Hintergrund: Die demographischen Veränderungen der Gesamtbevölkerung in Deutschland beeinflussen die Entwicklung der Arztzahlen in Deutschland seit Jahren negativ. Die aktuelle Versorgungslandschaft in Deutschland zeichnet sich durch eine sinkende Anzahl ärztlicher und nicht-ärztlicher Leistungserbringer aus, die einer wachsenden Anzahl von Menschen gegenüberstehen, die Versorgungsleistungen beanspruchen. Der Sicherstellungsauftrag einer flächendeckenden ambulanten Versorgung ist aufgrund der Abnahme der Anzahl an Hausarztpraxen v.a. in ländlich geprägten Gebieten gefährdet. Diverse Lösungsansätze wurden und werden aktuell umfangreich diskutiert. Ein vielversprechender Ansatz, den beschriebenen Herausforderungen zu begegnen, sind integrierte, telemedizinische Versorgungskonzepte. Fragestellungen: Die Zielstellung der Dissertation ist die zusammenfassende Darstellung des Einflusses einer im häuslichen Bereich genutzten Telemonitoring-Anwendung (TMA) auf verschiedene Outcomes in der gesamten Studienkohorte multimorbider Patienten ab 65 Jahren sowie in definierten Risikogruppen und soziodemographischen Subgruppen. Um die formulierte Zielstellung zu erreichen, wurden Gründe exploriert, die zur Nichtakzeptanz und Nichtnutzung der TMA durch die Studienteilnehmer geführt haben und mit welchen Schwierigkeiten die Nutzung verbunden war. Zudem wurde untersucht, wie adhärent die Studienpatienten im Umgang mit der TMA waren, inwieweit die patientenseitige Adhärenz und die gesundheitsbezogene Lebensqualität miteinander assoziiert waren und inwieweit sich die Lebensqualität der Studienteilnehmer während der Nutzung der TMA verändert hat. Material und Methoden: In die Gesamtstudie wurden Patienten eingeschlossen, wenn sie u.a. 65 Jahre und älter waren und mindestens zwei chronische Erkrankungen aufwiesen (Multimorbiditätskriterium). Nach Studieneinschluss wurden die Studienteilnehmer durch das Deutsche Rote Kreuz (DRK) mit der TMA ausgestattet, die von Philips Medical Systems GmbH bereitgestellt wurde. Die TMA bestand aus einem Blutdruckmessgerät mit integrierter Herzfrequenzmessung, einem Sauerstoffsättigungs-Messgerät, einer Personenwaage sowie aus einem Tablet mit der Motiva-Software. Nach Einführung in die Anwendung durch einen Techniker des DRK wurden die Studienteilnehmer in den interprofessionellen und interdisziplinären Versorgungsprozess eingebunden und begannen, ihre Vitalwerte über die telemedizinischen Geräte gemäß einem hausärztlich empfohlenen Regime zu messen sowie Fragebögen zum Gesundheitszustand zu beantworten. Die Vitaldaten wurden via Bluetooth von den Messgeräten an das Tablet und anschließend an das Care Coordination Center des DRK transferiert, die die Werte kontinuierlich auf Interventionsbedarf überprüften. Im Falle einer Überschreitung der vorab hausärztlich definierten krankheitsspezifischen Vitalwertgrenzen erfolgte eine zügige Intervention. Die erste Teilstudie wurde in einem gemischt-methodischen Ansatz durchgeführt und fokussierte die Motive für die risiko- und subgruppenspezifische Nichtakzeptanz und die Nichtteilnahme potentiell geeigneter Patienten. Die zweite Teilstudie nutzte eine quantitative Methodik und thematisierte die gruppenunspezifische Nichtakzeptanz, die patientenseitige Adhärenz sowie Herausforderungen im Umgang mit der TMA. In der dritten Teilstudie mit ebenfalls quantitativer Methodik wurden Unterschiede und Veränderungen in der gesundheitsbezogenen Lebensqualität zwischen den Studienpatienten mit und ohne Depression und/oder MCI im Verlauf der TMA-Nutzung eruiert und Assoziationen zwischen der patientenseitigen Adhärenz und Änderungen der gesundheitsbezogenen Lebensqualität untersucht. Ergebnisse: Drei Hausärzte in Dresden sowie sechs Hausärzte in Leipzig bewerteten insgesamt 257 ältere, multimorbide Patienten als zur Studienteilnahme potentiell geeignet, wovon 177 Patienten für die Studie rekrutiert wurden. Achtzig Patienten (31,1%) lehnten eine Teilnahme an der Studie ab (Nichtteilnehmer) und 61 Studienteilnehmer (34,5%) schieden im Verlauf der Studie aus (Studienabbrecher). Die Studienpatienten waren durchschnittlich 79,6 Jahre alt (SD=5,6). Studienabbrecher (81,3 Jahre (SD=5,8)) und Nichtteilnehmer (82,2 Jahre (SD=5,7)) waren signifikant älter als die aktiv an der Studie teilnehmenden Patienten (78,8 Jahre (SD=5,3)). Dominierende Abbruchgründe bei den Studienteilnehmern waren der fehlende empfundene Zusatznutzen bzw. die fehlende inhaltliche Abwechslung auf dem Tablet, kein Interesse bzw. Bedarf an einer telemedizinischen Betreuung sowie die zu hohe zeitliche Beanspruchung durch die Studienteilnahme. Alleinlebende (ledige und verwitwete) Studienpatienten gaben signifikant mehr Schwierigkeiten in der Handhabung des Tablets und der Motiva-Software an als verheiratete bzw. in Lebensgemeinschaft lebende Studienpatienten. Diese Probleme berichteten ebenso weibliche Studienpatienten, Studienteilnehmer ab 75 Jahren und jene mit einem niedrigen Schulbildungsgrad. Nichtteilnehmer nahmen aus Angst vor zu hoher zeitlicher Beanspruchung, aufgrund des fehlenden Interesses bzw. Bedarfes an einer telemedizinischen Betreuung sowie aus Angst vor Überforderung durch die eingesetzte Technologie nicht an der Studie teil. Studienpatienten hatten Schwierigkeiten im Umgang mit den Tablets (z.B. zu kleiner An-/Aus-Knopf) und der Software (z.B. persistierender Flugmodus, fehlende Dialogoption, zu kleine Symbol- und Schriftgrößen) sowie durch eine zu langsame oder instabile Internetverbindung. Im Hinblick auf das Adhärenzverhalten der Studienteilnehmer zeigte sich, dass jene, die Blutdruck und Herzfrequenz einmal wöchentlich messen sollten, dies seltener durchführten. Studienteilnehmer, die Blutdruck und Herzfrequenz mehr als einmal wöchentlich oder täglich messen sollten, maßen häufiger, als hausärztlich empfohlen. Die Adhärenz der Studienteilnehmer bezüglich ihrer Vitaldatenmessungen über die TMA war signifikant mit einer höheren psychischen Lebensqualität assoziiert, während die körperliche Lebensqualität unverändert blieb. In der Gesamtschau aller Studienpatienten verbesserte sich die psychische Lebensqualität im Gegensatz zur körperlichen Lebensqualität im Verlauf der TMA-Nutzung signifikant. Studienpatienten ohne psychische Beeinträchtigung und mit MCI wiesen im Verlauf signifikant höhere Werte für die psychische Lebensqualität auf als Patienten mit Depression und MCI. Zudem wiesen Studienpatienten mit Depression zum Nutzungsende eine signifikant niedrigere psychische Lebensqualität auf als jene mit MCI sowie Studienteilnehmer ohne psychische Beeinträchtigung. Studienpatienten mit Depression sowie mit Depression und MCI hatten eine über den Verlauf signifikant niedrigere körperliche Lebensqualität als Studienpatienten ohne psychische Beeinträchtigung. Schlussfolgerungen: Ein entscheidender Indikator und Treiber für eine effektive, nachhaltige und erfolgreiche Implementierung telemedizinischer Anwendungen sowie die Voraussetzung zur Ausschöpfung deren Potentials bleibt stets die Akzeptanz seitens der Endanwender. Die hier vorliegenden Ergebnisse zeigten, dass zu entwickelnde TMA auf die bestehende Krankheit der nutzenden Patienten zugeschnitten und entsprechend ihrer alters- bzw. krankheitsbedingten Funktionseinschränkungen gestaltet werden müssen, um eine gute Handhabbarkeit telemedizinischer Anwendungen zu erreichen. Nur dann werden Patienten Telemedizin in ihrem Alltag akzeptieren und dies als Gewinn für die eigene Gesundheitsversorgung begreifen, was sich letztlich an einer höheren gesundheitsbezogenen körperlichen und psychischen Lebensqualität abbilden lässt. Von wesentlicher Bedeutung ist der Einbezug vulnerabler Patientengruppen, z.B. mit Depression und MCI, in telemedizinische Entwicklungs- und Versorgungsprozesse, um deren Bedarfe rechtzeitig festzustellen, ihren Gesundheitszustand zu stabilisieren bzw. Verschlechterungen zu reduzieren. Die vorliegenden Befunde konnten einerseits zeigen, dass eine häuslich genutzte TMA ältere, multimorbide Menschen und ihre Versorger dabei unterstützen kann, die hausärztliche Versorgung sowie die Vernetzung von Leistungserbringern durch Telemonitoring nutzbringend zu begleiten. Andererseits können anwendungsspezifische Technikprobleme zur Verunsicherung des Patienten hinsichtlich des eigenen Gesundheitszustandes führen und die Handhabbarkeit der TMA beeinträchtigen. Die Reduzierung bzw. Beseitigung dieser Probleme ist für die Entwicklung einer bedarfsgerechten TMA für Patienten unumgänglich.:Abbildungsverzeichnis IV Abkürzungsverzeichnis V 1 Einführung in die Thematik 1 1.1 Entwicklung der demographischen und allgemeinärztlichen Struktur in Deutschland 1 1.2 Ursprung und Begriffsdefinitionen von Telemedizin 4 1.3 Zielsetzung telemedizinischer Methoden 5 1.4 Gesetzliche Grundlagen für die Digitalisierung im deutschen Gesundheitswesen 6 1.4.1 Die ärztliche Fernbehandlung von Patienten 9 1.4.2 Inanspruchnahme der Videosprechstunde in Deutschland 10 1.5 Anforderungen an telemedizinische Methoden 11 1.6 Chancen für eine Versorgungsoptimierung durch telemedizinische Maßnahmen 12 1.7 Herausforderungen für die Implementierung und Anwendung von Telemedizin 14 1.8 Stand telemedizinischer Versorgungsforschung für hochinzidente und hochprävalente chronische körperliche und psychische Erkrankungen 17 1.9 Wissenschaftlicher Rahmen der eigenen Arbeiten 21 1.9.1 Rahmen der vorliegenden Dissertation 21 1.9.2 Zielstellung der vorliegenden Dissertation 23 1.10 Wesentliche selbst erarbeitete wissenschaftliche Ergebnisse 23 2 Übersicht der Manuskripte 26 2.1 Motive für die Nichtakzeptanz und Nichtnutzung einer Telemonitoring-Anwendung im häuslichen Umfeld durch multimorbide Patienten über 65 Jahre 27 2.2 Adherence and acceptance of a home-based telemonitoring application used by multi-morbid patients aged 65 and older 41 2.3 Health-related quality of life in elderly, multimorbid individuals with and without depression and/or mild cognitive impairment using a telemonitoring application 57 3 Diskussion und Fazit 75 3.1 Diskussion der Ergebnisse 76 3.1.1 Patientenseitige Adhärenz und Akzeptanz der TMA 76 3.1.2 Berücksichtigung psychisch beeinträchtigter Menschen in telemedizinischen Vorhaben 78 3.1.3 Professionelle patientenorientierte telemedizinische Versorgung 80 3.1.4 Digitale Gesundheitskompetenz 82 3.1.5 Flächendeckende Digitalisierung des Gesundheitswesens 84 3.2 Stärken, Limitationen und Methodenkritik 85 3.3 Ableitung von weiterem Forschungsbedarf 86 3.4 Praktische Implikationen 88 3.5 Fazit 89 4 Zusammenfassung 91 5 Summary 94 6 Literaturverzeichnis 97 Darstellung des Eigenanteils i Weitere aus der Dissertation hervorgegangene Veröffentlichungen ii Danksagung iii Anlage 1 Erklärungen zur Eröffnung des Promotionsverfahrens iv Anlage 2 Erklärung über die Einhaltung der aktuellen gesetzlichen Vorgaben im Rahmen der Dissertation v Anlage 3 a. Bescheid der Ethikkommission der Technischen Universität Dresden vi b. Testat für die Erfüllung der Hinweise aus dem Bescheid vom 04.01.2016 der Ethikkommission der Technischen Universität Dresden ix

No / Measuring the quality of care for people using neuro-rehabilitation services is a complex area requiring reliable methods that account for variable communication abilities/cognitive functioning. Dementia Care Mapping (DCM) is an observational method widely used in dementia care to improve person-centred care, which may be usefully applied to neuro-rehabilitation settings. Evaluation is vital to determine the tool's acceptability in this setting. To explore the views of staff/patients regarding whether the use of DCM is acceptable in a neuro-rehabilitation setting. METHOD: DCM was conducted on an acute neuro-rehabilitation ward. Q-methodology, a technique for extracting subjective opinions, was used with 23 staff and 10 patients on the ward to evaluate the acceptability of DCM. RESULTS: Factor analysis was performed separately for staff and patient Q-sorts. Each found a "consensus" factor where all participants indicated positive acceptability for the use of DCM. Further exploratory factors indicated that some staff/patients had additional views/concerns that were not captured by the first consensus factor. CONCLUSIONS: The results from this preliminary study are promising and indicate that DCM is potentially an acceptable tool to use in acute neuro-rehabilitation. Further research is needed to explore the acceptability of this tool more widely across neuro-rehabilitation settings. IMPLICATIONS FOR REHABILITATION: Person-centred care is widely acknowledged as being important in all care settings, including neurorehabilitation. Dementia Care Mapping was deemed to be an acceptable approach for improving the quality of person-centred care on the basis of the views of staff and patients in a neurorehabilitation ward. Dementia Care Mapping, with adaptations for neurorehabilitation settings, successfully provides an acceptable framework for measuring and improving the quality of person-centred care in this setting.

Submitted by Angela Maria de Oliveira (amolivei@uepg.br) on 2018-11-30T15:35:07Z No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) Vera Lucia.pdf: 1869711 bytes, checksum: 2d479947d8ac00d7251c231ea52c9c12 (MD5) / Made available in DSpace on 2018-11-30T15:35:07Z (GMT). No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) Vera Lucia.pdf: 1869711 bytes, checksum: 2d479947d8ac00d7251c231ea52c9c12 (MD5) Previous issue date: 2018-07-31 / Introdução: O atendimento odontológico do bebê apresenta características peculiares e requer tecnologias apropriadas. Objetivo: Validar um dispositivo inovador, em formato de avental, criado para acomodar o bebê durante as consultas, quanto à aceitação por parte dos pacientes e avaliar a ansiedade materna frente as diferentes tecnologias utilizadas. Método: Foi delineado ensaio clínico, autocontrolado e cego, a partir de modelo experimental cruzado com períodos de wash out. O dispositivo teste foi comparado a dois controles: Macri e o sistema joelho a joelho. Inventário de Ansiedade de Beck aplicado avaliou a ansiedade das mães antes e após os atendimentos com cada método proposto. Parâmetros de pressão arterial e batimentos cardíacos maternos foram obtidos nos dois momentos. O comportamento dos bebês foi aferido pela escala de Frankl. Resultado: A população alvo foram 66 pares de mães/bebês, entre zero e 24 meses, usuários da Atenção Primária à Saúde. O comportamento dos bebês durante as consultas foi predominantemente positivo e similar para os três métodos testados, com vantagem para dispositivo Avental. Este mostrou-se similar à Macri quanto aos níveis de ansiedade materna com maior redução da Pressão Arterial Diastólica e dos batimentos cardíacos das mães. E apresentou melhores resultados quanto à redução da ansiedade materna e dos batimentos cardíacos por minuto quando comparado com o sistema joelho a joelho. Conclusão: O dispositivo Avental mostrou-se adequado ao atendimento odontológico dos bebês, com resultados similares ou melhores do que os métodos classicamente utilizados. Estudos futuros são necessários para avaliar suas qualidades do ponto de vista do profissional. / Introduction: The dental care of the baby presents peculiar characteristics and requires appropriate technologies. Objective: Validate an innovative, apron-shaped device designed to accommodate the baby during consultations, patient acceptance, and maternal anxiety about different technologies used.. Method: A clinical, selfcontrolled and blind trial was drawn from an experimental cross-over model with washout periods. The test device was compared to two controls: Macri and the knee to knee system. Beck's Anxiety Inventory applied assessed the anxiety of the mothers before and after the visits with each proposed method. Parameters of blood pressure and maternal heart rate were obtained at both moments. The behavior of the babies was measured by the Frankl scale. Outcome: The target population was 66 pairs of mothers / infants, between zero and 24 months, users of Primary Health Care. The behavior of the babies during the consultations was predominantly positive and similar for the three methods tested, with advantage to the Apron device. This was similar to Macri in terms of maternal anxiety levels with a greater reduction in diastolic blood pressure and in mothers' heart rate. And it showed better results in reducing maternal anxiety and heart rate per minute compared to the knee-to-knee system. Conclusion: The Apron device was adequate for the dental care of the babies, with similar or better results than the classically used methods. Future studies are needed to assess their qualities from the professional's point of view. Introduction: The dental care of the baby presents peculiar characteristics and requires appropriate technologies. Objective: Validate an innovative, apron-shaped device designed to accommodate the baby during consultations, patient acceptance, and maternal anxiety about different technologies used.. Method: A clinical, selfcontrolled and blind trial was drawn from an experimental cross-over model with washout periods. The test device was compared to two controls: Macri and the knee to knee system. Beck's Anxiety Inventory applied assessed the anxiety of the mothers before and after the visits with each proposed method. Parameters of blood pressure and maternal heart rate were obtained at both moments. The behavior of the babies was measured by the Frankl scale. Outcome: The target population was 66 pairs of mothers / infants, between zero and 24 months, users of Primary Health Care. The behavior of the babies during the consultations was predominantly positive and similar for the three methods tested, with advantage to the Apron device. This was similar to Macri in terms of maternal anxiety levels with a greater reduction in diastolic blood pressure and in mothers' heart rate. And it showed better results in reducing maternal anxiety and heart rate per minute compared to the knee-to-knee system. Conclusion: The Apron device was adequate for the dental care of the babies, with similar or better results than the classically used methods. Future studies are needed to assess their qualities from the professional's point of view.

As Unidades de Atenção Primária à Saúde (APS) devem ser a principal porta de entrada para o Sistema Único de Saúde (SUS). O objetivo deste estudo foi analisar acesso dos usuários do SUS às unidades de APS a partir de três dimensões: disponibilidade, acessibilidade e aceitabilidade. Trata-se de um estudo de caso com múltiplas abordagens realizado na Região de Saúde de Barretos, São Paulo. A investigação foi pautada em três aspectos que influenciam o acesso: fatores do sistema de saúde, percepção dos gestores e dos usuários. As fontes de evidências utilizadas foram dados secundários, análise espacial das unidades de APS com auxílio de Sistema de Informação Geográfica (GIS), entrevista com gestores da pesquisa Política, Planejamento e Gestão das Regiões e Redes de Atenção à Saúde no Brasil e entrevista com usuários do Programa Nacional de Melhoria de Acesso e da Qualidade da Atenção Básica. Os principais achados na dimensão da disponibilidade foram que o número da unidade de APS está de acordo com o recomendado pelo Ministério da Saúde. De acordo com os gestores nas unidades, há falta de integração entre os serviços e os médicos, que estão centrados nos principais centros urbanos da região. Para os usuários, o tempo de espera está dentro das expectativas. Na acessibilidade, a distribuição geográfica das unidades está adequada na maior parte dos municípios, onde os usuários realizam o trajeto em até 10 minutos e consideram como sendo fácil ou muito fácil o acesso, mas a maioria dos gestores desconhecem critérios de distribuição geográfica dos recursos. Na aceitabilidade, grande parte dos usuários aceita o cuidado recebido pelos profissionais de saúde das unidades de APS. O acesso às unidades de APS na região de Barretos revelou resultados positivos, porém a maior parte não possui ocupação profissional. Nos achados, fica evidenciada a necessidade dos gestores públicos aprimorarem a gestão em alguns aspectos como introdução de sistema de informação para agendamento de consultas, ampliação do horário de atendimento, utilização de SIG, pois permite a identificação de áreas mais vulneráveis e aquelas que necessitam de investimentos - e a melhoria na comunicação para que a população entenda o papel das unidades de APS para a prevenção e promoção à saúde, as quais possam se efetivar como coordenadoras do cuidado das Redes de Atenção à Saúde (RAS). A APS fortalecida permite que o sistema se organize nos três níveis da atenção, obtenha melhor desempenho no planejamento das ações, otimize os recursos e contribua para a melhoria das condições de vida da população na região / The Units of Primary Health Care (PHC) must be the main gateway to the Unified Health System (SUS). This study aims to analyze the access from users to PHC through three dimensions: availability, accessibility and acceptability. This is a case study with multiple approaches which took place in the region of Barretos, São Paulo. The research was focused considering three aspects that can influence the access: health systems factors, the perception of health professionals and users. The sources of evidence used were secondary data, spatial analyses of the Primary Care Center (PCC) using the Geographic Information System (GIS), interviews with the managers from the research Regions and Health Care Network and with users of the National Program to Improve Access and Quality of Primary Care . The main findings in the dimension of availability were that the number of units of PCC is according to the recommendation from the Ministry of Health. According to the units managers, there is a lack of integration between the services and the phisicians that are located in the main urban areas. The waiting time for the users, for scheduling appointments, is according to their expectation. Concerning the accessibility, the geographic location of the units are adequate for users in most counties. Users take about ten minutes to arrive to the units. They consider the access to it to be easy or very easy, but managers dont know the geographical location criteria for the resources. Regarding acceptability most users accept the Health Care Services, in the PHC. The access to the units in Barretos region had positive results, therefore most of the users dont have a professional occupation. It was evident in the findings the need for public managers to improve some management aspects, like to implement a new information system for scheduling appointments, extension of operation hours to the users, the utilization of a GIS, which can identify the more vulnerable areas, the ones that needs financial investments and improvement in communication, so that the population understands the role of the PHC units to prevent, promote and protect health, which can be effective as coordinators for the care of the Health System Network. The robust PHC allows the organization of the system on three health care levels, achieving a better performance on planning its action, optimizing the resources and contributing to the a better well-being for the population on its region

As Unidades de Atenção Primária à Saúde (APS) devem ser a principal porta de entrada para o Sistema Único de Saúde (SUS). O objetivo deste estudo foi analisar acesso dos usuários do SUS às unidades de APS a partir de três dimensões: disponibilidade, acessibilidade e aceitabilidade. Trata-se de um estudo de caso com múltiplas abordagens realizado na Região de Saúde de Barretos, São Paulo. A investigação foi pautada em três aspectos que influenciam o acesso: fatores do sistema de saúde, percepção dos gestores e dos usuários. As fontes de evidências utilizadas foram dados secundários, análise espacial das unidades de APS com auxílio de Sistema de Informação Geográfica (GIS), entrevista com gestores da pesquisa Política, Planejamento e Gestão das Regiões e Redes de Atenção à Saúde no Brasil e entrevista com usuários do Programa Nacional de Melhoria de Acesso e da Qualidade da Atenção Básica. Os principais achados na dimensão da disponibilidade foram que o número da unidade de APS está de acordo com o recomendado pelo Ministério da Saúde. De acordo com os gestores nas unidades, há falta de integração entre os serviços e os médicos, que estão centrados nos principais centros urbanos da região. Para os usuários, o tempo de espera está dentro das expectativas. Na acessibilidade, a distribuição geográfica das unidades está adequada na maior parte dos municípios, onde os usuários realizam o trajeto em até 10 minutos e consideram como sendo fácil ou muito fácil o acesso, mas a maioria dos gestores desconhecem critérios de distribuição geográfica dos recursos. Na aceitabilidade, grande parte dos usuários aceita o cuidado recebido pelos profissionais de saúde das unidades de APS. O acesso às unidades de APS na região de Barretos revelou resultados positivos, porém a maior parte não possui ocupação profissional. Nos achados, fica evidenciada a necessidade dos gestores públicos aprimorarem a gestão em alguns aspectos como introdução de sistema de informação para agendamento de consultas, ampliação do horário de atendimento, utilização de SIG, pois permite a identificação de áreas mais vulneráveis e aquelas que necessitam de investimentos - e a melhoria na comunicação para que a população entenda o papel das unidades de APS para a prevenção e promoção à saúde, as quais possam se efetivar como coordenadoras do cuidado das Redes de Atenção à Saúde (RAS). A APS fortalecida permite que o sistema se organize nos três níveis da atenção, obtenha melhor desempenho no planejamento das ações, otimize os recursos e contribua para a melhoria das condições de vida da população na região / The Units of Primary Health Care (PHC) must be the main gateway to the Unified Health System (SUS). This study aims to analyze the access from users to PHC through three dimensions: availability, accessibility and acceptability. This is a case study with multiple approaches which took place in the region of Barretos, São Paulo. The research was focused considering three aspects that can influence the access: health systems factors, the perception of health professionals and users. The sources of evidence used were secondary data, spatial analyses of the Primary Care Center (PCC) using the Geographic Information System (GIS), interviews with the managers from the research Regions and Health Care Network and with users of the National Program to Improve Access and Quality of Primary Care . The main findings in the dimension of availability were that the number of units of PCC is according to the recommendation from the Ministry of Health. According to the units managers, there is a lack of integration between the services and the phisicians that are located in the main urban areas. The waiting time for the users, for scheduling appointments, is according to their expectation. Concerning the accessibility, the geographic location of the units are adequate for users in most counties. Users take about ten minutes to arrive to the units. They consider the access to it to be easy or very easy, but managers dont know the geographical location criteria for the resources. Regarding acceptability most users accept the Health Care Services, in the PHC. The access to the units in Barretos region had positive results, therefore most of the users dont have a professional occupation. It was evident in the findings the need for public managers to improve some management aspects, like to implement a new information system for scheduling appointments, extension of operation hours to the users, the utilization of a GIS, which can identify the more vulnerable areas, the ones that needs financial investments and improvement in communication, so that the population understands the role of the PHC units to prevent, promote and protect health, which can be effective as coordinators for the care of the Health System Network. The robust PHC allows the organization of the system on three health care levels, achieving a better performance on planning its action, optimizing the resources and contributing to the a better well-being for the population on its region

Thesis (M.P.H.)--University of Texas Health Science Center at Houston, School of Public Health, 2008. / Source: Masters Abstracts International, Volume: 46-03, page: 1499. Adviser: Shelton Brown. Includes bibliographical references.

Made available in DSpace on 2016-12-23T13:47:02Z (GMT). No. of bitstreams: 1 Creuza Rachel Vicente.pdf: 3384838 bytes, checksum: c3eca90bf4886725c29d5e5904662f2b (MD5) Previous issue date: 2012-03-15 / Introdução: A ocorrência da dengue sofre influência do comportamento, estrutura social e distribuição da população e sua transmissão pode variar de acordo com as áreas do município. Seu prognóstico depende do diagnóstico precoce e da imediata instituição do tratamento. Este estudo avalia fatores associados à ocorrência da dengue, enfatizando a distribuição territorial e os relacionados à dengue grave. Métodos: Foram realizados dois estudos, sendo um transversal e outro retrospectivo, sobre a totalidade dos casos de dengue que ocorreram em Vitória no ano de 2011, com base nos dados do Sistema de Informações de Agravos de Notificação. Resultados: Entre os casos confirmados, 53,4% ocorreram em mulheres, 74,7% em maiores de 15 anos e 6,3% evoluíram para gravidade. Os territórios de saúde de Jardim Camburi, Maruípe, Ilha das Caieiras, Santa Martha e Santo André responderam por 41,6% das notificações. Quase metade dos casos foram concluídos por critério laboratorial e, destes, 80% realizaram sorologia. Em todos os territórios, mais de 20% dos notificados realizaram sorologia e, na maioria, mais de 51% tiveram resultado positivo. Nas regiões de São Pedro, Maruípe e Santo Antônio, os afetados eram principalmente jovens, enquanto nas regiões Continental e Forte São João, eram pessoas mais velhas. Dos 371 casos de dengue grave, 78,7% foram de dengue com complicações e 21,3% de febre hemorrágica da dengue. Sessenta e sete por cento dos casos ocorreram em pessoas com idade superior a 15 anos. As Regiões de Saúde de Maruípe e São Pedro foram responsáveis por mais da metade dos casos de dengue grave (56,35%). Houve associação estatisticamente significante entre ocorrência de febre hemorrágica da dengue com idades mais jovens (menores de 15 anos) e maior tempo decorrido na procura por atendimento. Também houve associação estatisticamente significante entre maior tempo decorrido na procura pelo atendimento e idade menor que 15 anos. Os casos de dengue grave estavam concentrados em faixas etárias mais jovens na região de São Pedro. Conclusão: A distribuição territorial não foi uniforme, e pode ser determinada pela alta densidade populacional e pelas condições socioeconômicas. As diferenças de idade entre as regiões podem estar relacionadas à incidência da doença nestes locais. A grande proporção de sorologias positivas e o número de exames realizados possibilitaram uma boa detecção e acompanhamento dos casos de dengue. Os resultados corroboram os de outras pesquisas que apontam uma mudança no perfil da febre hemorrágica da dengue nas Américas e no Brasil, com crescente acometimento de jovens, e apontam a demora no tempo de procura por atendimento, baixa qualidade urbana e alta endemicidade como possíveis fatores de risco. / Introduction: The incidence of dengue, influenced by human behavior, social structure and population distribution, may vary with respect to the geographical areas of a given city. Its prognosis depends on early diagnosis and prompt initiation of treatment. This study evaluates factors related to the occurrence of dengue, emphasizing the territorial distribution and risk factors for severe dengue. Methods: A cross-sectional and a retrospective study on all cases were conducted with dengue cases of Vitória in 2011, based on data from the Information System of Notifiable Diseases (SINAN). Results: 53.4% of confirmed cases occurred in women, 74.7% were 15 years old or older, and 6.3% were severe forms. The health territories of Jardim Camburi, Maruípe, Ilha das Caieiras, Santa Martha and Santo André accounted for 41.6% of reported cases. Almost half of the cases had final classification based on laboratory tests, and of these, 80% were submitted to serological tests. Of all territories, more than 20% of those reported cases had been submitted to serological tests, and more than 51% of them had a positive result. In the regions of São Pedro, Santo Antônio e Maruípe, the affected individuals were younger, while in Continental Region and Forte São João Region, they were older. Of the 371 cases of severe dengue, 78.7% were classified as dengue with complications and 21.3% were classified as dengue hemorrhagic fever, whose age distribution disclosed a frequency of 67.1% in individuals 15 years old or older. Regions of Maruípe and São Pedro were responsible for over half of cases of severe dengue (56.3%). There was a statistically significant association between the occurrence of dengue hemorrhagic fever and younger ages (under 15 years) and longer time interval between the beginning of symptoms and seeking for care. People younger than 15 years old take longer to seek for care. The frequencies of cases of severe dengue were concentrated in younger age groups in the region of São Pedro. Conclusion: The geographical distribution was not uniform, and can be influenced by the high population density and socioeconomic conditions. The age differences between regions may be related to disease incidence in these locations. A large proportion of positive tests and a great number of tests performed allowed a good detection and monitoring of dengue cases. The results corroborate those of other studies that indicate a change in the profile of dengue hemorrhagic fever in the Americas and Brazil, with growing involvement of young people, and indicate the time delay in seeking treatment, urban poor quality and high endemic scenario as possible risk factors.

BackgroundThe prompt seeking of medical care after the onset of symptoms suggestive of acute coronary syndromes (ACS)/acute myocardial infarction (AMI) is associated with the receipt of coronary reperfusion therapy, and effective cardiac medications in patients with an ACS/AMI and is crucial to reducing mortality and the risk of serious clinical complications in these patients. Despite declines in important hospital complications and short-term death rates in patients hospitalized with an ACS/AMI, several patient groups remain at increased risk for these adverse outcomes, including women and the elderly. However, recent trends in age and sex differences in extent of pre-hospital delay, hospital management practices, and short-term outcomes associated with ACS/AMI remain unexplored. The objectives of this study were to examine the overall magnitude, and changing trends therein, of age and sex differences in duration of pre-hospital delay (1986-2005), hospital management practices (1999-2007), and short-terms outcomes (1975-2005) in patients hospitalized with ACS/AMI. MethodsData from 13,663 residents of the Worcester, MA, metropolitan area hospitalized at all greater Worcester medical centers for AMI 15 biennial periods between 1975 and 2005 (Worcester Heart Attack Study), and from 50,096 patients hospitalized with an ACS in 106 medical centers in 14 countries participating in the Global Registry of Acute Coronary Events (GRACE) between 2000 and 2007 were used for this investigation. Results In comparison with men years, patients in other age-sex strata exhibited significantly longer pre-hospital delay, with the exception of women < 65 years; had a significantly lower odds of receiving aspirin, angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), beta blockers, statins, and undergoing coronary artery bypass graft surgery (CABG) surgery or percutaneous coronary intervention (PCI), and were significantly more likely to develop atrial fibrillation, cardiogenic shock, heart failure, and to die during hospitalization and in the first 30 days after admission. There was a significant interaction between age and sex in relation to the use of several medications and the development of several of these outcomes; in patients Conclusions Our results suggest that the elderly were more likely to experience longer prehospital delay, were less likely to be treated with evidence-based treatments during hospitalization for acute coronary syndrome, and were more likely to develop adverse outcomes compared to younger persons. Younger women were less likely to be treated with effective treatments and were more likely to develop adverse outcomes compared with younger men while there was no sex difference in these outcomes. Interventions targeted at older patients, in particular, are needed to encourage these high-risk patients to seek medical care promptly to maximize the benefits of currently available treatment modalities. More targeted treatment approaches during hospitalization for ACS/AMI for younger women and older patients are needed to improve their hospital prognosis.