cobertura de 44,68 por cento e 53,41 por cento , respectivamente. O indicador de tratamento odontológico básico concluído apresentou um aumento significativo entre os anos 2006 e 2008, de 44,89 para 79,93. A proporção de exodontia em relação aos procedimentos apontou queda de 24,26 em 2004 para 3,84 em 2011. A média da ação coletiva de escovação dental supervisionada foi o indicador com maior variabilidade (de 1,25 a 23,27) entre os anos. Os valores de ceo-d e CPO-D indicaram padrões diferentes de cárie dentária entre os grupos. Foram examinados 368 pacientes em 2007 e 423 em 2013. Aos 5 anos, apresentou-se uma média de ceo-d de 6,43 em 2007 e 5,85 em 2013. Aos 12 anos de idade, média de CPO-D de 2,54 em 2007 e 2,78 em 2013. No grupo etário de 15 a 19 anos, verificou-se uma média de 6,89 em 2007 e 4,65 em 2013, sendo o único grupo com diferença estatisticamente significante (p<0,05). O Índice de Cuidados Odontológicos diminui em todos os grupos entre 2007 e 2013, sendo que aos 5 anos houve uma diminuição de 21,74 por cento para 7,14 por cento , aos 12 anos de 44,09 por cento para 16,35 por cento e de 63,14 por cento para 41,14 por cento no grupo etário de 15 a 19 anos. Conclusão - Este estudo descreve avanços e dificuldades na implementação do programa de saúde bucal no Baixo, Médio e Leste Xingu, com implicações importantes para programas de saúde bucal em áreas indígenas e para a produção de indicadores válidos nos serviços de atenção à saúde indígena. As estratégias de intervenções e parcerias com instituições privadas e públicas identificadas para melhorar a organização dos serviços, a equidade e o acesso da população indígena à saúde bucal, buscaram diminuir os entraves burocráticos e as iniquidades de saúde. A busca da integralidade da atenção através de parcerias com a própria comunidade e com outros setores foi realizada através de estratégias sensíveis às especificidades locais. Os resultados refletem uma tendência de diminuição da cárie nos dentes permanentes, apresentando um declínio da média de CPO-D no grupo etário de 15 a 19 anos e de avanços do programa. A efetiva diferenciação proposta nas conferências nacionais e nas políticas direcionadas aos povos indígenas, não tem se concretizado integralmente. O direito e o acesso à saúde para os povos indígenas são grandes desafios, sendo ainda tratados de forma homogênea e não diferenciada. Sugere-se a incorporação efetiva da realização de levantamentos epidemiológicos de saúde bucal que sejam específicos para cada realidade e que os programas busquem tecnologias, determinantes e especificidades no cotidiano do trabalho, para buscar minimizar os impactos que a sociedade nacional envolvente vem produzindo na saúde indígena. / Introduction - Since the creation of the Unified Health System (SUS), many changes have taken place in public policies related to indigenous population in Brazil. The intense struggle of the indigenous movements supported the proposal of the creation and organization of the Subsystem of the Indigenous Healthcare in 1999. The National Health Foundation (FUNASA) has been designated as manager and executor of actions indigenous health in the country, from 1999 to 2010. After 2010, responsibility for indigenous health was awarded the Indigenous Health Special Secretariat (SESAI). In 2011, the National Oral Health Policy defined the reorganization of the oral health care model for indigenous population, proposing that it be planned from a diagnosis of the health-disease conditions and subsidized by the epidemiology and information on the indigenous territory, monitor the impact of actions through appropriate indicators. Objective Analyze oral health component of the National Indigenous Health Policy focused on attention of oral health of the Xingu Indigenous Park, considering the trends of tooth decay among children and youth and the actions from 2004 to 2013. Method - research with quali-quantitative approach, the case study type, using secondary data from the Xingu Indigenous Special Sanitary District and the Xingu Project at the Federal University of São Paulo, from which evaluation indicators were generated. It was analyzed the evolution of the first programmatic dental consultation coverage indicators, basic dental treatment finished, extraction of proportion in relation to the procedures, average collective action of supervised toothbrushing the Lower, Middle and East Xingu. The indices of dental caries experience (DMFT and dmft) were used for ages 5 and 12 years and those aged 15-19 years from epidemiological surveys conducted in 2007 and 2013, using the standardization recommended by the World Health Organization (WHO). To contextualize the indicators, a review of scientific literature on oral health of indigenous population in Brazil from 1999 to 2014 was carried out and an analysis of proposals related to the oral health of indigenous population in five National Conference of Indigenous Health (1986 to 2013), the 3rd National Conference on Oral Health (2004) and the 13th and 14th National Health Conferences (2007 and 2011). Results - It was observed a cover of first programmatic dental consultation greater than 60 per cent in all years studied, except in 2009 and 2010 with a cover of 44.68 per cent and 53.41 per cent , respectively. The basic dental treatment finished indicator showed a significant increase between 2006 and 2008, from 44.89 to 79.93. The proportion of extraction for procedures faced decrease of 24.26 in 2004 to 3.84 in 2011. The average of collective action of supervised toothbrushing was the indicator with the highest variability (1.25 to 23.27) among years. The values of dmft and DMFT showed different patterns of dental caries between groups. 368 patients were examined in 2007 and 423 in 2013. At 5 years old, performed an average of dmft of 6.43 in 2007 and 5.85 in 2013. At 12 years old, a DMFT average of 2.54 in 2007 and 2.78 in 2013. In the age group 15-19 years of 6.89 in 2007 and 4.65 in 2013, the only group with a statistically significant difference (p < 0.05). The Dental Care index decreased in all groups between 2007 and 2013, and to 5 years old there was a decrease of 21.74 per cent to 7.14 per cent , to 12 years old 44.09 per cent to 16.35 per cent and 63 14 per cent to 41.14 per cent in the age group 15-19 years. Conclusion - This study shows progress and difficulties in the implementation of oral health program in the Lower, Middle and East Xingu, with important implications for oral health programs in indigenous territories and to produce valid indicators in care services for indigenous health. The strategies of interventions and partnerships with private and public institutions identified to improve the organization of services, equity and access of the indigenous population to oral health, sought to reduce the bureaucratic barriers and health inequities. The pursuit of integrality care through partnerships with the community and other sectors was conducted through sensitive strategies to local conditions. The results reflect a trend of reduction in decay in permanent teeth, showing a decline in DMFT average in the age group 15-19 years and the progress of the program. The effective differentiation proposed in national conferences and targeted policies on indigenous population, has not fully realized. The right and access to health care for indigenous population are major challenges still being treated evenly and undifferentiated. It is suggested the effective incorporation to carry out epidemiological surveys of oral health that are specific to each reality and that programs seek technologies, and specific determinants in daily work, to seek to minimize the impacts that nacional society surrounding has produced in indigenous health.

Submitted by Silvana Teresinha Dornelles Studzinski (sstudzinski) on 2017-04-17T12:36:44Z No. of bitstreams: 1 Fabiana Leticia Sbaraini_.pdf: 5124289 bytes, checksum: cb23d2cbad86ea4ffb96495823b0dc32 (MD5) / Made available in DSpace on 2017-04-17T12:36:44Z (GMT). No. of bitstreams: 1 Fabiana Leticia Sbaraini_.pdf: 5124289 bytes, checksum: cb23d2cbad86ea4ffb96495823b0dc32 (MD5) Previous issue date: 2016-09-27 / Nenhuma / O tema de pesquisa desta tese é a saúde indígena, pensada na trama de políticas, práticas e relações interculturais de cuidados em saúde. Neste sentido, a tese está direcionada a analisar as políticas em torno dos processos de Saúde/adoecimento/cuidado voltadas para a população indígena do estado de Roraima. Explorou-se densamente o microuniverso da Casa de Saúde Indígena de Boa Vista- CASAI-RR, com o intuito de expandir o olhar a outros contextos significativos, como o da implementação da Política Nacional de Saúde dos Povos Indígenas e o do próprio curso das políticas indigenistas no Brasil. O objetivo central da pesquisa foi o de analisar a articulação de políticas do ponto de vista da interculturalidade para pensar a saúde indígena, refletindo a partir dos diálogos e tensões entre atores sociais no contexto da CASAI-RR. Optou-se como delineamento da pesquisa a etnografia, porque ela possibilita interações de face a face, fortalecendo as relações interpessoais entre os atores sociais envolvidos na pesquisa. A pesquisa etnográfica era centrada nos gestores das políticas de saúde indígena, profissionais de saúde que atuam na CASAI e indígenas das diversas etnias os quais estavam em fase de tratamento, incluindo neste universo alguns pajés. Ao longo do processo de imersão no microuniverso da CASAI, tornou-se possível construir e reconstruir as práticas e concepções a respeito de saúde e doença, num processo contínuo, abrindo espaço à emergência de novos modelos de atenção à saúde, dando enfoque ao caráter relacional e nas múltiplas vozes que integram o cenário social pesquisado. No que concerne à construção de políticas públicas, estas têm sido permeadas por diálogos, negociações, conflitos, construções históricas e políticas de diferentes grupos socioculturais. Essa característica se acentua na construção da interculturalidade presente na saúde indígena, buscando favorecer espaços de diálogo entre distintas racionalidades e as práticas de saúde, as quais são um tema central na luta dos povos indígenas pela conquista de seus direitos em termos de acessos e serviços com qualidade. Estudos dessa magnitude se tornam essenciais para uma compreensão mais ampla sobre o discurso cultural, igualdade e reconhecimento da pluralidade étnica e cultural das sociedades, em especial, no contexto da atenção diferenciada à saúde indígena. / The research theme of this thesis is the indigenous health, thought in policies, practices and intercultural relations in health care. In that way, the thesis is aimed at analyzing the policies around the processes of health / illness / care aimed at the indigenous population in Roraima. It was deeply explored the microuniverse of Indigenous Health House in Boa Vista, called Casai-RR, to understand other contexts, such as the implementation of National Health Policy of Indigenous Peoples and the course related to this thematic. The objective of the research was to analyze the policy of interculturalism indigenous health, from the dialogues and tensions between social actors in Casai-RR. It was chosen as the study design ethnography, by enabling face to face interactions, strengthening interpersonal relationships between the actors involved. Ethnographic research was focused on managers of indigenous health policies, health professionals working at Casai and indigenous people from different ethnic groups who were undergoing treatment, including some shamans. Throughout the process, it was possible to build and reconstruct practices and conceptions of health and disease, in a continuous process, making room for the emergence of new health care models, with emphasis on character relational and multiple voices that are part of the social scene. As regards the construction of public policies, they have been permeated by dialogue, negotiation, conflict, historical buildings and different socio-cultural groups policies. This characteristic is accentuated in the construction of this interculturalism in indigenous health, which seeks to promote the dialogue between different rationalities and health practices, which by the way, has been a central theme in the struggle of indigenous peoples for the conquest of their rights in terms of access and services with quality.Research like this become essential for broad understanding of the cultural discourse of equality and recognition of ethnic and cultural diversity of societies, especially in the context of differentiated indigenous health care.

The purpose of this study was to identify any barriers or enablers as influences on wound care self-management by Indigenous people. A qualitative, interpretive study sought to investigate how participants perceived their wounds and their general health, and to identify the influences on them accessing wound care services. There is a dearth of information on culturally appropriate practice in wound management for Indigenous Australians. This research project was therefore significant in attempting to bridge the gap in nursing knowledge of Indigenous clients' perceptions of barriers and enablers for seeking wound care services,especially in relation to lower leg ulcers. The lack of culturally sensitive wound management practices potentially impacts on Indigenous clients' behaviours in seeking treatment from their health service providers. Participant observations and semi-structured interviews with the research participants investigated the management of their wounds, and the ways in which their culture influences wound management. The main aim was to understand participants' comprehension of the importance of wound care through reflection. Understanding the enhancing or obstructive influences on wound management practices was expected to provide a foundation for teaching self care of wounds in Indigenous populations and inform health professionals' approach to health education. The data were analysed using thematic analysis, which generated common themes related to the research questions. These themes are: visibility, of the problem,4 perceived versus actual level of knowledge, acceptance of co-morbid health conditions and pre-determined path of ill health. These findings indicated that in one region, participants' perception of poor health was related to visibility of the problem. Participants chose to have their visible wounds managed by Silver Chain Nursing Association, whereas Diabetes and Hypertension and any other non-visible disorders were seen as appropriate to the Aboriginal Medical Service (AMS). Further to this finding, most participants displayed a sense of helplessness and hopelessness when sharing information about their diagnosis of diabetes, believing this was the norm. Many also believed that having a strong family history of a particular disease resulted in the participants also inheriting the disease. During post interview educational sessions many of the Indigenous participants were surprised by the evidence based-research reported to them by the researcher that diabetes is a manageable disease with life style changes. Another issue highlighted was the perceived level of knowledge the participants had about wound care. Reassurance was given by the participants that their level of knowledge about how to manage their wounds was adequate. However, none of the participants were concerned about the length of time that their wound/s had or were being managed, between 3 months and 5 years. This acceptance that although a wound is not getting any worse and not getting any better was the norm is cause for concern, and indicates a low level of health literacy. This theme was 'perceiving an imbalance in perceptions of wound care knowledge with actual knowledge'. The most important recommendation from the study findings is the need to consider health literacy more carefully in the development of health promotion and health education for Indigenous clients with wounds.

It is accepted protocol among Indigenous communities to identify one's link to land. I was born and raised in Brisbane. My birth grandmother is a Goreng Goreng woman, my birth grandfather is a Punthamara man. However, I was adopted by a Koombumberri man and an anglo-celtic mother after being removed at birth under the Queensland government policy of the day. The action of my removal and placement has had profound effects upon my growing and my place within my community today. For the last 15 years I have worked in the health sector. My current position is as a Lecturer within the Department of Nursing, Faculty of Science, University of Southern Queensland, Toowoomba. My areas of expertise are Indigenous Health and Primary Health Care. I have been employed in this capacity since January 2000. Prior to my full time employment as a nursing academic I have primarily been located within three areas of health which have directly impacted upon my current research. I was first positioned within health by undertaking my General Nurse Certificate through hospital-based training commenced in the late 1980s. For me this training meant being immersed within whiteness and specifically the white medical model. This meant learning a set of skills in a large institutionalised health care service with the provision of doctors, nurses, and allied medical staff through a hospital. Within this training there was no Indigenous health curriculum. The lectures provided on 'differing cultures' and health were on Muslim and Hindu beliefs about death. At that point I was painfully aware of the glaring omission of any representation of Indigenous health and of acknowledgment of the current outstanding health differentials between Indigenous and non-Indigenous Australians. I knew that the colonisation process inflicted upon Indigenous Australians was one of devastation. The decline in our health status at the time of colonisation had been felt immediately. Since this time our health has been in decline. While in the 1980s it was now no longer acceptable to shoot us, poison our waterholes, and incarcerate us on missions, we were still experiencing the influence of the colonisation process, which had strong repercussions for our current health status. Our communities were and remain rife with substance abuse, violence, unemployment, and much more. For Indigenous Australians these factors cannot be separated from our initial experience of the colonisation process but are seen as the continuation of it. However, there was no representation of this and I received my first health qualification.

Wide health gaps exist between Canada’s Inuit population and their non-Indigenous counterparts in nearly all categories. Two basic public health protection principles in any community worldwide are access to safe drinking water and sanitary wastewater management. The purpose of this research was to explore the relationships between public health and municipal water and wastewater systems in Coral Harbour, Nunavut. Using a qualitative case study approach, I conducted 37 interviews with residents and key informants and thematically analyzed the data. Findings suggest that crowded households experiencing domestic water shortages may result in negative health consequences. As well, pre and early settlement water customs are influencing current public health risks thereby requiring special consideration by municipal planners. Given these findings, recommendations include increasing domestic water access, strengthening source water monitoring programs, and establishing intergovernmental public health policies that co-benefit water resource management agendas as well as other priority issues in Nunavut.

Introduction: The lifespan of Mi’kmaq First Nations men continues to be eight years less than that of other Canadian men. Therefore, this study examined the intersecting relationships between the social determinants of gender, health practices and other factors on the health of Mi’kmaq boys and men living in Elsipogtog First Nation. Goal: To promote the health of Mi’kmaq men living in Elsipogtog First Nation and to decrease the health disparities among Mi’kmaq men and other Canadian men. Objectives: (a) To explore how Mi’kmaq men construct their masculinities across the lifespan within Mi’kmaq culture; (b) To examine Mi’kmaq men’s perceptions of health and health practices and how their practices of masculinity influence these practices; (c) To explore how the experiences of illness and health influence Mi’kmaq men’s perceptions of their masculinity and the configuration of its practices; (d) To contribute to the scholarship of masculinities, health, culture, race, and inequity; (f) To build research capacity among members of the community of Elsipogtog; and (e) To identify strategies or programs that will support the health of Mi’kmaq men and their ability to care for their own health. Method: A community based participatory action research study based on an Indigenist critical social theoretical approach was used to gather and analyze the data. A research team of four Mi’kmaq people worked with me to analyze the data from an Indigenous perspective. A community advisory committee advised the research team regarding recruitment issues and the findings of the study. Thirty Mi’kmaq men and seven women were interviewed. Findings: The masculinities practices of Mi’kmaq men were: (a) respecting women, (b) fathering their children, (c) providing for their families, (d) caring for the environment, (e) respecting self and others, and (f) respecting sexually diverse family friends and self. During their lifetimes, many participants dealt with multiple losses, addiction, racism, sexual abuse, suicide attempts, and poverty. Their masculinity practices, culture, and spiritual health practices served as resiliency factors that contributed to their health status and practices Conclusions: The masculinity practices of Mi’kmaq men were strengths in their health.

The Sachigo Lake Wilderness Emergency Response Education Initiative represented a partnership between Sachigo Lake First Nation in northern Ontario Canada, and medical professionals and university researchers from outside the community. This study was one component of a larger community-based participatory research program to develop locally relevant first response training to address the isolation from emergency healthcare in Sachigo Lake. The aim of this qualitative study was to complete a formative evaluation to understand how a five-day comprehensive training course implemented in May 2012: (a) met the local needs of Sachigo Lake; and (b) fostered resilience and community capacity. The results of this study describe the unique features of delivering first aid training in a remote context and illustrate the intrapersonal and interpersonal impacts of the program. Health promotion through community based first aid education is a model with potential to improve emergency care in the absence of formal emergency medical services.

Doctor of Philosophy(PhD) / The thesis explores the complexities of primary health care in a setting characterised as being both isolated and remote, and in the process identifies factors critical for developing successful PHC programs in such settings and more broadly. The four questions underpinning the study are 1) is a PHC approach relevant to the chosen small remote Australian community; 2) to what extent was a PHC approach being implemented; 3) what are the barriers and enablers to developing and implementing a PHC approach; and 4) what are the crucial factors for PHC programs in similar communities. The first chapter provides the background to the study, beginning with the range of descriptions of primary health care and the many themes needed to understand how it plays out in a small community. The Menindee community and some of the local health service players are introduced. Chapter Two explores complexity theory and complex adaptive systems and its relevance to organisations and managing change, particularly in complex environments. Chapter Three examines the evolution of primary health care, its philosophy, principles and elements as both a model of health care and of development. Chapter Four addresses social determinants, the life course and the long-term effects of inequity, before considering current factors that impact on health and health services. These include the beginning and end of the life course and those in the ‘middle’ where the effects of the obesity and diabetes epidemics are being played out at a younger age. The chapter concludes by noting common themes across the three chapters. Chapter Five describes the research design and methods. A case study using mixed methods was chosen and the theoretical framework provides an exploration of complexity and transdisciplinarity. What changed during the course of the study, questions of scope and its limitations are stated. Chapter Six is a quantitative analysis of the study community, which examines community demographics, the life course, a summary of adult and child health, and service use. These enable an understanding of the community profile, its uniqueness and its similarity to other communities that might benefit from a comprehensive PHC approach. The questions to be explored in the qualitative phase are identified. Chapter Seven is a qualitative study of the community in the midst of change. An individual interview guide approach was used and representatives from the community, local and regional health service providers were interviewed. Chapter Eight provides a synthesis of the two studies as they address themes from the complexity, PHC and social inequity literature. Five themes had particular significance to the study community: social determinants and Indigenous health; community size, resilience and change; chronic disease programs and prevention; vulnerable groups; and a complex adaptive systems perspective. The second section answers the four study questions. The thesis concludes with a discussion of PHC rhetoric and reality, the relevance of the study and its limitations, and issues requiring further research when considering primary health care in smaller communities.

No description available.