Introdução: A presente tese, a partir de uma análise estratégica, articula as dimensões da teoria organizacional no campo da administração pública, o objeto de estudo-trabalho processo saúde-doença, a prática profissional integral e o planejamento estratégico situacional, por meio da Estratégia de Atenção Primária à Saúde. O propósito é o de, a partir da articulação das dimensões referidas, compreender e situar os Programas de Saúde do México a nível nacional e do Distrito Federal, a nível local, e estabelecer sob que pressuposto, de bem-estar ou qualidade, se encontram elaborados. Revisão da literatura: Entre outros aspectos revisados, destaca-se a importância da dimensão da teoria organizacional (normativa, sistêmica e cultural-crítica) como categorias fundamentais para compreender a relação entre as unidades primárias de análise de cada teoria e as categorias de indivíduo-grupo, organização e sociedade. Apresenta-se como uma segunda dimensão, a inter-relação entre a teoria e a prática profissional integral do processo saúde-doença, assim como suas conexões com a teoria da organização. Descrevem-se, como terceira dimensão, os aspectos teóricos do planejamento estratégico situacional e sua relação com a Estratégia de Atenção Primária à Saúde. Desenvolvem-se os pressupostos de bem-estar e qualidade, sob os princípios sociais, econômicos e políticos em que se encontram os Programas. Objetivo: Estabelecer através da análise estratégica, em suas diferentes dimensões, o tipo de teoria organizacional, os elementos teórico-metodológicos do planejamento estratégico sob as premissas da Estratégia da Atenção Primária à Saúde e a inter-relação com o objeto de estudo-trabalho e a prática profissional, que permita determinar o tipo de pressuposto de bem-estar ou qualidade que sustenta aos Programas nacional e local estudados. Metodologia: O estudo foi realizado em base ao método qualitativo de estudo de caso, para compreender o processo da análise estratégica, a partir da interdependência dialógica dos marcos geral, particular e singular dos Programas nacional e local. A pesquisa se enfocou nas informações imersas nos Programas de Saúde, a través de uma revisão dialógica dos documentos oficiais e em entrevistas semidirigidas, realizadas com planejadores das respectivas Secretarias de Saúde. Assim, foram descritas as unidades primárias de análise do campo da administração pública que permite diferenciar a forma de estabelecer a teoria da organização prevalente nos Programas. Ao mesmo tempo, se definiram 9 cenários matriciais e 72 subcenários lineares, para compreender a relação do processo saúde-doença e a prática profissional, como elementos chaves que tem uma correspondência com o objeto de estudo-trabalho e sua resposta científico-técnico-social de acordo com a teoria da organização, com o planejamento estratégico situacional ou empresarial, e os pressupostos de qualidade e bem-estar utilizado pelos dois Programas. Resultados: O Programa Nacional tende a uma teoria organizacional de tipo sistêmica, sob o pressuposto teórico de qualidade, sendo que seu objeto de estudo se enfoca para a doença e/ou a saúde, em forma isolada. Em decorrência, a prática profissional está baseada no modelo biomédico tradicional economicista, formal e científico, fundamentado em um planejamento estratégico empresarial; dimensões que corroboram o pressuposto teórico de qualidade. O Programa do Distrito Federal se situa em uma teoria organizacional de tipo sistêmica com tendência à teoria cultural-crítica, sendo seu objeto de estudo o processo saúde-doença e a prática profissional se constitui por ações integradas, em um modelo de atenção ampliada de saúde, ainda que separe o campo da atenção pessoal da coletiva. Neste sentido, o planejamento estratégico é de tipo empresarial, com alguns conteúdos sociais que incide para o pressuposto teórico do bem-estar. Discussão e Considerações gerais: O processo de análise estratégica permitiu compreender que em seu contexto teórico-metodológico o Programa nacional é prescritivo, disjuntor e normatizador, e o Programa local é prescritivo, articulador e social. Existe neste último, a possibilidade de construir a articulação das diferentes dimensões desenvolvidas neste trabalho. A rede estaria constituída pela conjunção da teoria organizacional cultural - critica, pelo objeto de estudo processo saúde-doença e por uma prática profissional social, desenvolvidas por meio do planejamento estratégico situacional, sob os elementos constitutivos da Estratégia de Atenção Primária à Saúde. Este processo pode incidir em uma futura sociedade do bem-estar, na que a emancipação seja o elemento chave para uma cultura da saúde. Considera-se que, de não desenvolver-se a articulação de diferentes dimensões da análise estratégica, com uma base teórica de sustentação, se seguirá produzindo programas de saúde com características predominantemente regulatórias, fragmentadas e reducionistas. / Introduction: This thesis, based on a strategic analysis, articulates the dimensions of organizational theories in the field of public administration, the subject matter of health-sickness process study-work, full professional practice and situational strategic planning, by means of the Strategy of Primary Attention to Health. The purpose is to comprehend and place the Health Programs of Mexico at the national level and of the Federal District at the regional level, with a basis on the articulation of the aforesaid dimensions, and to establish under which assumption, of wellbeing or quality, they are prepared. Review of literature: In addition to other reviewed aspects, emphasis is placed on the importance of the dimension of organizational theories (normative, systemic and cultural-critical) as essential category for understanding the relation between the primary units of analysis of each theory and the categories of individual-group, organization and society. A second dimension to appear is the interrelation between theory and full professional practice of the health-sickness process, as well as its connections with the theory of organization. The theoretical aspects of situational strategic planning and its relation with the Strategy of Primary Attention to Health are described as a third dimension. The assumptions of wellbeing and quality are developed under the social, economic and political principles in which the Programs can be found. Goal: To establish, by means of strategic analysis, in its different dimensions, the type of organizational theory, the theoretical-methodological elements of strategic planning under the assumptions of the Strategy of Primary Attention to Health and the interrelation with the study-work subject and professional practice, which permits the determination of the type of assumption of wellbeing or quality that sustains the national and regional Programs studied. Methodology: The study was carried out with a basis on the qualitative case study method, to understand the strategic analysis process from the dialogic interdependence of the general, particular and singular milestones of the national and regional Programs. The survey focused on information included in Health Programs, through a dialogic review of official documents and in semi-targeted interviews, held with planners from the respective Departments of Health. Hence a description was made of the primary units of analysis of the field of public administration that permits the differentiation of the manner of establishing the theory of organization that is prevalent in the Programs. At the same time, 9 matricial scenarios and 72 linear sub-scenarios were defined to understand the relation of the health-sickness process and professional practice, as key elements that establish a correspondence with the study-work subject matter and its scientific-technical-social response is in conformity with the theory of organization, with situational or corporate strategic planning, and the assumptions of quality and wellbeing utilized by the two Programs. Results: The National Program is conducive to an organizational theory of the systemic type, under the theoretical assumption of quality, where its study subject is focused on sickness and/or health, in an isolated manner. Consequently, professional practice is based on the economicist, formal and scientific traditional biomedical model, founded on corporate strategic planning; dimensions that corroborate the theoretical assumption of quality. The Program of the Federal District is situated in an organizational theory of the systemic type, which is conducive to the cultural-critical theory. Its study subject is the health-sickness process and professional practice comprises of integrated actions, in a model of expanded attention to health, even though it separates the field of personal attention from the collective field. To this effect, strategic planning is of the corporate type, with some social contents that comes within the scope of the theoretical assumption of wellbeing. Discussion and General Considerations: The strategic analysis process made it possible to understand that in its theoretical-methodological context the national Program is prescriptive, disjunctive and regulatory, and the local Program is prescriptive, articulating and social. The latter features the possibility of building the articulation of the different dimensions developed in this study. The network is apparently formed by the conjunction of the cultural-critical organizational theory, the health-sickness process study subject and a social professional practice, developed by means of situational strategic planning, under the constitutive elements of the Strategy of Primary Attention to Health. This process can lead to a future society of welfare, in which emancipation is the key element for a culture of health. It is considered that, due to the non-development of the articulation of different dimensions of strategic analysis, with a theoretical foundation, the tendency will be to continue producing health programs with predominantly regulatory, fragmented and reductionist characteristics.

A presente pesquisa visa analisar a dinâmica dos benefícios assistenciais do governo federal, buscando entender se a mesma se coaduna com a teoria dos ciclos eleitorais. Nesse sentido, foi avaliado se o número de concessões destes benefícios tenderia a crescer com a aproximação da eleições. Para atingir tal objetivo, foram utilizados dados mensais do número de concessões de três dos principais benefícios assistenciais brasileiros: o Benefício de Prestação Continuada, o Bolsa Família e o Auxílio Doença. Com base na análise das séries de tempo e dos dados em painel associados a estes últimos, foi possível detectar que a proximidade das eleições tende a afetar o número de concessões de benefícios assistenciais na maior parte dos casos analisados. Entretanto, a discussão dos resultados atingidos parece apontar no sentido de que os efeitos eleitorais encontrados não são tão somente resultados de manipulações eleitorais de políticos que visam à reeleição, mas frutos de uma dinâmica mais ampla, que seria característica de períodos eleitorais. / This research aims to analyze the dynamics of the welfare benefits of the federal government, seeking to understand whether it is consistent with the theory of electoral cycles. Accordingly, we assessed whether the number of concessions to these benefits tend to increase with the approaching elections. To achieve this, we used monthly data on the number of leases of three major Brazilian welfare benefits: the Benefício de Prestação Continuada, the Bolsa Família and Auxílio Doença. Based on the analysis of time series and panel data associated with the latter, it was possible to detect that the proximity of elections tends to affect the number of grants of welfare benefits in most cases analyzed. However, the discussion of the results indicate that the effects of elections are not solely the results of manipulations of politicians who seek reelection, but fruits of a wider dynamic that would be characteristic of elections.

Le vertige (V), l'étourdissement (E) et l'instabilité (I) sont des symptômes fréquents, traditionnellement considérés comme ayant des étiologies vestibulaires et extra-vestibulaires différentes. La prévalence de chaque symptôme et la manière dont ils sont liés entre eux ainsi qu'avec la migraine, l'agoraphobie, la susceptibilité au mal des transports (SMT), le malaise vagal (MV), l'anxiété/dépression (AD) et la prise de médicaments, ont été l'objet de cette étude. Un questionnaire auto-administré a été complété par 2897 adultes de la population lorraine, âgés de 18 à 86 ans, dont 1471 femmes. La prévalence sur un an du V était de 48,3%, celle de l'I de 39,1% et celle de l'E de 35,6%. Les VEI étaient corrélés entre eux et apparaissaient en général en diverses combinaisons (69,4%) ; 90% des épisodes de VEI avaient une durée inférieure ou égale à 2 mn et une fréquence < 1/mois. Les trois symptômes étaient similaires concernant leur prédominance féminine, le profil temporaire des épisodes et le lien avec les chutes et les nausées. Les VEI augmentaient avec le nombre de médicaments indépendamment de l'âge. Chaque VEI était corrélé avec chaque co-morbidité. Les facteurs de risque étaient pour l'agoraphobie : AD>sexe féminin>VEI, pour la SMT : sexe féminin > AD > migraine. En ajustant sur les trois VEI entre eux, le V reste un facteur de risque significatif pour chaque co-morbidité, suggérant que le V est un symptôme aussi peu spécifique que les deux autres et que les VEI représentent un spectre de symptômes résultant de diverses causes / Vertigo (V), dizziness (D) and unsteadiness (U) are common symptoms traditionally considered to result from different kinds of vestibular and non-vestibular dysfunctions. The prevalence of each symptom and how they relate to each other and to migraine, agoraphobia, motion sickness susceptibility (MSS), vaso-vagal episodes (VVE) and anxiety-depression (AD) was the object of this population-based study in north-eastern France. A self-administered questionnaire was returned by 2987 adults (age span 18-86 years, 1471 women). The 1-year prevalence for V was 48.3%, for U 39.1% and for D 35.6%. The VDU symptoms were correlated with each other, occurred mostly (69.4%) in various combinations rather than in isolation, less than once per month, and 90% of episodes lasted < or = 2 minutes and occurred < 1/month. The three symptoms were similar in terms of female predominance, temporary profile of the episodes and their link to falls and nausea. Symptom associations including I and symptom episodes of >1 hour increased the risk of falls. The number of drugs taken increased VDU even when controlling for age. Each VDU symptom was correlated with each co-morbidity. The risk factors were for agoraphobia: AD>female gender>VDU; for MSS: female gender>AD>migraine. Logistic regressions controlling for each vestibular symptom showed that V correlated with each co-morbidity, suggesting that V is a symptom as unspecific as the other two and that the three symptoms represent a spectrum resulting from a range of mechanisms or disorders

INTRODUÇÃO: O impacto do diagnóstico do câncer de cabeça e pescoço e as consequências de seu tratamento podem alterar profundamente a qualidade de vida de um indivíduo. OBJETIVOS: Realizar a validação psicométrica do Patients Concerns Inventory - PCI-HeN para o Português-Brasil, caracterizar nos momentos pré-tratamento e após o diagnóstico, os graus de ansiedade e depressão, a qualidade de vida, a intensidade dos sintomas, suas necessidades, preferências e atitudes em relação às informações, suas preocupações, expectativas, o grau de preenchimento de suas expectativas (pós-tratamento). MÉTODOS - Parte I: Estudo transversal. Após as etapas de tradução e adaptação transcultural, a validade de construto foi realizada pela comparação do PCI com o Questionário de Qualidade de Vida da Universidade de Washington (UW-QOL). Parte II: Estudo prospectivo longitudinal. Os participantes completaram a Escala de Ansiedade e Depressão (HADS), o Questionário de Qualidade de Vida da Universidade de Washington (UW-QOL), o Inventário de Sintomas do M.D. Anderson (MDASI- HeN), o Questionário de Informação dos Pacientes (QIP), a versão em Português validada do Inventário de Preocupações dos Pacientes (IPP), o Protocolo de Avaliação das Expectativas (PAE) e o Protocolo de Preenchimento das Expectativas (PPE). Na primeira etapa, os testes não paramétricos de Mann-Whitney ou Kruskal-Wallis foram utilizados para avaliar a associação do número de itens/profissionais selecionados com as características dos pacientes. O teste de Mann-Whitney também foi utilizado para associar os escores dos domínios do UW-QOL com os itens/profissionais específicos selecionados pelos pacientes. Associações entre os itens/profissionais específicos selecionados com as características dos pacientes foram avaliadas por meio do teste Qui-Quadrado ou o teste Exato de Fisher. RESULTADOS - Parte I: Oitenta e quatro pacientes participaram do processo de validação. Os itens mais selecionados pelos pacientes no IPP foram: medo do câncer voltar, boca seca, mastigar/comer, e fala/voz/ser entendido. Os profissionais mais assinalados pelos pacientes foram o fonoaudiólogo, dentista e psicólogo. Os domínios físico e sócio-emocional do UW-QOL apresentaram correlações significantes com o número de preocupações e de profissionais selecionados. Resultados - Parte II: As amostras foram constituídas respectivamente por 104 pacientes (pré-tratamento), 80 pacientes (aos 6 meses) e 62 pacientes (aos 12 meses). Em todos os momentos do estudo, a maioria dos pacientes apresentou escores de ansiedade e de depressão dentro dos limites de normalidade. A qualidade de vida apresentou um declínio nos primeiros meses, seguida por uma melhora geral ao longo do primeiro ano. Os sintomas mais assinalados no MDASIH& N foram dor, preocupações, problemas de sono e dificuldade para engolir/mastigar (pré-tratamento), dificuldades para engolir/mastigar, boca seca e catarro (aos 6 meses) e boca seca, dificuldades para engolir/mastigar e preocupações (aos 12 meses). Em todas as épocas, a maioria dos pacientes desejava receber toda a informação possível. As principais preocupações dos pacientes e os principais profissionais por eles assinalados, foram: mastigar/comer, tratamento do câncer, fala/voz/ser entendido e engolir; fonoaudiólogo, nutricionista e oncologista/radioterapeuta. Em geral, as expectativas dos pacientes no momento prétratamento, eram boas. As expectativas dos pacientes em relação aos itens ligados à alimentação: mastigar/comer, boca seca, engolir, paladar e perda de peso foram as menos preenchidas após o tratamento. Foram encontradas diversas associações significativas entre a qualidade de vida global dos pacientes e o grau de preenchimento de várias expectativas após o tratamento. CONCLUSÕES: O Inventário de Preocupações dos Pacientes-IPP pode ser considerado apropriado e psicométricamente válido para uso em pacientes brasileiros portadores de câncer de cabeça e pescoço. Ao longo de um ano após o diagnóstico os pacientes com neoplasias de cabeça e pescoço tendem a apresentar diminuição de comorbidades (ansiedade e depressão), boa qualidade de vida (com declínio aos 6 meses), predomínio de sintomatologia física/funcional associada à preocupações, desejam todas as informações possíveis, têm preocupações eminentemente físicas/funcionais, associadas ao medo de recidiva da doença e priorizam o contato com os clínicos responsáveis pelo tratamento e reabilitação, têm suas expectativas gerais preenchidas e o nível de satisfação de suas expectativas impacta a qualidade de vida global / INTRODUCTION: The impact of cancer diagnosis and consequence of its treatment have a major effect on quality of life on these patients. OBJECTIVES: To perform a psychometric validation of the Patients Concerns Inventory - PCI-HeN in Portuguese-Brazil and characterize, at pre-treatment, and after diagnosis, the degree of anxiety and depression of patients, their quality of life, severity of symptoms, their preferences regarding information, their concerns, expectations, extent to which expectations were met (post-treatment). METHODS - Part I: Cross-sectional study. After the translation and transcultural adaptation stages, construct validity was determined by comparing the PCI against the University of Washington Quality of Life Questionnaire (UW-QOL). Part II: Prospective, longitudinal study. Participants completed the Anxiety and Depression Scale (HADS), the University of Washington Quality of Life Questionnaire (UW-QOL), the MD Anderson Symptom Inventory (MDASI-HeN), the Information Styles Questionnaire (ISQ), the validated Portuguese version of the Patient Concerns Inventory (PCI), the Expectations Assessment Protocol (EAP), and the Meeting Expectations Protocol (MEP). In stage one, non-parametric Mann-Whitney or Kruskal-Wallis tests were employed to assess the association of number of items/professionals selected with patient characteristics. The Mann-Whitney test was also used to associate scores on the UW-QOL domains with specific items/professionals selected by patients Associations of specific items/professionals selected with patient characteristics were assessed using the Chisquare or Fisher Exact tests. RESULTS - Part I: Eighty-four patients took part in the validation process. The items most frequently selected by patients on the PCI were: fear of cancer coming back, dry mouth, chewing/eating and speech/voice/being understood. The professionals most indicated by patients were speech/language therapist, dentist and psychologist. The physical and social-emotional domains of the UW-QOL were significantly correlated with number of concerns and of professionals selected. Results - Part II: The samples comprised 104 patients (pretreatment), 80 patients (at 6 months) and 62 patients (at 12 months), respectively. At all study timepoints, anxiety and depression scores of most patients were within normal limits. A decline in quality of life was evident in the first few months, followed by a general improvement during the course of the first year. The most frequently reported symptoms on the MDASI-H&N were pain, concerns, disturbed sleep and difficulty swallowing/chewing (pre-treatment), difficulties swallowing/chewing, dry mouth and catarrh (at 6 months), and dry mouth, difficulties swallowing/chewing and concerns (at 12 months). At all timepoints, most patients wished to receive all possible information. The main patient concerns and professionals selected were: chewing/eating, cancer treatment, speech/voice/being understood, swallowing; speech-therapist, nutritionist and oncologist/radiotherapist. In general, patient expectations at pre-treatment were good. Patient expectations for food-related items: chewing/eating, dry mouth, swallowing, taste and weight loss were the least met after treatment. A number of significant associations were found between global quality of life of patients and extent to which various expectations were met after treatment. CONCLUSIONS: The Patient Concerns Inventory-PCI was shown to be appropriate and psychometrically valid for use in Brazilian head and neck cancer patients. During the course of one year after diagnosis, the head and neck cancer patients tended to exhibit a decrease in comorbidities (anxiety and depression), good quality of life (with decline at 6 months), predominance of physical/functional symptoms associated with concerns, desire for all possible information, predominantly physical/functional concerns, associated with fear of disease recurrence and prioritized contact with the physicians responsible for treatment and rehabilitation, had general expectations met and the extent to which expectations were met impacted global quality of life

RESUME<p>La Trypanosomiase Humaine Africaine (THA) appelée également « maladie du sommeil» est une maladie parasitaire provoquée par un protozoaire du genre Trypanosoma dont deux sous-espèces (T. brucei gambiense et T. brucei rhodesiense) sont pathogènes à l’homme. La stratégie de lutte contre cette maladie est essentiellement basée sur le dépistage précoce et le traitement des malades, complété avec le contrôle du vecteur. Cependant, l’utilisation du service de dépistage de la THA par les communautés exposées représente un défi majeur. L’adhésion aux campagnes de dépistage actif avec des équipes mobiles spécialisées était en-dessous de 50% dans certains villages endémiques fin des années nonante. De surcroît, l’utilisation des services de santé fixes en RDC est si faible que ceci compromet le dépistage passif dans les formations sanitaires fixes. Notre hypothèse est que cette faible utilisation des services de santé pourrait elle-même être due à un problème d’acceptabilité du dépistage et traitement de la THA par les communautés vivant dans les zones de transmission de la THA. Tout ceci compromet l’élimination de la THA comme problème de santé publique, un but que s’est fixé la communauté internationale d’ici 2020.<p>Ce travail a comme objectif d’explorer cette dimension socioculturelle de la maladie qui est souvent négligée dans le contrôle de la THA et générer une meilleure connaissance de ces aspects.<p><p>Nous avons réalisé cinq études en total pour adresser la question de la sous-utilisation des services de dépistage et traitement de la THA par les communautés et sa relation avec l’acceptabilité des services. Nous avons d’abord développé une première étude qui évalue les résultats du traitement de la THA en analysant rétrospectivement les données de routine du programme de contrôle de la THA pour l’année 2006 à 2008. Ensuite, nous avons réalisé trois études qualitatives par focus group (groupe focalisé) et entretiens individuels pour documenter la dimension socioculturelle de la lutte contre la THA. D’abord une étude qui a exploré les perceptions sur la THA dans la communauté, suivi par une étude qui explore les perceptions sur le traitement de la THA et une autre qui se concentre sur les pratiques diagnostics des professionnels de santé face à un syndrome neurologique en contexte de ressources limitées. <p><p>Une cinquième étude combine une enquête-ménage avec des focus groups et des entretiens individuels pour explorer les perceptions de la communauté sur la santé en général et les services de santé. <p>Nous avons comparé les obstacles à l’utilisation des services de dépistage et traitement de la THA identifiés dans ce travail avec les messages de sensibilisation sur la THA utilisés au programme de contrôle de la THA en RDC et nous avons développé des recommandations stratégiques.<p><p>L’évaluation des indicateurs de performances sur l’issue de traitement montre que le taux de suivi post-thérapeutique est faible dans son ensemble :25 % pour le premier suivi de six mois et moins d’un pourcent des patients revient pour la dernière visite de contrôle au mois 24. Nous avons aussi observé dans cette étude un taux d’échec au mélarsoprol et à la pentamidine respectivement de 30% et de 22 % au Kasaï Oriental qui sont cependant difficilement interprétables, car le dénominateur est incomplet. Comme très peu de patients reviennent au contrôle post-thérapeutique, cette proportion est probablement biaisée vers ceux qui sont en échec de traitement.<p><p>L’étude de perception de la THA montre que la maladie est bien connue dans les communautés vivant dans les zones à risque. Par contre, plusieurs obstacles au dépistage et traitement de la THA ont été identifiés. Les plus importants sont :la toxicité des médicaments de la THA, les obstacles financiers, l’inadéquation entre le programme de dépistage des équipes mobiles et les occupations des communautés, les interdits qui accompagnent le traitement de la THA, le manque de confidentialité et la peur de la ponction lombaire. <p>L’étude sur la perception du traitement de la THA a montré que le mélarsoprol est perçu comme un médicament toxique et est surnommé « médicament des interdits ». Par contre, le régime NECT est perçu comme un nouveau médicament moins toxique qui a rendu les interdits liés au mélarsoprol obsolètes sauf un seul, celui de ne pas avoir de rapport sexuel pendant la période de traitement et de suivi post thérapeutique qui est de 6 mois. Les interdits ont été instaurés de manière empirique par les professionnels de santé et les communautés pour mitiger les effets indésirables du mélarsoprol. Leur violation pourrait entrainer des conséquences graves et mortelles. Ces interdits sont fortement ancrés dans les croyances de la communauté et constituent aujourd’hui un obstacle au dépistage et traitement. <p><p>L’étude sur les pratiques diagnostiques des professionnels de santé en matière de syndrome neurologique en contexte de ressources limitées a montré qu’en zone rurale le diagnostic est principalement clinique. Les obstacles perçus au diagnostic de confirmation sont essentiellement d’ordre financier puisque le patient doit tout financer de sa poche. Autres obstacles évoqués sont le manque d’outils de diagnostic et la perception de la communauté qui voit le clinicien comme un devin (petit dieu) ou oracle capable de « deviner » directement la maladie sans passer par un processus diagnostique de laboratoire.<p>L’étude sur les perceptions de la santé et des services de santé a montré que les capacités de travailler (82%) et les capacités de se mouvoir (66%) sont les signes de bonne santé les plus perçus. 90% des responsables des ménages perçoivent positivement la santé de leur ménage. Les opinions sur le service de santé sont partagées.<p><p>Les études présentées dans ce travail ont généré des nouvelles connaissances sur la dimension socioculturelle de la THA. L’analyse des messages de sensibilisation sur la THA utilisés par le programme de contrôle de la THA en RDC en termes de comparaison avec les obstacles au dépistage et traitement de la THA identifiés dans ce travail montre que ces aspects socioculturels bien qu’étant des véritables goulots d’étranglements dans la dynamique de la lutte contre la THA ne sont pas bien ciblés par la communication sur la THA. <p>Les perspectives des communautés exposées au risque de la THA doivent être adressées par un dialogue continu entre professionnels de santé et communautés adapté aux réalités locales. Ainsi il sera possible d’améliorer de manière opérationnelle les stratégies d’information, éducation et communication, et de façon plus large, le dépistage et traitement de la THA en intégrant la dimension socioculturelle de la THA dans la politique de lutte contre la THA. <p><p>SUMMARY<p>Human African Trypanosomiasis (HAT), also known as “sleeping sickness” is a parasitic disease caused by protozoa of the species Trypanosoma. There are two types that infect humans, Trypanosoma brucei gambiense and Trypanosoma brucei rhodesiense. The strategy used to control sleeping sickness consists of early case detection and treatment of patients, together with vector control. Meanwhile, utilization/access to HAT screening by the affected communities remains a major challenge. Adherence to active screening programs with mobile units was below 50% in certain endemic villages end of the 90’s. Moreover, utilization of fixed health facilities in DRC is so low that it compromises passive case finding. Our hypothesis is that this low utilization of health services is caused by a problem of acceptance of case detection and treatment of HAT by the communities living in the HAT transmission zones. This compromises the target of the international community to eliminate HAT as a public health problem by 2020. This thesis wants to explore and tries to generate more knowledge on the socio-cultural aspect that is often neglected in the control of HAT. <p><p>We conducted five studies to address the lack of community participation in HAT screening and treatment activities and the relation with acceptance of these services. <p>The first study evaluated the results of HAT treatment by retrospectively analyzing data of the routine HAT control program for the period 2006-2008. <p><p>Afterwards we performed three qualitative studies consisting of focus group discussions and individual interviews to document the socio-cultural dimension of the fight against HAT. The first study explored the community perceptions regarding sleeping sickness. The second study explored the perceptions regarding HAT treatment and a third study focused on diagnostic practices of health professionals in low-resource settings facing a neurological syndrome. <p><p>The fifth study consists of a household survey, focus group discussions and individual interviews to explore community perception regarding health in general and health services. We compared the identified barriers to screening and treatment of HAT with awareness messages on sleeping sickness used by the HAT control program in DRC and we developed strategic recommendations. The evaluation of performance indicators for treatment showed that compliance with post-treatment follow-up is very poor: 25% for the first post-treatment follow-up examination at six months and less than 1% of the patients returns for the final examination at 24 months. In this study we also observed a treatment failure rate of respectively 30% and 22% for melarsoprol and pentamidine in Kasai-Oriental. However, these date are difficult to interpret because of an incomplete denominator. As only few patients return for follow-up visits, this proportion is probably biased towards those in treatment failure.<p> <p>The study on the perception of sleeping sickness shows that the disease is well known amongst the communities living in the endemic areas. However, several screening and treatment barriers were identified. The most important are: drug toxicity, financial barriers, the incompatibility between the itineraries of the mobile screening teams and the local communities’ activities, the prohibitions related to HAT treatment, lack of confidentiality and fear of lumbar punctures. The study on the perceptions regarding HAT treatment show that melarsoprol is perceived as a toxic drug and is nicknamed the ‘taboo drug’. On the other hand the NECT regime is perceived as the new drug that is less toxic and that has abolished all the taboos of melarsoprol with the important exception of sexual intercourse during the treatment period and the post-treatment follow-up period of six months. <p><p>The prohibitions have been established empirically by healthcare providers and communities to mitigate the side effects of the melarsoprol regimen. Violating these restrictions is believed to cause severe and sometimes mortal complications. Communities adhere strictly to these prohibitions and this constitutes a barrier for HAT screening and treatment.<p><p>The study focusing on diagnostic work-up of neurological syndromes in low-resource settings by health care providers has shown that in rural areas diagnosis is usually clinical. Barriers to confirmation of diagnosis are mainly related to the purchasing power of the patient. Other reported barriers are a lack of diagnostic tools and the communities’ perceptions associated with the care provider. Clinicians are perceived as diviners being able to directly identify the cause of the illness without using laboratory tests. The study regarding the perceptions on health and health services has shown that ability to work (82%) and ability to move (66%) are the most perceived signs of good health. 90% of the household responsibles positively perceive the health of their family. The opinions on the health services are divided. <p><p>The studies presented in this thesis have generated new insights on the socio-cultural dimension of HAT. The analysis of the awareness messages on HAT in DRC compared with the reported HAT screening and treatment barriers have shown that <p>although these sociocultural aspects are real bottlenecks in the dynamic of the fight against HAT, they are not targeted by the communication on HAT. <p><p>The prospects for communities at risk of HAT should be addressed through continuous dialogue between health professionals and communities adapted to local realities.<p><p>It will thus be possible to operationally improve the information strategies, education and communication, and more broadly, screening and treatment of HAT by integrating the socio-cultural dimension in the fighting policy against sleeping sickness.<p> / Doctorat en Sciences / info:eu-repo/semantics/nonPublished

Made available in DSpace on 2017-07-24T19:38:12Z (GMT). No. of bitstreams: 1 VivianePaula.pdf: 3188050 bytes, checksum: 1b1ca9983470b6e6a3669cfd52a8c846 (MD5) Previous issue date: 2007-03-06 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / The enzymes dihydrofolate reductase-thymidylate synthase (DHFR-TS) and pteridine reductase (PTR) are involved in the pterin/folate dependent metabolism; together they represent an important target for chemotherapy of parasitic leishmanias and trypanosomes. Xray crystallography was used to elucidate accurately the structure of the PTR1 enzyme from Trypanosoma brucei in complex with inhibitors which are analogous to the substrate. The ligands assayed for crystallization were the substrate folate and the inhibitors melamine, 6-thioguanine, WSG1012, WSG1034, WSG3065, WSG3066 and WSG3067. Of these, four yielded crystals with diffraction patterns sufficient for a complete dataset. WSG3065 (later revealing the lack of the ligand), WSG3066 and WSG3067 are three of the several structures presented in this work which came from the cited crystallization assays; added to these are the refined structures complexed with triamterene and cyromazine, proceeded from two other datasets already available. The datasets were processed with the programs Mosflm / Scala and Xds / Xscale, the structures were refined using the programs CNS and Refmac5 and validated with the programs Procheck, Whatcheck, Sfcheck and ValidationPDB. All refined structures belong to the space group P21 with unit cells around a = 79, b = 90, c = 82, b = 115, 4 monomers each of 268 residues per asymmetric unit and complex active sites. Besides the inhibiting ligands (except WSG3065) present in the structure, other ligands were found either near or outside the active site: dithiothreitol, glycerol, ethylene glycol, sodium and acetate ions. Analyses on the ligand positions and corresponding interactions with the protein were carried out to understand modes of inhibition and to guide the design or the discovery of new compounds which are potent, but selective to the parasitic enzyme, inhibitors. Thereby, initial docking studies were performed aiming at identifying new molecules or lead compounds with inhibitory capabilities. / As enzimas dihidrofolato redutase-timidilato sintase (DHFR-TS) e pteridina redutase (PTR) estão envolvidas no metabolismo pterina/folato dependente; juntas, representam um importante alvo para a quimioterapia de leishmanias e tripanossomas parasitas. A Cristalografia por Raios X foi utilizada para elucidar acuradamente a estrutura da enzima PTR1 de Trypanosoma brucei complexada com inibidores que são análogos ao substrato. Os ligantes ensaiados para cristalização foram o substrato folato e os inibidores melamina, 6-tioguanina, WSG1012, WSG1034, WSG3065, WSG3066 e WSG3067. Destes, quatro forneceram cristais com padrões de difração suficientes para um conjunto de dados completo. WSG3065 (mais tarde revelando ausência do ligante), WSG3066 e WSG3067 são três das estruturas apresentadas neste trabalho derivadas dos ensaios de cristalização citados; somadas a estas estão as estruturas refinadas dos complexos com triantereno e ciromazina, provenientes de dois outros conjuntos de dados anteriormente disponíveis. Os conjuntos de dados foram processados com os programas Mosflm / Scala e Xds / Xscale, as estruturas refinadas usando-se os programas CNS e Refmac5 e validadas com os programas Procheck, Whatcheck, Sfcheck e ValidationPDB. Todas as estruturas refinadas apresentaram grupo espacial P21 com celas unitárias aproximadas a = 79 = 90, c = 82 , b = 115, 4 monômeros de 268 resíduos cada por unidade assimétrica e sítios ativos complexos. Além dos ligantes inibidores presentes nas estruturas (exceto WSG3065), outros ligantes foram encontrados próximos ou fora do sítio ativo: ditiotreitol, glicerol, etilenoglicol, íons sódio e íons acetato. Análises das posições dos ligantes inibidores e correspondentes interações com a proteína foram realizadas a fim de se entender modos de inibição e, em particular, assistir ao planejamento ou à descoberta de novos compostos que sejam inibidores potentes, mas seletivos, para a enzima parasitária. Assim, estudos iniciais de atracagem (docking) foram realizados visando identificar novas moléculas ou arcabouços com capacidades inibitórias.

Made available in DSpace on 2016-04-26T20:21:27Z (GMT). No. of bitstreams: 1 Helio Gustavo Alves.pdf: 717855 bytes, checksum: 6f8f8163ce42bf81feccfc8f6150e1fa (MD5) Previous issue date: 2012-11-28 / This paper aims at tracing the connection between sickness-assistance and disability retirement with the provision pension and rehabilitation and the professional qualification. The goal is to show that if there was a program of rehabilitation and professional habilitation and if it were applied to the policyholders apart for disability, besides these ones have a chance of qualifying to another profession, the INSS would no longer afford the benefits and raise again with social contributions by the policyholders return to work, as well as rescuing the principle of human dignity for the worker being rehabilitated and professionally qualified. Therefore, the effectiveness of rehabilitation programs and professional qualification would make INSS to have great savings for failing to pay benefits, and also to start receiving social security contributions, and mainly, would guarantee the policyholders the right to return to working life, preserving, as a consequence, their human dignity / O presente trabalho tem como objetivo traçar a ligação entre o auxílio-doença e a aposentadoria por invalidez com a prestação previdenciária reabilitação e a habilitação profissional. Tem-se como meta demonstrar que se existisse o programa de reabilitação e habilitação profissional e se o mesmo fosse aplicado aos segurados afastados por incapacidade, além destes terem a chance da qualificação para outra profissão, o INSS deixaria de bancar os benefícios e voltaria a arrecadar com as contribuições sociais pelo retorno do segurado ao trabalho, bem como, resgataria o princípio da dignidade da pessoa humana por ter sido o trabalhador reabilitado e habilitado profissionalmente. Portando, a eficácia do programa de reabilitação e habilitação profissional faria com que o INSS tivesse uma grande economia por deixar de pagar os benefícios e, ainda, por passar a receber as contribuições sociais e, principalmente, se garantiria ao segurado o direito de volta à vida laboral, preservando-se, como consequência, sua dignidade humana

INTRODUÇÃO: A Miastenia gravis (MG) é uma desordem imunológica com antígenos alvos conhecidos, com produção de anticorpos contra o receptor nicotínico de acetilcolina, AAChR e Musk, na junção neuromuscular, dificultando a transmissão do impulso nervoso e provocando fadiga e fraqueza flutuantes na musculatura ocular, facial, dos membros e respiratória. A terapêutica sintomática com inibidores de acetilcolinesterase e a etiopatogênica como a timectomia, corticosteróides, agentes citostásticos e imunoglobulinas são utilizadas e indicadas em acordo com a incapacidade e gravidade clínicas. A qualidade de vida (QV) é uma ferramenta utilizada para quantificar a eficácia e a resposta às terapêuticas adotadas, avaliar a efetividade e custos econômicos de novas estratégias terapêuticas, contribuir para planejar e aplicar os recursos para a saúde na comunidade. OBJETIVO: Avaliar a influência da terapêutica na QV e evolução clínica dos pacientes com MG. CASUÍSTICA: Foram avaliados 51 pacientes com MG, 38 submetidos a tratamento conservador e 13 timectomizados. MÉTODOS: Os instrumentos genéricos quantitativos de QV como WHOQOL, qualidade de vida relacionada à saúde (QVRS) SF-36, e depressão (BDI) foram utilizados. ESTATÍSTICA: Empregou-se análise univariada com os testes de Wilcoxon, U-Mann-Whitney, Fisher e razão de chance para avaliar a evolução clínica, a QV e QVRS e depressão; análise multivariada para a caracterização dos dois grupos de terapêutica considerando a interação de múltiplos fatores. RESULTADOS: O grupo submetido à terapêutica conservadora foi constituído por 16 pacientes do sexo masculino e 22 do feminino, com média de idade de 33,71±2,76 anos; o grupo timectomizado foi constituído por 6 homens e 7 mulheres, média de idade de 32,23±4,16 anos. Os pacientes do grupo conservador apresentaram melhora clínica estatisticamente significante (p <0,05) dos aspectos clínicos, da QV, da QVRS e depressão. Os timectomizados apresentaram melhora estatisticamente significante dos aspectos físicos e psicológicos da QV e QVRS e depressão, e melhora clínica evidente e não significante (p = 0,06). A análise multivariável mostrou r=0,65 para comparação das áreas; Wilks? Lambda para analisar as distâncias, X2 = 22,67; gl = 7; p = 0,05; as medidas centrais mostraram média = -0,42 dp = 1,0 para o grupo conservador; e média = 1,22, dp = 1,0 para o grupo timectomizado. CONCLUSÕES: Nesta amostra e no período avaliado constatamos que: 1) Os pacientes submetidos ao tratamento conservador apresentaram diferenças significantes com melhora clínica acentuada, de QV, de QVRS e depressão; 2) os timectomizados apresentaram melhora clínica, da QV e QVRS em seus aspectos físicos e psicológicos, e efetiva e significante melhora dos índices de depressão; 3) a análise multivariada revelou que a timectomia produziu efeito benéfico e significativo na recuperação da saúde e bem estar nos pacientes. / INTRODUCTION: Myasthenia gravis (MG) is an immune mediated disease with production of antibodies against post-synaptic acetylcholine receptor of neuromuscular junctions (AAChR,Musk) and orders in nervous impulse transmission. The disease´s clinical characteristics include fatigability and fluctuating weakness of voluntary muscles. Acetylcholinesterase inhibitors, thymectomy, corticosteroids, cytostatic agents and immunoglobulin are widely used and are indicated according to the patient´s disability and severity. Clinical manifestations, Quality of life (Qol), health-related (HRQol) analysis are used to evaluate response to therapy. Nowadays, Qol index is an important tool to evaluate the medical outcome, treatment efficacy, cost effectiveness and net benefit of new therapeutic strategies to determine whether their cost can be justified in the planning and application of health policies. OBJECTIVE: To evaluate the influence of conservative treatment and thymectomy on Qol and clinical response of myasthenic patients. SUBJECTS: Fifty-one myasthenic patients were chosen; 38 were submitted to conservative therapy and 13 to thymectomy. METHODS: Quantitative Qol tools such as WHOQOL, SF-36 and BDI were employed to evaluate Qol, HRQol and depression. STATISTICS: Univariate analysis by means of the Wilcoxon, U-Mann Whitney and Fisher tests, Chi-Square, odd ratio were used to follow the patient?s clinical status, evolution of Qol, HRQol and depression. Discriminant analysis was used to analyze the interation of multiple factors in the characterization of conservative and thymectomized groups. RESULTS: The conservative group of patients was constituted of 16 males and 22 females average age 33.71±2.76 years; the thymectomized group was composed of 6 males, 7 females, average age 32.23±4.16 years. Patients submitted to conservative therapy improved significantly in clinical progress, Qol, HRQol and depression. The follow-up of thymectomized patients showed a strong trend for clinical progress and significant improvement in physical and psychological Qol domains as well as in depression index. Discriminant analysis showed r = 0.65, p <0.05; Wilk?s Lambda X2 = 22.67, gl = 7; mean = -0.42, SD = 1.0 for conservative group; and mean = 1.22, SD = 1.0 for timectomized group. CONCLUSIONS: A prospective evaluation of a myasthenic patients sample revealed: 1) conservative treatment was found to have a strong and significant impact on clinical progress, Qol, HRQol and depression; 2) Thymectomy partly influenced Qol, specially physical and psychological aspects. There was also improvement in depression and clinical progress; 3) the evaluation of multiple parameters pointed to a strong and positive influence of thymectomy in the recovery of the patients.

Introdução: A presente tese, a partir de uma análise estratégica, articula as dimensões da teoria organizacional no campo da administração pública, o objeto de estudo-trabalho processo saúde-doença, a prática profissional integral e o planejamento estratégico situacional, por meio da Estratégia de Atenção Primária à Saúde. O propósito é o de, a partir da articulação das dimensões referidas, compreender e situar os Programas de Saúde do México a nível nacional e do Distrito Federal, a nível local, e estabelecer sob que pressuposto, de bem-estar ou qualidade, se encontram elaborados. Revisão da literatura: Entre outros aspectos revisados, destaca-se a importância da dimensão da teoria organizacional (normativa, sistêmica e cultural-crítica) como categorias fundamentais para compreender a relação entre as unidades primárias de análise de cada teoria e as categorias de indivíduo-grupo, organização e sociedade. Apresenta-se como uma segunda dimensão, a inter-relação entre a teoria e a prática profissional integral do processo saúde-doença, assim como suas conexões com a teoria da organização. Descrevem-se, como terceira dimensão, os aspectos teóricos do planejamento estratégico situacional e sua relação com a Estratégia de Atenção Primária à Saúde. Desenvolvem-se os pressupostos de bem-estar e qualidade, sob os princípios sociais, econômicos e políticos em que se encontram os Programas. Objetivo: Estabelecer através da análise estratégica, em suas diferentes dimensões, o tipo de teoria organizacional, os elementos teórico-metodológicos do planejamento estratégico sob as premissas da Estratégia da Atenção Primária à Saúde e a inter-relação com o objeto de estudo-trabalho e a prática profissional, que permita determinar o tipo de pressuposto de bem-estar ou qualidade que sustenta aos Programas nacional e local estudados. Metodologia: O estudo foi realizado em base ao método qualitativo de estudo de caso, para compreender o processo da análise estratégica, a partir da interdependência dialógica dos marcos geral, particular e singular dos Programas nacional e local. A pesquisa se enfocou nas informações imersas nos Programas de Saúde, a través de uma revisão dialógica dos documentos oficiais e em entrevistas semidirigidas, realizadas com planejadores das respectivas Secretarias de Saúde. Assim, foram descritas as unidades primárias de análise do campo da administração pública que permite diferenciar a forma de estabelecer a teoria da organização prevalente nos Programas. Ao mesmo tempo, se definiram 9 cenários matriciais e 72 subcenários lineares, para compreender a relação do processo saúde-doença e a prática profissional, como elementos chaves que tem uma correspondência com o objeto de estudo-trabalho e sua resposta científico-técnico-social de acordo com a teoria da organização, com o planejamento estratégico situacional ou empresarial, e os pressupostos de qualidade e bem-estar utilizado pelos dois Programas. Resultados: O Programa Nacional tende a uma teoria organizacional de tipo sistêmica, sob o pressuposto teórico de qualidade, sendo que seu objeto de estudo se enfoca para a doença e/ou a saúde, em forma isolada. Em decorrência, a prática profissional está baseada no modelo biomédico tradicional economicista, formal e científico, fundamentado em um planejamento estratégico empresarial; dimensões que corroboram o pressuposto teórico de qualidade. O Programa do Distrito Federal se situa em uma teoria organizacional de tipo sistêmica com tendência à teoria cultural-crítica, sendo seu objeto de estudo o processo saúde-doença e a prática profissional se constitui por ações integradas, em um modelo de atenção ampliada de saúde, ainda que separe o campo da atenção pessoal da coletiva. Neste sentido, o planejamento estratégico é de tipo empresarial, com alguns conteúdos sociais que incide para o pressuposto teórico do bem-estar. Discussão e Considerações gerais: O processo de análise estratégica permitiu compreender que em seu contexto teórico-metodológico o Programa nacional é prescritivo, disjuntor e normatizador, e o Programa local é prescritivo, articulador e social. Existe neste último, a possibilidade de construir a articulação das diferentes dimensões desenvolvidas neste trabalho. A rede estaria constituída pela conjunção da teoria organizacional cultural - critica, pelo objeto de estudo processo saúde-doença e por uma prática profissional social, desenvolvidas por meio do planejamento estratégico situacional, sob os elementos constitutivos da Estratégia de Atenção Primária à Saúde. Este processo pode incidir em uma futura sociedade do bem-estar, na que a emancipação seja o elemento chave para uma cultura da saúde. Considera-se que, de não desenvolver-se a articulação de diferentes dimensões da análise estratégica, com uma base teórica de sustentação, se seguirá produzindo programas de saúde com características predominantemente regulatórias, fragmentadas e reducionistas. / Introduction: This thesis, based on a strategic analysis, articulates the dimensions of organizational theories in the field of public administration, the subject matter of health-sickness process study-work, full professional practice and situational strategic planning, by means of the Strategy of Primary Attention to Health. The purpose is to comprehend and place the Health Programs of Mexico at the national level and of the Federal District at the regional level, with a basis on the articulation of the aforesaid dimensions, and to establish under which assumption, of wellbeing or quality, they are prepared. Review of literature: In addition to other reviewed aspects, emphasis is placed on the importance of the dimension of organizational theories (normative, systemic and cultural-critical) as essential category for understanding the relation between the primary units of analysis of each theory and the categories of individual-group, organization and society. A second dimension to appear is the interrelation between theory and full professional practice of the health-sickness process, as well as its connections with the theory of organization. The theoretical aspects of situational strategic planning and its relation with the Strategy of Primary Attention to Health are described as a third dimension. The assumptions of wellbeing and quality are developed under the social, economic and political principles in which the Programs can be found. Goal: To establish, by means of strategic analysis, in its different dimensions, the type of organizational theory, the theoretical-methodological elements of strategic planning under the assumptions of the Strategy of Primary Attention to Health and the interrelation with the study-work subject and professional practice, which permits the determination of the type of assumption of wellbeing or quality that sustains the national and regional Programs studied. Methodology: The study was carried out with a basis on the qualitative case study method, to understand the strategic analysis process from the dialogic interdependence of the general, particular and singular milestones of the national and regional Programs. The survey focused on information included in Health Programs, through a dialogic review of official documents and in semi-targeted interviews, held with planners from the respective Departments of Health. Hence a description was made of the primary units of analysis of the field of public administration that permits the differentiation of the manner of establishing the theory of organization that is prevalent in the Programs. At the same time, 9 matricial scenarios and 72 linear sub-scenarios were defined to understand the relation of the health-sickness process and professional practice, as key elements that establish a correspondence with the study-work subject matter and its scientific-technical-social response is in conformity with the theory of organization, with situational or corporate strategic planning, and the assumptions of quality and wellbeing utilized by the two Programs. Results: The National Program is conducive to an organizational theory of the systemic type, under the theoretical assumption of quality, where its study subject is focused on sickness and/or health, in an isolated manner. Consequently, professional practice is based on the economicist, formal and scientific traditional biomedical model, founded on corporate strategic planning; dimensions that corroborate the theoretical assumption of quality. The Program of the Federal District is situated in an organizational theory of the systemic type, which is conducive to the cultural-critical theory. Its study subject is the health-sickness process and professional practice comprises of integrated actions, in a model of expanded attention to health, even though it separates the field of personal attention from the collective field. To this effect, strategic planning is of the corporate type, with some social contents that comes within the scope of the theoretical assumption of wellbeing. Discussion and General Considerations: The strategic analysis process made it possible to understand that in its theoretical-methodological context the national Program is prescriptive, disjunctive and regulatory, and the local Program is prescriptive, articulating and social. The latter features the possibility of building the articulation of the different dimensions developed in this study. The network is apparently formed by the conjunction of the cultural-critical organizational theory, the health-sickness process study subject and a social professional practice, developed by means of situational strategic planning, under the constitutive elements of the Strategy of Primary Attention to Health. This process can lead to a future society of welfare, in which emancipation is the key element for a culture of health. It is considered that, due to the non-development of the articulation of different dimensions of strategic analysis, with a theoretical foundation, the tendency will be to continue producing health programs with predominantly regulatory, fragmented and reductionist characteristics.

Human African trypanosomiasis (sleeping sickness) is a devastating disease which is endemic in parts of sub-Saharan Africa. It is caused by the protozoan parasite T. brucei, which are transmitted by the bite of infected tsetse flies. Although the disease is fatal if left untreated, there is a lack of safe, effective and affordable drugs available; therefore new drugs are urgently needed. The aim of the work presented in this thesis is to develop novel trypanocidal compounds. It is divided into two parts to reflect the two distinct strategies employed to achieve this aim. The first part focuses on the inhibition of glycophosphoinositol (GPI) anchor synthesis by inhibiting the Zn2+-dependent enzyme, GlcNAc-PI de-N-acetylase. Trypanosomes have a variable surface glycoprotein (VSG) coat, which allows them to evade the human immune system. The GPI anchor attaches the VSG to the cell membrane; therefore inhibiting GPI synthesis should expose the parasite to the immune system. Initially, large substrate analogues were synthesized. These showed weak inhibition of the enzyme. Zinc-binding fragments were screened, and small molecule inhibitors based on salicylhydroxamic acid were then synthesized. These compounds showed modest inhibition, but the excellent ligand efficiency of salicylhydroxamic acid indicates this may be a promising starting point for further inhibitors. The second part details the P2 strategy. The P2 transporter is a nucleoside transporter unique to T. brucei, which concentrates adenosine. The transporter also binds and selectively concentrates compounds that contain benzamidine and diaminotriazine P2 motifs, which can enhance the potency and selectivity of these compounds. The sleeping sickness drugs melarsoprol and pentamidine contain P2 motifs. Compounds comprising a P2 targeting motif, a linker and a trypanocidal moiety were synthesized. Initially, a diaminotriazine P2 motif was attached to a trypanocidal tetrahydroquinoline (THQ) protein farnesyl transferase (PFT) inhibitor, with limited success. The P2 strategy was also applied to a non-selective, trypanocidal, quinol moiety. The quinol moiety was attached to diaminotriazine and benzamidine P2 motifs, and an increase in selectivity for T. brucei over MRC5 cells was observed.