Introdução: a Atenção Primária à Saúde (APS) é conceituada como o acesso preferencial de primeiro contato para provimento coordenado de cuidados integrais ao longo do tempo. Desde a implantação do Sistema único de Saúde (SUS), os serviços de APS cresceram em número e com eles ampliou-se o acesso, mas com heterogeneidade na qualidade dos serviços prestados. Na atenção secundária, o quadro se repete somado ao baixo número de pontos de oferta de serviço. Os grandes hospitais, apesar da incorporação tecnológica e da qualidade assistencial, são incapazes de absorver a alta demanda não resolvida nos primeiros níveis. Com isso tem-se um SUS fragmentado para enfrentar uma tripla carga de doenças, incrementada pelo envelhecimento populacional. Em função desse quadro, o Programa Telessaúde Brasil Redes está em expansão desde 2007 e é voltado principalmente para ações de suporte assistencial à APS, com foco na qualificação permanente dos profissionais de saúde. A telessaúde representa uma interação a distância, mediada por Tecnologias da Informação e Comunicação, entre pessoas e/ou equipamentos, de forma síncrona ou assíncrona e com finalidade assistencial ou educacional. Em que se pese a necessidade de maiores estudos de custo-efetividade, iniciativas na área têm-se mostrado capazes de melhorar o acesso de pacientes a consultas e serviços, reduzir o tempo de espera e qualificar os encaminhamentos de pacientes para consultas e procedimentos especializados. Apesar dos avanços, ainda é necessário modelar, aprimorar e documentar o conhecimento associado aos processos em telessaúde, bem como verificar a adequação desses processos. Método: estudo de caso baseado em análise documental, entrevistas com informantes-chave e análise estatística descritiva da produção de ações em telessaúde para solicitantes médicos do Rio Grande do Sul (RS), no período de setembro de 2013 a outubro de 2015, utilizando a Notação de Modelagem de Processos de Negócio (Business Process Model and Notation – BPMN) para modelar, aprimorar, documentar e discutir processos de telessaúde para a APS. Complementarmente, estudo descritivo de uma série histórica de 24 meses, da produção das ações de teleconsultoria assíncrona e síncrona, por todos os núcleos de telessaúde que utilizaram a Plataforma Nacional de Telessaúde no Brasil, no período de outubro de 2013 a setembro de 2015. Tanto a oferta como a demanda foram estimadas com base no número de unidades de saúde cadastradas na área de abrangência de cada núcleo de telessaúde. Resultados: foram mapeados os processos, atores e atividades envolvidas nas tipologias de ações de telessaúde em telediagnóstico, teleconsultorias via web, teleconsultorias via telefone por demanda espontânea e para apoio ao complexo regulador ambulatorial do estado. Foi encontrada uma média mensal de 0,01 a 0,02 solicitações de teleconsultoria via web por médico da APS do RS. Nas demais tipologias, o número médio mensal de teleconsultorias foi de 0,01 – 0,39 para telediagnóstico em espirometria, 0,05 – 0,34 para teleconsultorias espontâneas via telefone, e 0,01 – 0,69 para teleconsultorias de apoio ao complexo regulador. Em relação à produção de todos os núcleos de telessaúde do país, foram respondidas 29.575 teleconsultorias por 18 núcleos de telessaúde, para 43.421 usuários em 9.801 unidades de saúde. A oferta e a demanda mensais de teleconsultorias variaram entre 0,92 a 2,06 e 0,22 a 1,00 teleconsultorias, respectivamente. O percentual de unidades de saúde que realizou ao menos uma solicitação no mês manteve-se próximo a 0,1%, sendo que 87,3% dos usuários cadastrados não realizou nenhuma solicitação no período. Os temas solicitados cobriram todos os capítulos da Classificação Internacional da Atenção Primária e da Classificação Internacional de Doenças. A satisfação dos usuários foi de 95,6% e o percentual de dúvidas totalmente respondidas foi de 88,4%. Conclusões: existe um problema de baixas taxas de utilização por parte dos profissionais solicitantes. A capacidade ociosa decorrente do baixo uso indica a necessidade de integração horizontal de núcleos de telessaúde, com extrapolação das barreiras geográficas estaduais. Por outro lado, uma das formas de otimizar os investimentos públicos em telessaúde é a redução do número de núcleos de telessaúde, com centralização das tarefas meio, de coordenação, regulação, auditoria e monitoramento, de forma a gerar economia de custos e ganhos de escala e qualidade. Também são necessárias novas tipologias de oferta de ações de telessaúde, capazes de orquestrar de forma sinérgica e sistêmica todos os recursos disponíveis em teleconsultoria, telediagnóstico, teleducação e demais formas de telessaúde, de forma a inserir a telessaúde dentro das atividades diárias dos profissionais, gestores e pacientes. / Introduction: Primary Health Care (PHC) is defined as the preferential access of first contact for providing coordinated comprehensive care over time. Since the implementation of the Sistema Único de Saúde (SUS), PHC services grew in number, expanding its access, but with heterogeneity in the quality of services provided by it. In secondary care, the pattern repeats, coupled with a low number of service delivery points. Large hospitals in spite of technological development and quality of care, are unable to absorb the high unresolved demand of first levels. With this SUS is being fragmented facing a triple burden of disease, increased by population aging. Due to this framework, the Telehealth Program Brazil Networks is expanding since 2007, focused primarily on assistance support actions for PHC , and the ongoing training of health professionals. Telehealth is an interaction made of distance, mediated by Information and Communication Technologies between people and / or equipment, synchronously or asynchronously and welfare or educational purpose. Despite the need for greater cost-effectiveness studies, initiatives in this field have proven to be able to improve access of patients to consultations and services, reducing waiting time and qualifying the patient referrals to specialist consultations and procedures. Despite these advances, it is still necessary to model, improve and document the knowledge associated with telehealth processes and verify the adequacy of these processes. Method: a case study based on analysis of documents, interviews with key informants and descriptive statistical analysis of production activities in telehealth to referring physicians of Rio Grande do Sul (RS), from September 2013 to October 2015, using the Business Process modeling notation (BPMN) to model, improve, document and discuss telehealth processes for PHC. In addition, descriptive study of a historical series of 24 months of production of asynchronous and synchronous actions of teleconsulting by all telehealth centers that used the National Telehealth Platform in Brazil, from October 2013 to September 2015. Both the supply and demand were estimated based on the number of health units registered in the coverage area of each core telehealth center. Results: we mapped the processes, actors and activities involved in the types of telehealth actions in telediagnosis, teleconsultation via the web, tele-consultations via telephone by spontaneous demand and to support the ambulatorial regulatory complex of the state. We found a monthly average from 0.01 to 0.02 teleconsulting requests via web by doctors of the state of RS PHC. In the other types, the average monthly number of teleconsultation was 0.01 to 0.39 for remote diagnostics in spirometry, from 0.05 to 0.34 for spontaneous teleconsultation via telephone, and 0.01 to 0.69 for teleconsultation support regulatory complex. In the production of all the country's telehealth centers, 29,575 teleconsultations were answered by 18 telehealth centers to 43,421 users in 9,801 health units. The monthly supply and demand for teleconsultations ranged from 0.92 to 2.06 and 0.22 to 1.00 teleconsultations, respectively. The percentage of health units that conducted at least one request in the month remained close to 0.1%, and 87.3% of registered users have made no request in the period. The requested topics covered all chapters of the International Classification of Primary Care and International Classification of Diseases. User satisfaction was 95.6% and the percentage of fully answered questions was 88.4%. Conclusions: There is a problem of low rates of use by professional requesters. The idle capacity resulting from low use indicates the need for horizontal integration of telehealth centers, with extrapolation of the state geographical barriers. On the other hand, one of the ways to optimize public investment in telehealth is the reducing of number of telehealth centers with centralizing means tasks, coordination, regulating, auditing and monitoring in order to generate cost savings and economies of scale and quality. It is also needed new types of offer telehealth actions, able to orchestrate a synergic and systemic way of all available resources in teleconsulting, telediagnostic, tele-education and other forms of telehealth in order to insert the telehealth within the daily activities of professionals, managers and patients. / Telemedicina

Objetivo: Esta tese possui o objetivo primário de avaliar os impactos de um curso de aperfeiçoamento baseado no desenvolvimento de competências para atuação do farmacêutico na Atenção Primária em Saúde do sistema público de saúde brasileiro. Os objetivos secundários do estudo são delimitar os fatores que influenciam a mudança nas práticas nos serviços farmacêuticos e avaliar o grau de implementação dos objetivos pedagógicos do curso nas práticas relatadas pelos egressos. Métodos: Este estudo de caso apresenta o conjunto de estratégias utilizados na avaliação de impactos do curso anos após seu término. A pesquisa avaliativa foi planejada utilizando o método do modelo lógico de avaliação. As etapas da pesquisa envolveram análise documental; oficina de avaliação na qual foi aplicada a técnica do grupo nominal e entrevistas semiestruturadas aplicadas pelo telefone. Os resultados foram analisados utilizando abordagens qualitativa e quantitativa para compreensão dos fatores comuns aos processos de mudança observados. Resultados: Um perfil de atividades do farmacêutico foi construído considerando as experiências dos profissionais e as expectativas de aprendizagem na época do curso. A oficina de avaliação produziu o consenso sobre os fatores que influenciam as mudanças na perspectiva de um grupo de egressos. Também foram estudadas as contribuições do curso para a vida profissional e as necessidades de formação dos farmacêuticos. Os fatores que influenciam a mudança estudados tanto no coletivo quanto no individual foram agrupados em quatro dimensões de análise dos fatores de contexto que influenciam a mudança. A interação do farmacêutico no trabalho em equipe multiprofissional e a relação com o gestor aparecem como fatores relevantes para o farmacêutico promover mudanças em seu modo de produzir trabalho em saúde. Conclusão: Ao final do estudo verificamos que o curso produziu efeitos na implementação de novos serviços, na mudança das práticas e na visão dos farmacêuticos sobre a atuação no âmbito da Atenção Primária. Ainda se deve avançar muito na problematização dos processos de trabalho em que o farmacêutico está inserido. As estratégias de coleta, sistematização e análise dos resultados atenderam aos objetivos propostos pela pesquisa e as perspectivas investigadas contribuíram para ampliar a visão sobre os impactos do programa educacional. / Objective: This thesis has the primary objective of evaluating the impact of an improvement course based on developing competencies for the pharmacists that works in primary health care in the public system of Brazilian health. Secondary objectives of the study are to define the factors influencing the change in practices in pharmaceutical services and assess the degree of implementation of the pedagogical objectives of the course in the practices reported by graduates. Methods: This case study presents the set of strategies used in the impact assessment of the course years after its completion. The evaluative research was designed using the method of logical model of evaluation. The research steps involved document analysis; workshop in which it was applied the Nominal Group Technique and semi-structured interviews applied by the phone. The results were analyzed using both qualitative and quantitative approaches to understanding the factors common to those observed change processes. Results: A pharmaceutical activity profile was built considering the experiences of professionals and learning expectations at the time of the course. The workshop produced consensus on the factors that influence changes in the perspective of a group of graduates. Ongoing contributions to the work and the training needs of pharmacists were also studied. Factors influencing the change studied both the collective and the individual were grouped into four dimensions of analysis of the context of factors that influence change. The interaction between the pharmacist at work in multidisciplinary team and the relationship with the manager appear as relevant factors for the pharmacist promote changes in the way of producing health work. Conclusion: At the end of the study we found that the course was effective in implementing new services, changing practices and vision of pharmacists about acting within the scope of Primary Care. Still should go a long way questioning the work processes in which the pharmacist is inserted. The collection strategies, organization and analysis of the results met the objectives proposed by the research and the outlook investigated contributed to broader view of the impact of educational program.

L’enjeu de cette thèse est de construire un modèle d’évaluation de dispositif de formation et de le confronter à l’empirie. Nous avons mené une recherche-intervention dans le cadre d’un appel à projets, et réalisé l’évaluation d’une expérimentation sociale ayant les traits d’un dispositif de formation. Dans ce contexte de recherche commanditée, nous explicitons l’émergence d’un espace pour la recherche et l’articulation d’un volet social (à visée praxéologique) et d’un volet académique (à visée heuristique). Le modèle d’évaluation se base sur une logique de reddition des comptes, mais aussi de développement des acteurs. Il se scinde en deux orientations : connaître pour objectiver et connaître pour expliquer. La première orientation développe une approche quantitative mesurant l’efficacité du dispositif, la seconde orientation la complète et permet de l’interpréter. Elle propose une approche qualitative mesurant les évolutions cognitives des destinataires du dispositif, caractérisant les effets non escomptés et l’efficacité perçue par les acteurs. L’analyse des données a permis de consolider des éléments du modèle, de pointer des limites et de proposer des points d’appui pour contribuer à le stabiliser. Nous avons proposé l’ajout d’un volet s’intégrant à la seconde orientation connaître pour expliquer. Il porte sur l’analyse du changement dans la mise en place du dispositif. De plus, nous avons proposé cinq points d’appui : méthodologique, axiologique, heuristique, épistémologique et politique qui renforce la cohérence générale du modèle. Le modèle d’évaluation de dispositif de formation a résisté à l’empirie. / The aim of this thesis is to construct a model for evaluating training programs and to check its relevance by confronting it with empirical data. We conducted this intervention-research in the framework of a call for proposals and evaluated a social experiment bearing the characteristics of a training program. Within this context of commissioned research, we explain the emergence of an area for the research and articulation of a social dimension (for praxeological purposes) and an academic dimension (for heuristic purposes). The evaluation model is based on the method of accountability but also on the development of the actors involved. It mobilizes two different methodological orientations: “acquiring knowledge to objectify” and “acquiring knowledge to interpret”. The first takes a quantitative approach and measures the efficiency of the program; the second completes the first and facilitates its interpretation. The second orientation takes a qualitative approach measuring the cognitive developments of the training beneficiaries, characterizing the unexpected effects and efficiency as perceived by the actors involved. Thanks to the data analysis, we have been able to consolidate certain elements of the model, highlight some of its limits and offer some leverage points to help stabilize it. We propose adding a component to the second orientation “acquiring knowledge to interpret”, in order to focus on the analysis of change in the implementation of the program. Likewise, we provide five methodological, axiological, heuristic, epistemological and political leverage points which strengthen the general coherence of the model. The evaluation model has withstood the confrontation with empirical data.

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No. of bitstreams: 1 Dissertação - Ednardo Fornanciari Antunes.pdf: 5627481 bytes, checksum: d589e1d957de65e32a36f3c4e154f244 (MD5) Previous issue date: 2012-08-27 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Introduction: Despite the introduction of effective therapy, with the fall in the number of cases each year, and permanent vigilance, perseveres leprosy as a public health problem in many countries and in Brazil. The characteristics of infectivity and chronicity of the disease and the peculiarity of peripheral nerve predilection of Mycobacterium leprae, the allies still present insufficient information about the disease by population and health workers, allow that Brazil continues as the second country in the number of cases and register many with disabilities and deformities installed. To contain the spread of the disease and seeking its elimination as a public health problem, Brazil imposed in recent decades strategies among which stands out the program of decentralization of leprosy and its integration with primary care network throughout the country, considered as a solution to achieve this goal. Objectives: This study aimed to evaluate the actions of leprosy control, its decentralization and the influence of organizational context in its implementation in the city of Cáceres - MT between 2004 and 2009 as well as conducting epidemiological characterization of disease in the period. Methodology: We performed an evaluative analysis of the implementation of the type of structure and process to estimate the degree of implementation of actions for the control of leprosy in Cáceres and decentralization in basic health units in the urban area. We used closed and semi-structured instrument based on standards for leprosy program activities and the structure of health facilities. We visited ten health units serving leprosy cases in the county where the items were verified physical installation, material resources and human resources trained in leprosy, with scores assigned by weight, with 15 points, 15 points and 10 points respectively. Were also analyzed 419 records of patients diagnosed with leprosy between 2004 and 2009 and interviewed the coordinators of the health units, the coordinator of the PCH and municipal health manager for process analysis, assessing the routine of the health unit, concentration parameters in leprosy and composition of the chart, assigning score by weight, with 20 points, 25 points and 15 points respectively. Retrieved weighted average score achieved by the plant, the degree of implementation was calculated by simple rule of three and classified into one of the categories: implemented, acceptable, poor, critical. Was also conducted epidemiological characterization of disease during the study period by comparing the epidemiological data obtained from medical records with the data available in SINAN. Results: The epidemiological characterization shows majority of new cases (89.5%) in men (60.9%), economically active age group (73.8%), mixed race (45.3%) from the urban area (82.6), clinical tuberculoid (31.5%), zero degree of disability (58.4%), and classified as paucibacillary (64.9%). The data found in the records differ from data available on SINAN, and found 34 cases more, increasing the detection rate and 17 cases that have not reported in epidemiological investigation forms the input mode and not included in SINAN. The implementation of actions to leprosy control in the municipality was classified as acceptable, gaining 38.45 points (ratio of 73.9%). Conclusion: There is no agreement entres data in records and data recorded in SINAN, and the first rise the detection of the disease in the period: The implementation of actions in leprosy was considered acceptable, being hindered by physical installation of health facilities, lack of resources trained human leprosy; performance of doctors and community workers, lack of trained professionals; not completeness of records; mainly as a laboratory and degree of disability. The organizational context influences the implementation of the CMS by not ix acting in strategy formulation and execution control of health policy for leprosy; high turnover of local health managers; turnover of health professionals, especially doctors; funds not target and financial dependence on other sources. Considering the parameters of this review, leprosy control activities are decentralized in Cáceres. / Introdução: Apesar da introdução de uma terapêutica eficaz, com a queda do número de casos a cada ano, e da vigilância permanente, a hanseníase persevera como problema de saúde pública em vários países e no Brasil. As características de infecciosidade e cronicidade da doença e a peculiaridade de predileção por nervos periféricos do Mycobacterium leprae, aliadas a ainda presente insuficiência de informações a respeito da doença pela população e agentes da saúde, permitem que o Brasil persista como segundo país em número de casos e registre muitos deles com incapacidades e deformidades instaladas. Para conter o avanço da doença e buscando sua eliminação como problema de saúde pública, o Brasil instituiu nas últimas décadas estratégias entre as quais se destaca a descentralização das ações programáticas de hanseníase e sua integração com a rede básica de saúde em todo o país, consideradas como uma das soluções para o alcance dessa meta. Objetivos: O presente estudo objetivou avaliar as ações de controle da hanseníase, sua descentralização e a influência do contexto organizacional em sua implantação no município de Cáceres - MT entre 2004 e 2009, bem como realizar caracterização epidemiológica da doença no período. Metodologia: Foi realizada uma pesquisa avaliativa do tipo análise da implantação da estrutura e processo para estimar o grau de implantação das ações para o controle da hanseníase em Cáceres e sua descentralização nas unidades básicas de saúde da zona urbana. Utilizou-se de instrumentos fechados e semiestruturados baseados em normas para as ações programáticas de hanseníase e para a estrutura das unidades de saúde. Foram visitadas dez unidades de saúde que atendem casos de hanseníase no município, onde foram verificados os itens instalação física, recursos materiais e recursos humanos capacitados em hanseníase, sendo atribuída pontuação por peso, sendo 15 pontos, 15 pontos e 10 pontos respectivamente. Também foram analisados 419 prontuários de pacientes diagnosticados com hanseníase entre 2004 e 2009 e entrevistadas as coordenadoras das unidades de saúde, a coordenadora do PCH e a gestora municipal de saúde para análise do processo, avaliando a rotina da unidade de saúde, parâmetros de concentração em hanseníase e composição do prontuário, atribuindo-se pontuação por peso, sendo 20 pontos, 25 pontos e 15 pontos respectivamente. Obtida média ponderada da pontuação alcançada pelas unidades, o grau de implantação foi calculado por regra de três simples e classificado em uma das categorias: implantado, aceitável, insatisfatório, crítico. Foi ainda realizada caracterização epidemiológica da doença no período estudado comparando-se os dados epidemiológicos levantados nos prontuários com os dados disponíveis no SINAN. Resultados: A caracterização epidemiológica mostra maioria de casos novos (89,5%), em homens (60,9%), faixa etária ativa economicamente (73,8%), raça parda (45,3%), proveniente da zona urbana (82,6), forma clínica tuberculóide (31,5%), grau de incapacidade zero (58,4%), e classificado como paucibacilar (64,9%). Os dados encontrados nos prontuários divergem dos dados disponíveis no SINAN, sendo encontrados 34 casos a mais, aumentando o coeficiente de detecção e 17 casos que não têm informados nas fichas de investigação epidemiológica o modo de entrada e que não constam no SINAN. A implantação das ações de controle da hanseníase no município foi classificada como aceitável, obtendo 38,45 pontos (proporção de 73,9%). Conclusão: Não há concordância entres os dados nos prontuários e os dados registrados no SINAN, sendo que os primeiros elevam a detecção da doença no período; a implantação das ações em hanseníase foi considerada aceitável, sendo prejudicada pela instalação física das vii unidades de saúde, falta de recursos humanos capacitados em hanseníase; atuação de médicos e agentes comunitários; falta de profissionais capacitados; não completitude dos prontuários, principalmente quanto a exames laboratoriais e grau de incapacidade. O contexto organizacional influencia a implantação pela não atuação do CMS na formulação de estratégias e controle da execução da política de saúde para hanseníase; alta rotatividade de gestores municipais de saúde; rotatividade de profissionais de saúde, principalmente médicos; recursos financeiros não direcionados e dependência financeira de outras fontes. Considerando os parâmetros desta avaliação, as ações de controle da hanseníase estão descentralizadas em Cáceres.

Este é um estudo de caso com abordagens qualitativa e quantitativa, tendo como objetivo a descrição do histórico e a avaliação do processo de expansão do PSF em um município do Sul do Brasil, ocorrido entre dezembro de 2002 e dezembro de 2004. Foi utilizado o referencial Donabedian para avaliação de estrutura, processo e resultado e posterior comparação, em um estudo tipo before and after, na evolução da cobertura pelo PSF, calculada pela sistemática do Ministério da Saúde, de 23,85%(dez/2002) para 70%(dez/2004). A discussão dos resultados foi realizada em conjunto com uma descrição do histórico da expansão de 11 para 33 equipes de saúde da família através de pesquisa documental onde, mediante análise de conteúdo, se procedeu a identificação de temas relativos à estrutura, processo e resultado relacionados com o PSF. Em relação à estrutura, foram comparados recursos financeiros, recursos humanos, instalações físicas, veículos, referência especializada, exames complementares e gastos com medicamentos. Proporção de organização de prontuários individuais por famílias, cobertura por consultas médicas e de enfermagem e cobertura de visitas domiciliares no PSF foram os itens analisados em processo. Para a avaliação de resultado foram comparadas as taxas de mortalidade infantil, percentual de cobertura de gestantes com mais que 6 consultas de pré-natal, taxas de incidência de internações no SUS por infecções respiratórias e doença diarréica em menores de 5 anos. A comparação entre os momentos evidencia um significativo incremento em todos os itens de estrutura comparados, com destaque para recursos financeiros e humanos, referência especializada e instalações físicas. Em relação a processo, foi adotada maciçamente uma sistemática de arquivamento de prontuários individuais por famílias cadastradas, houve um aumento dos quantitativos de consultas médicas no PSF com redução de consultas de clínica médica, pediatria e de urgência. Como resultante, na comparação entre os momentos, houve queda no quantitativo e cobertura de consultas nas especialidades básicas. A cobertura por consultas de enfermagem aumentou em 160,7% no período de comparação. A cobertura de visitas domiciliares na sistemática do SISPACTO aumentou em 92,3% entre os momentos analisados, sendo estudada a variação por categoria profissional. Na avaliação de resultado ocorreu uma piora na cobertura de gestantes com mais que 6 consultas de pré-natal com redução de 61,6% para 50,0%. Os coeficientes de internação no SUS por infecção respiratória aguda e por doença diarréica aumentaram em 29,1% e 15,3%, respectivamente. A mortalidade infantil reduziu em 33,0 %, de 28,8‰ para 19,3‰. A descrição histórica resgata o período anterior à expansão até o final de 2004, término da análise deste estudo. A combinação dos dados quantitativos com a descrição histórica permitiu identificar os elementos facilitadores e dificultadores em um processo de expansão / This is a study of case with qualitative and quantitative approach. It has as objective the description of the historical description and the evaluation of the Family Health Program (FHP) expansion process in a South of Brazil city, occurred between December of 2002 and December of 2004. It was used the Donabedian model for structure, process and result evaluation and subsequent comparison, in a before and after study type, in the covering area evolution of the program, calculated by the Health Department systematic, from 23,85%(dec/2002) to 70%(dec/2004). The results discussion was carried out joined to a historical description expansion from 11 to 33 Family’s Health teams. It was done through documentary research, where, using the content analysis, it was possible to identify the subjects related to the structure, process and results related to the FHP. Related to the structure was compared financial resources, human resources, physical installations, vehicles, specialized reference, complementary examinations and expenses with medicines. The items analyzed in process were ratio of individual medical record organization for families, covering for medical and nursing consultations and covering of home visits in the FHP. For the result evaluation the taxes of children’s mortality, percentage of pregnant covering with more than 6 prenatal consultations, rates of hospital admission incidence, using the Brazilian Health System, for respiratory infections and diarrhea illness in children under 5 years old were compared. The comparison between the moments evidences a significant meaningful in all items of structure compared, with prominence for financial and human resources, specialized reference and physical installations. About the process, it was adopted an individual medical record filling systematic for registered families. There was an increase in the number of medical consultations in the FHP with reduction for the medical clinic, pediatrics and urgency consultations. As resultant, in the comparison between the moments, it reduced the amount and the consultations covering in the basic specialties. The covering of nursing consultations increased in 160, 7% in the period of comparison. The home visits covering in the systematic of the SISPACTO increased in 92,3% between the analyzed moments, the variation was studied in each professional category. In the results evaluation occurred a worsening in the pregnant with more than 6 consultations of prenatal covering, with reduction from 61,6% to 50,0%. The coefficients of hospital admission using the Brazilian Health System for respiratory infection and diarrhea illness had increased in 29,1% and 15,3%, respectively. Children’s mortality reduced in 33,0%, from 28,8‰ to 19,3‰. The historical description refers to the period before the expansion until the end of 2004, when the analysis of this study was finished. The facilities and limiters in an expansion process are identified by the combination of the quantitative data with the historical description.

This dissertation consists of three essays examining the role of two particular social safety net programs, the Temporary Assistance for Needy Families (TANF) program and the Supplemental Nutrition Assistance Program (SNAP), on the well-being of children from disadvantaged households. While the impact of these programs on the adults and parents of the household have been studied extensively, less is known about their effect on children. This is true for both their immediate impact on child well-being and any long-run impacts on children who grow up under these programs. Given the demonstrated importance of child well-being on later life adult outcomes, understanding the lasting effects of the programs is of great policy importance. In Essay 1, I examine the effect of welfare reform on long-run educational attainment and family structure outcomes on children who grew up under the reformed welfare system. In the early 1990’s, the United States reformed its welfare system through state waivers and the TANF program. These changes altered family resources and potential investments for childhood human capital, which in turn could affect later adult outcomes. Using data from the Panel Study of Income Dynamics (PSID) Child Development Supplement (CDS) and the Transition to Adulthood Supplement (TAS), I examine the short-run effects of welfare reform on cognitive and noncognitive outcomes and the long-run impact of welfare reform on adult education and family structure through age 28. I find that as children, these individuals have higher reading test scores by an average of 6 percent of a standard deviation. As adults, I find robust evidence that these treated individuals are on average 9 percent more likely to graduate college. I also find some evidence that they are more likely to be married and less likely to have a child out of wedlock. The impacts of welfare reform are larger for women than men for childhood test scores and college completion, marriage rates, and out of wedlock births as adults. In Essay 2, I continue to study the effects of welfare reform on child well-being, here focusing on the effect of welfare reform on the health insurance coverage, healthcare utilization, and the health status of children. In addition to changing the overall resources available to the family to invest in child health, welfare reform also has specific implications for health insurance coverage. As mothers were moved to work they could gain private coverage and welfare reform eliminated automatic eligibility for Medicaid. In this essay, I use data from the PSID CDS. I find a 3-5 percent decrease in the likelihood that a child has had their annual checkup but no change to the insurance coverage of children. For health status, I find lower rates of asthma by 17 percent among African American children and an increase of 3-5 healthy days a year for all children. I present suggestive evidence that the improvements in child health are driving the reduction in healthcare utilization. Given the evidence in the literature on the importance of childhood health, these improvements have potentially large ramifications for future adult health. Finally, in Essay 3 I explore the effect of the real purchasing power of SNAP benefits for households with children on dietary quality of food acquisitions and food insecurity. SNAP, formerly food stamps, is one of the most important components of the social safety net. However, there is concern that benefits are inadequate given high food insecurity rates among participating households. Currently SNAP does not account for variation in local food prices and does not sufficiently consider the dietary needs of adolescent children. Using data from the Food Acquisition and Purchase Survey (FoodAPS), I exploit variation in county level food prices and family composition to estimate the purchasing power of food expenditures for SNAP and SNAP–eligible households to test for the effect of additional benefits on dietary quality and food security. I find that a ten percent increase in purchasing power is associated with increased per person weekly acquisition of grains, proteins, dairy, and vegetables by 1.5-2.5 percent. However the quantity of added sugars also increases by approximately two percent, suggesting an ambiguous impact on health. In line with these modest changes in quantity, I do not find a statistically significant impact of purchasing power on food insecurity rates.

Under the No Child Left Behind Act of 2001, states created statewide systems of support, in collaboration with existing agencies, to deliver targeted assistance to districts and schools identified as in need of support. With limited personnel and resources, state education agencies partnered with outside agents to address the needs of a growing number of low-performing schools. Support and services for low-performing schools were designed to increase opportunities for schools to meet academic content and achievement standards for all students. Strong outside agents (skilled in systems change, knowledge of interventions and capacity for relationship-building) have been shown to produce changes in low-performing schools, but the long-term effect of those changes is unclear. One barrier to the implementation of the statewide system of support, and to any useful evaluation of its impact, is the presence of vulnerable populations, such as students with disabilities. Because low-performing schools tend to have larger student populations identified with academic risk factors like disability status, understanding how the partnership between state education agencies and outside agents improves outcomes for students with disabilities, specifically, is essential in evaluating the overall impact of the statewide system of support. The purpose of this research is to examine how a mid-sized state’s implementation of the statewide system of support provision, as outlined in The No Child Left Behind Act of 2001, by incorporating an existing regional training and technical assistance system, one focused specifically on improving special education, impacted instructional delivery for students with disabilities.

A lack of evaluation and evidence of effectiveness prompted this study of the Distributed Common Ground System's (DCGS) proficiency maintenance tool, Ready Intelligence Program (RIP). The goal was to close the gap between research and practice and inform stakeholders at the local Distributed Ground Station (DGS) of evaluation results. Guided by a logic model as the theoretical foundation, this study examined how proficiency is perceived by DCGS crewmembers because of RIP at a military installation with intelligence, surveillance, and reconnaissance missions. This qualitative study used an outcomes-based program evaluation report based on interviews with 5 crewmembers, observations of program participant activities, and reviews of training documents and program reports. Data were transcribed into NVivo 10 for organization, and inductive code words and categories were applied. Data interpretations were confirmed via triangulation and then sent to the participants for member-checking. An external evaluator reviewed the study's methodology, data, and findings for veracity. The project that resulted from the study was a program evaluation report that identified 4 overarching themes. It was concluded that (a) there was a lack of awareness of RIP, (b) RIP had minimal impact on perception of proficiency, (c) the program was occasionally applied ineffectively, and (d) management of the program was insufficient. It is recommended that existing RIP training be emphasized to crewmembers to increase awareness. Additionally, an ongoing program evaluation is recommended with a quantitative measure of proficiency achievement. This study promotes social change by improving attitudes toward positional proficiency and RIP as a maintenance tool, improving program maintenance, and facilitating regular program evaluations.

The purpose of this study was to evaluate outcomes of the service-learning requirement in the Associate of Science in Nursing (ASN) curriculum at the local college. The problem addressed in this study was that the local ASN program lacked formal evaluation of the service-learning requirement. Guided by Kolb's model of experiential learning, a goal-based, summative evaluation employed as a qualitative case study explored the perceptions of 20 stakeholders including graduates, faculty members, and key community informants. The research questions focused on how service learning influenced a student's learning of cultural competence and the impact service learning had on the community. In-depth qualitative data were collected through face-to-face or phone, semi-structured interviews. Qualitative content analysis was the analytic method used in this study. To ensure trustworthiness, students' perceptions were triangulated with faculty's and community members' perceptions as related to outcomes of service learning, and interpretations were validated through member checking. Key results from the study indicated that service learning was perceived as a valuable component in the curriculum that influenced the students' knowledge of social and cultural factors, as well as their level of cultural competence in clinical practice. In addition, service learning was perceived as having a positive impact on the community. An evaluation report was created to provide administrators at the local college summative data upon which to base decisions regarding curriculum requirements or changes. Positive social change may result if nursing students are involved in civic engagement and have an opportunity to develop a more critical consciousness while serving the local needs of the community.

Middle-school students in Nova Scotia are perceived to have low self-efficacy for achieving learning outcomes. Strong self-efficacy beliefs developed through effective curricula have been linked to improved academic performance. However, there is a need for the formal evaluation of effective curricula that aim to improve self-efficacy. The purpose of this project study was to investigate a 10-week, after-school mentorship (ASM) curriculum that has never been evaluated. The outcomes of the curriculum design are to strengthen self-efficacy beliefs via relationship building exercises, public speaking training, and character education. Bandura's theory on self-efficacy, which states that treatment influences can alter the strength of self-efficacy, informed the conceptual framework. Evaluation questions explored apparent changes in the self-efficacy of the students from the perspective of 7 adult-caregivers and the program's instructor. Interview data were triangulated with quantitative descriptive statistics on the self-efficacy scores of 10 middle-grade students before and after program participation using the Children's Hope Scale. Comparison of the mean, median, and mode pre- and posttest scores did not show statistically significant differences in self-efficacy beliefs of the students. However, analysis of interview data revealed that children's self-efficacy beliefs grew, the largest increase being in those described as reserved at the beginning of the program. This study promotes positive social change through an increased understanding that can inform efforts to increase self-efficacy in middle-school students