Orientador: Íris Fenner Bertani / Banca: Regina Maura Rezende / Banca: Cirlene Aparecida Hilário da Silva Oliveira / Resumo: A estratégia Programa Saúde da Família (PSF) tem avançado no Brasil, por meio da mudança de conceito sobre saúde e doença, metodologias empregadas que favorecem a prevenção e promoção da saúde, a facilidade de acesso, o vínculo entre equipe e comunidade e os canais de desenvolvimento de cidadania. O trabalho das Equipes de Saúde da Família (ESF) é voltado para o cuidado integral das pessoas, ou seja, a atenção à saúde desde a criança até a pessoa idosa, como também, o estudo do contexto de vida que as rege, como por exemplo, as questões de epidemiologia e saneamento básico. Uma das ações desenvolvidas pelas ESF é a atenção às pessoas portadoras de hipertensão arterial sistêmica (HAS), promovendo a prevenção secundária, aquela que evita o surgimento de agravos da doença. Esse trabalho é realizado por meio de grupos sócio-educativos, da clínica tradicional (consulta médica) e orientações dos agentes comunitários de saúde (ACS). O objetivo deste trabalho compreende em conhecer, por amostragem, o perfil da população portadora de HAS atendida nas ESF. Este objetivo partiu do contato com o modelo desenvolvido por Green (PRECEDE-PROCEED), que enfatiza a importância de um planejamento contínuo quando se pretende implantar um programa ou atividade de atendimento em serviços de saúde. O que se questiona na proposta do levantamento do perfil, é se de fato as ESF conhecem sua população, e, se os trabalhos desenvolvidos são direcionados para as necessidades das demandas. Talvez esta falta de conhecimento possa explicar a dificuldade de algumas equipes na adesão de seus usuários ao tratamento adequado e contínuo. Diante disto, foi elaborado um questionário com itens como os fatores sócio-demográficos, a composição familiar, situação de trabalho, ambiente residencial, tipo de acesso aos serviços de saúde, entre outros. Os sujeitos escolhidos... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The strategy of Family Health Program (FHP) has advanced in Brazil, through the change of concept on health and disease, methodologies employed to support the health prevention and promotion, the easiness of access, the link between the staff and the community and the channels for citizenship development. The work of the Family Health Staff (FHS) is dedicated to the entirely people care, that is, the health care from the childhood to the elderly, and also, the research of the life context that reign them, for example, issues of epidemiology and sanitation. One of the activities developed by the FHS is the attention to people with hypertension (SAH), promoting the secondary prevention, which avoids the appearance of disease worsening. This work is accomplished by means of socio-educational groups, the traditional clinical (medical consultation) and information from community health agents (CHA). The objective of this paper comprehends in knowing, by sampling, the profile of the population which suffering from HAS attended in the FHP. This goal arose from the contact with the Green's model (PRECEDE-PROCEED), which emphasizes the importance of a continuous planning when you set forth a program or activity of care in the health service. What is questioned in this proposal is weather the FHS knows its population, and if the work is targeted to the needs of the demands. Maybe this lack in knowledge can explain the some team difficulty in having its users adhered to the appropriate and continuous treatment. So, it was elaborated a questionnaire was prepared with items such as socio-demographic factors, family composition, job situation, residential environment, access to health services, among others. The subjects were chosen in the survey were people suffering SAH attended and followed by the FHS from Franca, who agreed to participate through the Term of Free and Informed Consent (TFIC)... (Complete abstract click electronic access below) / Mestre

Acompanhando a tendência mundial, o Brasil apresenta um processo de envelhecimento de sua população, caracterizado pelo aumento das condições crônicas, inclusive do câncer. O quadro convoca mudanças profundas nos sistemas de saúde, demandando a implantação de Redes de Atenção, a fim de garantir acesso a todos os níveis de atenção, superando a fragmentação do cuidado. Com o intuito de conhecer os avanços no que se refere à atenção oncológica em rede, analisou-se o acesso ao tratamento do câncer em São Paulo, especialmente a partir do surgimento da Lei dos sessenta dias. Foram considerados os sistemas de monitoramento da atenção oncológica no município, além de analisados os itinerários assistenciais de usuárias, utilizando o câncer de mama como condição traçadora. Não foi possível identificar uma redução do tempo de espera para iniciar o tratamento, a partir do banco do Registro Hospitalar de Câncer de são Paulo, considerando que não há completude na base a partir de 2013, sendo observado que o tempo indicado na lei foi ultrapassado nos dois anos anteriores. Da mesma forma, notou-se um aumento da proporção de estádios avançados nesse período. Ainda com relação à variável tempo, as informações no SIGA demonstraram que, em 2013, o tempo médio para uma consulta em Onco-mastologia nos serviços de gestão municipal que estão sob regulação foi de apenas 4 dias. Por meio dos Sistemas de Informação Ambulatorial e Hospitalar, observou-se um aumento estatisticamente significativo na produção de radioterapia e de cirurgias oncológicas entre os anos 2011 e 2014, e uma tendência de redução dos procedimentos quimioterápicos. O Sistema de Informação sobre Câncer de Mama demonstrou aumento no percentual de mamografias alteradas, aspecto que, ao ser analisado em conjunto com o aumento da proporção de estadiamentos avançados, pode ser indicativo de maior dificuldade no acesso ao diagnóstico precoce do câncer de mama. Observou-se que a judicialização esteve muito relacionada a acesso a medicamentos quimioterápicos, de prescrição após a entrada nos serviços especializados, o que confirma que o acesso ao tratamento de câncer de mama no município não apresenta grandes barreiras. Um importante efeito visualizado com o surgimento da Lei foi a padronização dos protocolos de acesso aos serviços de gestão municipal e estadual. Entretanto, a rede de oncologia em São Paulo continua fragmentada dentre seus componentes estruturais, as ações permanecem no plano da construção de fluxos de encaminhamento, ficando restrita à atenção especializada. A atenção oncológica na cidade é atravessada pelo setor privado, o que deixa na dependência dos prestadores a disponibilização de vagas para acesso e o fluxo interno de cada serviço. O poder ainda continua com os grandes prestadores, não sendo bem conhecidos os caminhos para o acesso a algumas instituições, nem publicizadas as informações sobre fila e tempo de espera. A legislação sozinha não é indutora de melhoria de acesso, nem muito menos de garantia de integralidade. Um importante desafio para o SUS é a integração dos serviços e a construção de redes de atenção com centralidade na APS, garantindo, acima de tudo, o diagnóstico em tempo oportuno e a efetiva gestão sobre os serviços privados contratados de média e alta complexidade. / Following the global trend, Brazil has an aging process of the population, characterized by an increase in chronic conditions, including cancer. The framework calls for changes in health care systems, demanding the implementation of Healthcare Networks to ensure access to all levels of healthcare, overcoming the fragmentation of health care delivery. In order to know the progress in relation to cancer care network, because of the urgent need for integrated access to cancer treatment, it was analyzed the access to cancer treatment in Sao Paulo, particularly since the advent of Law \"of sixty days. Thus, it was considered the monitoring system of cancer care, as well as analyzed the assistance itineraries of the patients, using breast cancer as a tracer. From the São Paulos database Hospital Cancer Registry, it was not possible to identify a reduction in the waiting time to start the treatment, considering that the data base is not complete from 2013, and observed that the time specified in the law was passed in the previous two years. Likewise, it was noted an increase in the proportion of advanced stages during this period. Through the Outpatient clinical and hospital Information Systems Database, there was a statistically significant increase in the production of radiotherapy and cancer surgery between the years 2011 and 2014 and a trend of reduced chemotherapy procedures. Breast Cancer Information Systems Database demonstrated an increase in the percentage of abnormal mammograms, aspect which can be indicative of greater difficulty in access to diagnosis of breast cancer, when it is analyzed with the increase in the proportion of advanced stages of tumors. It was observed that the Litigation was closely related to access to chemotherapeutic drugs, from prescription after entry into the specialized services, which confirms that the access to breast cancer treatment in the municipality does not present major barriers. It was observed that the law organized the access to cancer treatments flows, standardizing the protocols between the state and the municipality in health management. However, Oncology care network in São Paulo is disjointed from its structural components and away from other healthcare networks, besides it is very strongly crossed by the private health assistance and dedicated to specialized healthcare sector. We understand that the law might be dispositif\" of changing for improving access to oncology services, because it built parameters to the society. However, only the law by itself is not an inducer of improving health services accessibility, and it doesnt guarantee of an integrative care. Finally, the emergence of the law is still very recent, it is not possible to visualize many related effects, which necessitates the continuation of observations in order to associate if the kind of strategy results benefit to public policies in the country.

Submitted by Rosivalda Pereira (mrs.pereira@ufma.br) on 2017-06-22T19:59:38Z No. of bitstreams: 1 MarceloRodrigues.pdf: 8995271 bytes, checksum: 112019fbb382d1d188823f17595346f5 (MD5) / Made available in DSpace on 2017-06-22T19:59:38Z (GMT). No. of bitstreams: 1 MarceloRodrigues.pdf: 8995271 bytes, checksum: 112019fbb382d1d188823f17595346f5 (MD5) Previous issue date: 2016-03-17 / Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) / Fundação de Amparo à Pesquisa e ao Desenvolvimento Científico e Tecnológico do Maranhão (FAPEMA) / Programa de Apoio à Núcleos de Excelência (PROCEX) / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / Introduction: the inequities in access to health care have directly interfered in infant mortality’s indicators and also have changed the dynamic of health’s system. Despite the importance of the issue, most studies did not analyses with details the factors associated with the difficulty of access at regions that have different socioeconomic characteristics. Objective: analyze the factors associated with the difficulty of access to child’s health services at São Luis/MA and Ribeirão Preto/SP. Methods: a prospective cohort study which involved 3308 children at São Luís and 3128 children at Ribeirão Preto, 13-35 months old. The prevalence rate (RP) was estimated by the Poisson regression with robust error variance in a hierarchical modeling, based on the adaptation of the Behavioral Model of Andersen. Results: the rate of difficult access at São Luís was 29,4%, while at Ribeirão Preto, the rate was 9,0%. At São Luís, the hierarchical analysis showed that the difficult of access was associated with the following variables: male child, more than a brother at home, lower maternal education, lower maternal age, be registered in the Family Health Strategy (ESF), has morbidity and wore perception of health’s state. At Ribeirão Preto, the difficulty of access was associated with the highest number of brothers at home, higher maternal education, lower economic class and be registered in the ESF. Conclusions: social inequalities in access to health were more prevalent at São Luis. The demographic’s predisposing and need factors were more expressive at São Luís, while the social structure’s predisposing and the enabling factors were more expressive at Ribeirão Preto. / Introdução: as iniquidades no acesso aos serviços de saúde têm interferido diretamente nos indicadores de morbimortalidade infantil, além de alterar a dinâmica do sistema de saúde. Apesar da importância do tema, a maior parte dos estudos não analisa detalhadamente os fatores associados às dificuldades de acesso em regiões socioeconômicas distintas. Objetivo: analisar os fatores associados à dificuldade de acesso aos serviços de saúde infantil em São Luís/MA e Ribeirão Preto/SP. Métodos: estudo de coorte prospectivo do qual participaram 3308 crianças em São Luís e 3128 crianças em Ribeirão Preto, de 13 a 35 meses de idade. Foram estimadas as razões de prevalência (RP) por meio da regressão de Poisson com variância robusta em uma modelagem hierarquizada, baseada na adaptação do Modelo Comportamental de Andersen. Resultados: a taxa de dificuldade de acesso em São Luís foi de 29,4%, enquanto que a de Ribeirão Preto foi de 9,0%. Em São Luís, na análise hierarquizada, dificuldade de acesso associou-se às seguintes variáveis: criança do sexo masculino, mais de um irmão no domicílio, baixa escolaridade materna, menor idade da mãe, ter cadastro na Estratégia de Saúde da Família (ESF), presença de morbidade e pior percepção do estado de saúde. Em Ribeirão Preto, a dificuldade de acesso foi associada ao maior número de irmãos no domicílio, maior escolaridade materna, classe econômica mais baixa e ter cadastro na ESF. Conclusões: as desigualdades sociais no acesso à saúde foram mais prevalentes em São Luis. Os fatores predisponentes demográficos e de necessidade em saúde foram mais expressivos em São Luís, ao passo que os fatores predisponentes de estrutura social e capacitantes o foram em Ribeirão Preto.

Thesis (LLM. (Labour Law)) -- University of Limpopo, 2013 / In the 18th years of our young but thriving democracy, several programmes were established to improve access to health care for disadvantaged groups in South Africa. Although numerous studies have been conducted examining trends on access to health care, considerable controversy remains. Nearly all authors concur that important progress has been made, and that gaps in access to health care narrowed considerably. Some however, go further and conclude that the evidence indicates that all significant gaps have been eliminated and access to health care is universally shared. Evidence on access to health care has important policy implications. If the task of assuming access to health care has been largely accomplished, further expansion of South African health care programmes to promote access would be unwarranted. If selected population groups lag behind others in access to health care, targeted policies to close remaining gaps may be warranted. The introduction of the National Health Insurance Scheme call for the health reform in South Africa and it will change the whole health sector and offers equal benefits on access to quality health care services to everyone in South Africa.

BACKGROUND Increasingly, it is recognised that the unique needs of people from culturally and linguistically diverse backgrounds (CaLDB) should be addressed within a framework of cultural competence. To date, there are limited data on the issues facing CaLDB patients in the Cardiac Rehabilitation (CR) setting. Appreciation of an individual???s values, attitudes and beliefs underpins negotiation of behaviour change in the CR setting. Therefore an understanding of patient and professional interactions is of key importance. OBJECTIVES The focus of this study has been to undertake an exploration of CR service delivery to people from culturally and linguistically diverse backgrounds, using Arabic speaking people as an exemplar of a CaLDB group. More broadly, this research project has sought to identify factors, which influence the practice of health professionals towards CaLDB patients, and to develop a model for evaluation of culturally competent health care in the CR setting. The study sought to achieve these aims by addressing the following research questions: 1. In what way do health practitioners in CR adjust their treatment and support to accommodate the perceived needs of CaLDB communities? 2. In what way do factors (such as individual and organisation perspectives) influence the adjustment of clinical practice and service delivery of CR practitioners; and what are practitioners??? and patients??? perception of barriers and facilitators to service delivery? 3. To what level are CaLDB patients satisfied with CR services? This study design is comprised of the following elements: (1) interviews with health practitioners and Arabic speaking background patients as an exemplar of CaLDB patients; (2) review of policy and procedure documents and medical records; and (3) field observation. METHOD This thesis embraces a qualitative approach as the primary method of investigation to align with the exploratory and descriptive nature of the study. The main methods used in the study were: in depth interviews with health professionals and patients; field observations; appraisal of relevant documents and consultation with expert panels. Study samples were selected through a purposive sampling strategy.Data were analysed using the method of content analysis, guided by the research questions. FINDINGS In total, 25 health professionals (20 female and 5 male) and 32 patients (21 male and 11 female) were interviewed. The method of qualitative content analysis was used for data analysis. Data analysis revealed four major themes: 1) The challenging context; 2) Tuning practices; 3) Influencing factors; and 4) Goodness of fit. The study demonstrated a challenging context for CR delivery, both from the perspective of patients and health professionals. Data reveal a process of reflection, negotiation, and navigation of care by CR health professionals in an effort to understand and meet the diverse needs of CALDB patients. CONCLUSION On the basis of the study findings, a process-oriented model of tuning practice to achieve cultural competence in CR delivery is proposed to inform policy, research and clinical practice.

This thesis is based on a study conducted for the state of Oregon's Office of Mental Health Services (OMHS). OMHS' primary research objectives included 1) the identification of the unfunded population (individuals who are uninsured and ineligible for Medicaid) who seek services at community mental health programs and 2) an examination of this group's access to atypical antipsychotic and antidepressant medications. OMHS sought this data in order to inform legislative decisions regarding a forthcoming state budget proposal for a specialized atypicals fund. The author collected ethnographic data through semi-structured interviews with 57 mental health clinicians and 41 mental health advocates throughout Multnomah, Linn and Lincoln counties. While answers to the primary research objectives were inconclusive, the qualitative data characterizes the target population and contextualizes the unfunded client's medication access issues at county-related mental health clinics. Specifically, the study results indicate that 1) the complex characteristics of the unfunded population and the inadequacies of the available medication resource programs should be examined more thoroughly before allocating appropriated funds, 2) insufficient mental health services in general is the foremost problem for unfunded clients, and that which contributes to difficulties in accessing psychotropic medications, and 3) appropriated funds from the state's budget would not adequately resolve the medication needs for the target population. The study findings suggest that the state's concern with atypical medications overshadows existing practical, everyday problems in the clinics. The author analyzes the study from a Critical Medical Anthropology perspective, examining the relationships between the global and local contexts surrounding atypical medications, and discussing the practical use of the research data. From this perspective, the state's preoccupation with supplying atypical medications for the target population appears to be driven more by the pharmaceutical industry's profit-making interests and the historical role of the public psychiatric field than by quality health care decisions. The author also discusses medical hegemony in terms of the psychiatric field, and the ways in which this effects the asymmetrical power within the Oregon mental health system. / Graduation date: 2000

Objective: To determine who avoids the dentist and declines recommended dental treatment due to cost. Methods: A secondary data analysis was undertaken. Weights were utilized to ensure data were nationally representative. Univariate and bivariate descriptive statistics were calculated and logistic regressions were used to observe the characteristics that were predictive of reporting cost barriers to care. Results: Over 17 per cent of the Canadian population reported avoiding a dental professional due to cost, and 16.5 per cent reported declining recommended dental treatment due to cost. These individuals had a higher prevalence of needing treatment, had more untreated decay, missing teeth, and reported having poor oral health and oral pain often. Having no insurance, lower income, and reporting “poor to fair” oral health were the greatest predictors of reporting cost barriers to care. Conclusions: Individuals who report cost barriers experience more disease and treatment needs than those who do not.

Objective: To determine who avoids the dentist and declines recommended dental treatment due to cost. Methods: A secondary data analysis was undertaken. Weights were utilized to ensure data were nationally representative. Univariate and bivariate descriptive statistics were calculated and logistic regressions were used to observe the characteristics that were predictive of reporting cost barriers to care. Results: Over 17 per cent of the Canadian population reported avoiding a dental professional due to cost, and 16.5 per cent reported declining recommended dental treatment due to cost. These individuals had a higher prevalence of needing treatment, had more untreated decay, missing teeth, and reported having poor oral health and oral pain often. Having no insurance, lower income, and reporting “poor to fair” oral health were the greatest predictors of reporting cost barriers to care. Conclusions: Individuals who report cost barriers experience more disease and treatment needs than those who do not.

published_or_final_version / Social Work and Social Administration / Doctoral / Doctor of Philosophy

BACKGROUND Increasingly, it is recognised that the unique needs of people from culturally and linguistically diverse backgrounds (CaLDB) should be addressed within a framework of cultural competence. To date, there are limited data on the issues facing CaLDB patients in the Cardiac Rehabilitation (CR) setting. Appreciation of an individual???s values, attitudes and beliefs underpins negotiation of behaviour change in the CR setting. Therefore an understanding of patient and professional interactions is of key importance. OBJECTIVES The focus of this study has been to undertake an exploration of CR service delivery to people from culturally and linguistically diverse backgrounds, using Arabic speaking people as an exemplar of a CaLDB group. More broadly, this research project has sought to identify factors, which influence the practice of health professionals towards CaLDB patients, and to develop a model for evaluation of culturally competent health care in the CR setting. The study sought to achieve these aims by addressing the following research questions: 1. In what way do health practitioners in CR adjust their treatment and support to accommodate the perceived needs of CaLDB communities? 2. In what way do factors (such as individual and organisation perspectives) influence the adjustment of clinical practice and service delivery of CR practitioners; and what are practitioners??? and patients??? perception of barriers and facilitators to service delivery? 3. To what level are CaLDB patients satisfied with CR services? This study design is comprised of the following elements: (1) interviews with health practitioners and Arabic speaking background patients as an exemplar of CaLDB patients; (2) review of policy and procedure documents and medical records; and (3) field observation. METHOD This thesis embraces a qualitative approach as the primary method of investigation to align with the exploratory and descriptive nature of the study. The main methods used in the study were: in depth interviews with health professionals and patients; field observations; appraisal of relevant documents and consultation with expert panels. Study samples were selected through a purposive sampling strategy.Data were analysed using the method of content analysis, guided by the research questions. FINDINGS In total, 25 health professionals (20 female and 5 male) and 32 patients (21 male and 11 female) were interviewed. The method of qualitative content analysis was used for data analysis. Data analysis revealed four major themes: 1) The challenging context; 2) Tuning practices; 3) Influencing factors; and 4) Goodness of fit. The study demonstrated a challenging context for CR delivery, both from the perspective of patients and health professionals. Data reveal a process of reflection, negotiation, and navigation of care by CR health professionals in an effort to understand and meet the diverse needs of CALDB patients. CONCLUSION On the basis of the study findings, a process-oriented model of tuning practice to achieve cultural competence in CR delivery is proposed to inform policy, research and clinical practice.