The prevalence of big data has rapidly changed the usage and mechanisms of data analytics within organizations. Big data is a widely-used term without a clear definition. The difference between big data and traditional data can be characterized by four Vs: velocity (speed at which data is generated), volume (amount of data generated), variety (the data can take on different forms), and veracity (the data may be of poor/unknown quality). As many industries begin to recognize the value of big data, organizations try to capture it through means such as: side-channel data in a manufacturing operation, unstructured text-data reported by healthcare personnel, various demographic information of households from census surveys, and the range of communication data that define communities and social networks. Big data analytics generally follows this framework: first, a digitized process generates a stream of data, this raw data stream is pre-processed to convert the data into a usable format, the pre-processed data is analyzed using statistical tools. In this stage, called statistical learning of the data, analysts have two main objectives (1) develop a statistical model that captures the behavior of the process from a sample of the data (2) identify anomalies in the process. However, several open challenges still exist in this framework for big data analytics. Recently, data types such as free-text data are also being captured. Although many established processing techniques exist for other data types, free-text data comes from a wide range of individuals and is subject to syntax, grammar, language, and colloquialisms that require substantially different processing approaches. Once the data is processed, open challenges still exist in the statistical learning step of understanding the data. Statistical learning aims to satisfy two objectives, (1) develop a model that highlights general patterns in the data (2) create a signaling mechanism to identify if outliers are present in the data. Statistical modeling is widely utilized as researchers have created a variety of statistical models to explain everyday phenomena such as predicting energy usage behavior, traffic patterns, and stock market behaviors, among others. However, new applications of big data with increasingly varied designs present interesting challenges. Consider the example of free-text analysis posed above. There's a renewed interest in modeling free-text narratives from sources such as online reviews, customer complaints, or patient safety event reports, into intuitive themes or topics. As previously mentioned, documents describing the same phenomena can vary widely in their word usage and structure. Another recent interest area of statistical learning is using the environmental conditions that people live, work, and grow in, to infer their quality of life. It is well established that social factors play a role in overall health outcomes, however, clinical applications of these social determinants of health is a recent and an open problem. These examples are just a few of many examples wherein new applications of big data pose complex challenges requiring thoughtful and inventive approaches to processing, analyzing, and modeling data. Although a large body of research exists in the area of anomaly detection increasingly complicated data sources (such as side-channel related data or network-based data) present equally convoluted challenges. For effective anomaly-detection, analysts define parameters and rules, so that when large collections of raw data are aggregated, pieces of data that do not conform are easily noticed and flagged. In this work, I investigate the different steps of the data analytics framework and propose improvements for each step, paired with practical applications, to demonstrate the efficacy of my methods. This paper focuses on the healthcare, manufacturing and social-networking industries, but the materials are broad enough to have wide applications across data analytics generally. My main contributions can be summarized as follows: • In the big data analytics framework, raw data initially goes through a pre-processing step. Although many pre-processing techniques exist, there are several challenges in pre-processing text data and I develop a pre-processing tool for text data. • In the next step of the data analytics framework, there are challenges in both statistical modeling and anomaly detection o I address the research area of statistical modeling in two ways: - There are open challenges in defining models to characterize text data. I introduce a community extraction model that autonomously aggregates text documents into intuitive communities/groups - In health care, it is well established that social factors play a role in overall health outcomes however developing a statistical model that characterizes these relationships is an open research area. I developed statistical models for generalizing relationships between social determinants of health of a cohort and general medical risk factors o I address the research area of anomaly detection in two ways: - A variety of anomaly detection techniques exist already, however, some of these methods lack a rigorous statistical investigation thereby making them ineffective to a practitioner. I identify critical shortcomings to a proposed network based anomaly detection technique and introduce methodological improvements - Manufacturing enterprises which are now more connected than ever are vulnerably to anomalies in the form of cyber-physical attacks. I developed a sensor-based side-channel technique for anomaly detection in a manufacturing process / PHD / The prevalence of big data has rapidly changed the usage and mechanisms of data analytics within organizations. The fields of manufacturing and healthcare are two examples of industries that are currently undergoing significant transformations due to the rise of big data. The addition of large sensory systems is changing how parts are being manufactured and inspected and the prevalence of Health Information Technology (HIT) systems in healthcare systems is also changing the way healthcare services are delivered. These industries are turning to big data analytics in the hopes of acquiring many of the benefits other sectors are experiencing, including reducing cost, improving safety, and boosting productivity. However, there are many challenges that exist along with the framework of big data analytics, from pre-processing raw data, to statistical modeling of the data, and identifying anomalies present in the data or process. This work offers significant contributions in each of the aforementioned areas and includes practical real-world applications. Big data analytics generally follows this framework: first, a digitized process generates a stream of data, this raw data stream is pre-processed to convert the data into a usable format, the pre-processed data is analyzed using statistical tools. In this stage, called ‘statistical learning of the data’, analysts have two main objectives (1) develop a statistical model that captures the behavior of the process from a sample of the data (2) identify anomalies or outliers in the process. In this work, I investigate the different steps of the data analytics framework and propose improvements for each step, paired with practical applications, to demonstrate the efficacy of my methods. This work focuses on the healthcare and manufacturing industries, but the materials are broad enough to have wide applications across data analytics generally. My main contributions can be summarized as follows: • In the big data analytics framework, raw data initially goes through a pre-processing step. Although many pre-processing techniques exist, there are several challenges in pre-processing text data and I develop a pre-processing tool for text data. • In the next step of the data analytics framework, there are challenges in both statistical modeling and anomaly detection o I address the research area of statistical modeling in two ways: - There are open challenges in defining models to characterize text data. I introduce a community extraction model that autonomously aggregates text documents into intuitive communities/groups - In health care, it is well established that social factors play a role in overall health outcomes however developing a statistical model that characterizes these relationships is an open research area. I developed statistical models for generalizing relationships between social determinants of health of a cohort and general medical risk factors o I address the research area of anomaly detection in two ways: - A variety of anomaly detection techniques exist already, however, some of these methods lack a rigorous statistical investigation thereby making them ineffective to a practitioner. I identify critical shortcomings to a proposed network-based anomaly detection technique and introduce methodological improvements - Manufacturing enterprises which are now more connected than ever are vulnerable to anomalies in the form of cyber-physical attacks. I developed a sensor-based side-channel technique for anomaly detection in a manufacturing process.

Purpose: Social determinants of health (SDoH) and rurality have both been shown to contribute to severe maternal morbidity (SMM). Appalachian communities often embody this compounded risk, but regional SMM is under-explored. This study’s purpose is to explore SMM in rural areas of Appalachian states. Aims: There are two specific aims. 1) Describe the prevalence of rural SMM in Appalachian states. 2) Investigate the relationship between SMM and SDoH, specifically income, education, and care access. Methods: An IRB exempt, descriptive correlational study was conducted. Birth data (2018-2022) were extracted from the CDC WONDER database for 12 Appalachian states. Demographic, income, and education data were obtained from the U.S. Census. Access was measured by March of Dimes (MoD) maternity care categorizations. Descriptive statistics and Pearson’s correlations were conducted in IBM SPSS. Results: Rural SMM rates correlated with poverty (r =.803, p Conclusions: This study describes rural SMM in Appalachian states, showing correlation with poverty, education, and maternity care access. Limited access to care is correlated with a higher SMM burden for rural areas. This points to the need for further exploration into rural SMM, and the interplay of SDoH and geography in relation to maternal health.

This study explored doctor of physical therapy (DPT) students’ attitudes, perceived knowledge, and perceived competence specific to social and structural determinants of health (SDOH). Current students in a DPT program housed within a college of public health in an urban research institution served as the participants for this research. The primary purpose of this study was to explore students’ self-evaluation and perceptions of competence with SDOH in hopes of gaining insight into elements of their education that contributed to their preparedness and/or what strategies and resources are needed to foster competence in this area. A secondary aim of this study was to explore how individual student factors and curricular factors impact students’ awareness of SDOH. A mixed methods study design employed bivariate and multivariate analysis of participants’ responses to self-report Likert scale survey questions and analysis of semi-structured interviews using qualitative description and phenomenological principles. Quantitative data analysis revealed differences in perceived skills competence based on cohort (year one, two, or three in the program) with first-year students demonstrating lower perceived competence. Analysis of attitudes and knowledge demonstrated that all participants held a positive perspective regarding the importance of SDOH as well as perceived foundational knowledge for this content. Quantitative analysis also detected subtle differences in specific sample beliefs and behaviors based on demographic variables such as gender identity, race, and first-generation student status. Qualitative data supported the quantitative findings with participants articulating specific elements of their identities and the DPT curriculum that contributed to their understanding of SDOH. An iterative coding process identified two primary themes that corresponded to the research aims: 1) Learners’ perceived importance of social and structural determinants of health and factors that impact how to address them; and 2) Learning about social and structural determinants of health: What learners bring with them and what they gain throughout the curriculum. These findings shed light on the elements of this educational program that foster students understanding of SDOH and the types of experiences that help clinical learners appreciate the impact of these upstream drivers of health for patients and populations. / Policy, Organizational and Leadership Studies

Life course literature states that early childhood development (ECD) can influence most aspects of health throughout the life-cycle. Canada ranked last among 25 wealthy nations in meeting ECD objectives. Fewer than 5% of children born have clinically detectable shortcomings in developmental health, increasing to 26% by school age with emerging socioeconomic associations. Understanding how social determinants of health (SDH) influence ECD at the household and neighbourhood scales would help identify conditions for optimal developmental outcomes. The effects of SDH on ECD in the Kingston, Ontario area were studied. SDH were classified via marginalization (ONMarg) and deprivation (Pampalon) indices. ECD was measured via 2006 Early Development Instrument (EDI) scores for children most at risk upon school entry (Grade One). The basic spatial unit of analysis was 2006 Census of Canada Dissemination Areas, subdivided into quintiles of deprivation (Q1 being the least deprived and Q5 the most). EDI results from each of the quintiles within the two indices were compared and then combined. The socioeconomic health gradient assumes that EDI scores will directly correlate to material and social deprivation. Social deprivation had a slightly greater impact than material deprivation on children’s developmental vulnerability, with Q5 being the most vulnerable in all competencies. Surprisingly, emotional health and social competence were significant areas of vulnerability for children in Q1 and Q2. “Village effects” – when social determinants at the neighbourhood level have protective effects on ECD despite material deprivation at the household level – were present within the Q3 and Q4 groups for the domains of social competency and emotional health. While the highest proportions of early childhood developmental vulnerability are found within the most deprived households, the largest numbers of vulnerable children are spread throughout the middle-class in a variety of neighbourhoods. Canadian policy should focus on mediating avoidable risks within this critical time to avoid future deleterious health effects and costs. Mapping the effects of SDH at the neighbourhood level generates knowledge that informs intersectoral action by policy makers to provide the supports needed to foster healthy children. / Thesis (Master, Geography) -- Queen's University, 2013-05-04 10:36:25.165

Abstract 1: A multi-level assessment of disproportionate population sex ratios and high-risk sexual behaviors among STD clinic patients Low male-to-female sex ratios in a population may influence high-risk sexual behaviors, such as multiple sex partners and inconsistent condom use, which facilitate the transmission of STDs. This study used multi-level modeling to assess whether population sex ratios were associated with these two individual-level behaviors. All analyses were stratified by gender. Interview data were collected from patients (N = 9,203, 48% male) attending participating STD clinics. Interviews included information on socio-demographics and sexual behavior, including number of sex partners in the previous 3 months and condom use at last sex. The sex ratio per census tract was obtained from the U.S. Census Bureau. There was no association between sex ratio and multiple sex partners or condom use for either men or women. That is, we found no evidence that a shortage of men in census tracts was associated with increased engagement in high-risk sexual behavior.   Abstract 2: A multi-level assessment of neighborhood vacancy rates and high-risk sexual behaviors among STD clinic patients The “broken windows” theory posits that physical neighborhood deterioration, and its association with reduced social cohesion, can lead to changes in individual behaviors. Thus individuals living in neighborhoods with high levels of deterioration may be more likely to engage in high-risk sexual behaviors. This study used multi-level modeling to evaluate the extent to which high residential vacancy rates increased the likelihood of individuals having multiple sex partners. Interview data, including data on patient demographics and sexual behaviors, were collected from patients (N = 6,347, 52% male) attending participating STD clinics in the Richmond, Virginia area from 2008-2010. Neighborhood vacancy rates were obtained from the U.S. Census Bureau. Fifty-one percent of men and 36% of women reported having 2 or more sex partners in the previous 3 months. Men who lived in census tracts with high vacancy rates were slightly more likely to report multiple sex partners (53.9%) compared to men who lived in low vacancy tracts (49.7%). In multi-level models, there was no association between high vacancy rates and having multiple sex partners among either women (OR = 0.98; 95% CI: 0.79, 1.20) or men (1.18; 95% CI: 0.99, 1.42). That is, we found no evidence that increased neighborhood deterioration, as measured by high residential vacancy rates, was associated with increased risk of having multiple sex partners among STD clinic patients.   Abstract 3: Residential segregation and gonorrhea rates in U.S. metropolitan statistical areas The residential segregation of black populations, often in areas of high economic disadvantage and low social status, may play a crucial role in the observed racial inequities in STD rates. An ecological analysis of 2005-2009 average gonorrhea rates was performed across 277 U.S. metropolitan statistical areas (MSAs). The black isolation index and Gini index of income inequality were used as proxy measures for racial and economic residential segregation respectively, derived from 2005-2009 U.S. Census estimates. We used logistic regression modeling to produce estimates of odds ratios (OR) and 95% confidence intervals (CI) for the association between a high black isolation index and Gini index, both independently and in combination, on gonorrhea rates in MSAs. Effect measure modification was assessed by calculating the relative excess risk due to interaction (RERI) between the two indices. Compared to MSAs with low levels of racial segregation, MSAs with high levels of racial segregation had increased odds of high gonorrhea rates (adjusted OR 5.54; 95% CI: 2.29-13.44). Adjustment for potential confounders did not noticeably impact the relationship between the Gini index and gonorrhea, with higher levels of income inequality predicting higher gonorrhea rates (adjusted OR = 2.47; 95% CI: 1.21-5.03). In combined models, the influence of racial residential segregation on gonorrhea rates was stronger than that of income inequality-based segregation; there was no evidence of additivity or a multiplicative interaction. Residential segregation by race or income equality may be a key component in the perpetuation of high rates of gonorrhea and other STDs among black populations in the U.S.

This study was a population-based retrospective cohort of all singleton births in British Columbia for the years 2001 to 2006. The purpose of this dissertation is to examine how social and physical environment factors influence the risk of adverse pregnancy outcomes and whether they interact with each other or with maternal characteristics to modify disease risk. The main environmental factors examined include ambient particulate air pollution (PM2.5), neighbourhood socioeconomic status (SES), neighbourhood immigrant density, neighbourhood level of post-secondary education level and the urban-rural context. Census dissemination areas (DAs) were used as the neighbourhood spatial unit. The data (N=242,472) was extracted from the BC Perinatal Data Registry (BCPDR) from Perinatal Services BC (PSBC). The main perinatal outcomes investigated include birth weight and indicators of fetal growth restriction such as small-for-gestational age (SGA), term low birth weight (tLBW), and intrauterine growth restriction (IUGR), preterm birth (PTB) and gestational age, gestational diabetes mellitus (GDM) and gestational hypertension (GH). Collectively, this dissertation contributes to the perinatal epidemiological literature linking particulate air pollution and neighbourhood SES context to adverse pregnancy outcomes. Assumptions about the linear effect of PM2.5 and smoking on birth weight are challenged showing that the effects are most pronounced between low and average exposures and that the magnitude of their effect is modified by neighbourhood and individual-level characteristics. These results suggest that focusing exclusively on individual risk factors may have limited success in improving outcomes without addressing the contextual influences at the neighbourhood-level. This dissertation therefore also contributes to the public health, sociological and community-urban development literature demonstrating that context and place matters. / Graduate / 0766 / 0573 / 0768 / anderse@uvic.ca

O Programa Nacional de Alimentação Escolar (PNAE) é uma importante ferramenta de política pública brasileira de combate à fome, de alcance da segurança alimentar e nutricional, de garantia do direito humano à alimentação adequada e de promoção do desenvolvimento rural. A partir da Lei no 11.947/ 2009, o PNAE passou a estar associado à abertura de mercado para os produtos da agricultura familiar. Esta lei determina que no mínimo 30% (trinta por cento) do total de recursos financeiros repassados pelo Fundo Nacional de Desenvolvimento da Educação (FNDE) aos estados e municípios deverão ser utilizados na aquisição de gêneros alimentícios diretamente da agricultura familiar, com a dispensa do processo licitatório. Deste encontro, da alimentação escolar com a agricultura familiar, emerge uma ótica favorável ao reconhecimento de que o agricultor familiar pode assumir responsabilidades sociais, ambientais e culturais, muito além da responsabilidade produtiva em torno da oferta de produtos alimentícios às escolas. A partir desta perspectiva, nossa hipótese admite que o agricultor familiar reconhece, em particular em razão de sua participação no PNAE, sua atuação enquanto agente social promotor de saúde. O objetivo da pesquisa foi analisar agriculturas familiares que abastecem escolas graças ao PNAE de modo a verificar em que medida se trata de uma atividade promotora de saúde, a partir da perspectiva de agricultores/as de duas cooperativas. O desenvolvimento da pesquisa se fundou em metodologia qualitativa em saúde. As duas cooperativas de agricultura familiar focalizadas foram, a Cooperacra, localizada no município de Americana/SP e a Coopamsp, localizada no município de São Pedro/SP. Foram realizadas entrevistas semiestruturadas com membros de suas diretorias e com agricultoras e agricultores cooperados. No total foram realizadas dezoito entrevistas, que foram gravadas, transcritas na integra e analisadas com base na metodologia de análise de conteúdo, sob o olhar dos referenciais da multifuncionalidade da agricultura e da promoção da saúde. A pesquisa evidenciou a importância do PNAE para a estruturação e fortalecimento das duas cooperativas, bem como para a reprodução socioeconômica das famílias cooperadas. O papel de promotores de saúde desempenhado pelos agricultores esteve especialmente vinculado à oferta de alimentos saudáveis aos escolares. Por alimentos saudáveis são compreendidos aqueles produzidos sem ou com o mínimo possível de agrotóxicos, frescos e produzidos localmente. Os agricultores também reconheceram o papel que desempenham na promoção da segurança alimentar e nutricional dos escolares e da sociedade de forma geral. Ademais, uma relação harmoniosa com a natureza e o cuidado com o meio ambiente também estiveram vinculados a maneiras de promover saúde, sendo identificados como funções sociais desempenhadas pelos agricultores. Concluímos que, para que o agricultor possa ser reconhecido enquanto agente promotor de saúde, é preciso primeiramente fortalecê-lo em sua atuação no meio rural. O reconhecimento político pelo PNAE favorece então uma atuação multifuncional de agricultores familiares. Portanto, o investimento em programas e políticas públicas voltadas às questões como a reforma agrária, o acesso ao crédito rural, a comercialização dos produtos agrícolas oriundos da agricultura familiar e a produção de alimentos ambiental, social e economicamente mais sustentáveis (como no caso da perspectiva agroecológica) constituem meios de melhorar a saúde da população brasileira. / The Brazilian School Feeding Program (Programa Nacional de Alimentação Escolar/ PNAE) is an important Brazilian public policy tool in the fight against hunger, ensuring food security, the human right to adequate food, and promoting rural development. Since the Law no. 11.947/2009, PNAE started to be associated with the opening of the market for family agriculture products. This law establishes that at least 30% (thirty percent) of the total financial resources from the National Education Development Fund should be used to purchase food directly from family agriculture, without the bidding process. From the combination of school feeding and family agriculture, a favorable view emerged - the understanding that family farmers can assume social, environmental and cultural responsibilities which go beyond the productive responsibility and the supply of food products to schools. From this perspective, our hypothesis admits that the family farmer recognizes, in particular because of his participation in this Program, his role as a social agent promoting health. The objective of the research was to analyze the family farming practiced to supply the Program in order to verify if it is a health promoting activity, from the perspective of the farmers of two cooperatives. The elaboration and development of the work were based on the methodology of qualitative research in health. Two cooperatives of family agriculture, Cooperacra, located in the city of Americana / SP and Coopamsp, located in the city of São Pedro / SP, were studied. Semi-structured interviews were conducted with board members and with cooperative farmers, totaling eighteen interviews. All the interviews were recorded, transcribed in full and analyzed based on the content analysis methodology, under the perspective of the multifunctionality in agriculture and health promotion. The research demonstrated the importance of PNAE for the structuring and strengthening of the two cooperatives, as well as for the socioeconomic reproduction of cooperated families The role of health promoters played by the farmers was especially linked to the provision of healthy food to schoolchildren, and healthy foods were understood as those produced with or without the least possible agrochemicals, fresh and locally produced. Farmers also recognized the role they play in promoting food and nutritional security for schoolchildren and society in general. Furthermore, the relationship with nature and care for the environment have also been linked to ways of promoting health, being identified as social functions performed by farmers. We conclude that, in order for farmers to be recognized as promoters of health, they must first be strengthened in their work in rural areas. It is necessary to politically recognize the importance of the multifunctional role of family farmers with the investment in programs and public policies focused on issues such as agrarian reform, access to rural credit, commercialization of agricultural and non-agricultural products, and food production which are economically, socially and environmentally more sustainable, such as agroecology.

O discurso da Comissão de Determinantes Sociais da Saúde (CSDH) instituída pela Organização Mundial de Saúde (OMS) constitui-se como objeto desde estudo. O contexto econômico-social, resultado das políticas neoliberais, aprofundou em âmbito mundial as desigualdades sociais. Em 2003, a CSDH foi instituída pela OMS, assumindo como objetivos a documentação de evidências das ações e políticas para promover a equidade em saúde, e articular um movimento global para que esta seja alcançada. As publicações da CSDH tornaram-se referência mundial no tema das desigualdades em saúde. Autores do campo da Saúde Coletiva identificaram importantes limitações e contradições na sua formulação teórico-metodológica, apesar de alguns reconhecerem uma possibilidade de avanço nesta iniciativa. A Saúde Coletiva constituiu-se como campo de teorias e práticas que superam a naturalização do processo de saúde. O marco teórico deste estudo é a teoria da determinação social da saúde, que afirma que a sociedade de classes, fundada na exploração da força de trabalho, produz diferentes desgastes e fortalecimentos advindos das formas de trabalhar, que determinam as formas de viver dos diferentes grupos sociais. Os perfis epidemiológicos são o objeto de ação da Saúde Coletiva, constituídos pelos perfis de reprodução social e pelos perfis de saúde-doença, definidos por meio de estudos da epidemiologia crítica. Objetivo geral: analisar o discurso da CSDH. Objetivos específicos: identificar e analisar os conceitos utilizados pela CSDH; identificar e analisar as diretrizes de ação propostas pela Comissão; comparar os conceitos de determinação social e determinantes sociais. Método: pesquisa qualitativa, que utiliza dados de fonte secundária - o documento da CSDH A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion. Publicado em 2010, o documento oferece a construção teórica e as diretrizes das ações de enfrentamento aos determinantes sociais da saúde propostas pela Comissão. Os resultados foram analisados pela metodologia da análise de discurso, para apreender a estrutura do discurso, o posicionamento da CSDH. Resultados: o construto teórico da Comissão não considera as contradições advindas da exploração do trabalho como fonte da riqueza e da desigualdade social, mas incorpora termos que remetem à estrutura social, como estratificação social e posição sócio-econômica. A dimensão histórica está ausente na teoria dos determinantes sociais da saúde, que retoma conceitos e formato originais do campo da Saúde Pública, como a multicausalidade, a circularidade entre doença e pobreza e o risco. O uso recorrente de termos relacionados à hegemonia ideológica neoliberal é necessário para estabelecer mediações que mantêm encobertas as contradições próprias do capitalismo. Baseando-se em um conceito impreciso de equidade, as ações propostas são focalizadas, tomam como objeto a vulnerabilidade e o risco individuais e têm como finalidade a responsabilização individual pela saúde e a liberdade de escolha, como o empowerment. As diretrizes de ação propostas aproximam-se ao ideário da promoção da saúde. Considerações finais: entende-se que a opção teórica da Comissão é intencional e alinhada com o atual regime de acumulação capitalista - dependente da organização flexível do trabalho - não constituindo uma mudança de perspectiva em relação ao objeto, representa uma inovação apenas no plano retórico. O referencial teórico-prático dos determinantes sociais da saúde é insuficiente para subsidiar o enfrentamento das desigualdades sociais e seus resultados no processo de saúde. Compreende-se que as práticas da Saúde Coletiva, como o monitoramento crítico e práticas emancipatórias, a partir da uma perspectiva de luta de classes, podem contribuir para responder à desigualdade nos perfis epidemiológicos. / Introduction: The discourse of the Comission on Social Determinants of Health (CSDH), established by the World Health Organization (WHO), is the object of study of this paper. The socio-economic context, result of neoliberal policies, has deepen worldwide social inequality, resulting from the capitalist accumulation regime. In 2003, CSDH, instituted by the WHO, assumed as goal the documentation of evidences of actions and policies to promote equity in health and articulate a global movement for it to be reached. CSDH publishes have become a worldwide reference on health equality. Writers of the Collective Health field indentified important limitations and contradictions in its theoretical-methodological formulation, although some perceive an advance in this initiative. The Collective Health has established itself as the field theories and practices that overcome the naturalization of the health process. The theoretical goal of this study is the social determination of health theory, which affirms that the classes society, founded on the exploitation of labor, produces different body distress and strengths arisen from the specificities of labor, which determines the different ways of living of different social groups. Epidemological profiles are the object of work of Collective Health, composed by the social reproduction profiles and the health-disease profiles, defined trought critical epidemiology researches. Objeticve: to analyze the CSDH discourse. Specific objectives: to identify and analize the concepts used by CSDH; to identify and analyze the action guidelines proposed by the Comission; to compare the concepts of social determination and social determinants. Methodological Procedures: qualitative research, using secondary source data - CSDH document A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion. Published in 2010, this document offers the theoretical construction and guidelines of coping actions toward the social determinants of health proposed by the Comission. The results have been analyzed through the discourse analyses method, to seize the structure of the discourse, the CSDH positioning. Results: the Comission\'s theoretical construct does not consider the contradictions from labor exploitation as the wealth and social inequality source, but it incorporates terms that refers to the social structure, as social stratification and socio-economical position. The historic dimension is absent on the social determinants of health theory, which recaptures original concepts and form from the Public Health field, as multicausality, the circularity between health and poverty, and the risk. The recurrent usage of terms related with hegemonic neoliberal ideology is necessary to establish mediations capable of covering the inherent capitalism contradictions. Based on a imprecise concept of equity, the actions proposed are focused, take the vulnerability and individual risks as an object, and perceive the individual accountability for its health and the freedom of choice as a goal, such as empowerment. The proposed action guidelines approach the Health Promotion ideals. Final considerations: understanding that the Commission\'s theoretical choice is intentional and aligned with the current capital accumulation regime - depending on the flexible organization of labor - without changing the perspective toward the object, its innovation is only at the rhetorical frame. The practical and theoretical referential of the social determinants of health is scarce to subsidize the confront of social inequality and its results on the health process. The understanding of how Collective Health practices, and critical monitoring and emancipatory practices, through a class struggle perspective, can contribute to a response toward the inequality on epidemiological profiles.

Esta tese tem o propósito de desenvolver uma argumentação normativa sobre justiça distributiva e saúde. São duas as questões que pautam a pesquisa: o que devemos uns aos outros, enquanto cidadãos de uma sociedade democrática, na promoção e proteção da saúde de nossos concidadãos? Quais obrigações e deveres de justiça que um Estado democrático possui perante a saúde de seus cidadãos? Para respondermos essas questões, inicialmente, buscamos apresentar um entendimento objetivo e publicamente acessível de necessidades de saúde. Essas necessidades estão relacionadas ao funcionamento normal das espécies e impactam o leque de oportunidades disponíveis ao longo de nossas vidas. Dialogando com a teoria da justiça como equidade, de Rawls, e com a extensão dessa teoria proposta por Daniels, defendemos que o conjunto das instituições, dos serviços, dos bens e dos recursos necessários à manutenção, ao reestabelecimento e à provisão de equivalentes funcionais ao funcionamento normal dos cidadãos devem ser distribuído de modo a respeitar o princípio de igualdade equitativa de oportunidades. Em sequência, desenvolvemos uma argumentação sobre o debate contemporâneo dedicado à definição e à defesa do princípio fundamental que deve balizar a justa distribuição dos mais variados distribuenda. Argumentamos que embora a justiça exija uma noção de igualdade (como a de igualdade democrática que defendemos) e não um patamar de suficiência ou um princípio de prioridade, esses critérios normativos podem auxiliar na formulação e na avaliação de políticas públicas e recomendações institucionais. Questionamos os ataques direcionados às teorias igualitárias, defendendo que essas teorias não podem ser reduzidas, nem obrigatoriamente exigem, a aplicação de princípios distributivos igualitários simples. Por fim, nos dedicamos a desenvolver uma argumentação sobre justiça e saúde centrada nas questões dos determinantes sociais da saúde e do gradiente social em saúde. Defenderemos, em diálogo com a literatura empírica sobre a questão, que políticas públicas de saúde devem ser baseadas em um ideal de igualdade democrática e devem assumir como uma pauta central a eliminação de iniquidades de saúde existentes entre grupos sociais, assim como combater injustiças estruturais presentes nas sociedades contemporâneas. / This thesis aims to develop a normative argument about distributive justice and health. Two questions underpin the study: what do we owe each other, as citizens of a democratic society, in the promotion and protection of the health of our fellow citizens? What justice obligations and duties does a democratic State have vis-à-vis the health of its citizens? Firstly, to answer these questions, we seek to present an objective and publicly accessible understanding of health needs. These needs are related to the normal functioning of species and impact the range of opportunities available throughout our lives. Drawing on Rawls\'s theory of justice as fairness, and on the extension to this theory, proposed by Daniels, we argue that the set of institutions, services, goods and resources necessary for the maintenance, reestablishment, and provision of functional equivalents to normal functioning, should be distributed in a way that respects the principle of fair equality of opportunity. Secondly, we develop an argument about the contemporary debate dedicated to the definition and defense of the fundamental principle that should mark the fair allocation of the most varied distribuenda. We argue that although justice requires a notion of equality (such as that the democratic equality we defend) rather than a threshold of sufficiency or a principle of priority, these normative criteria can aid in the formulation and evaluation of public policies and institutional recommendations. We question the attacks directed at egalitarian theories, arguing that these theories can not be reduced, nor do they necessarily require, the application of simple egalitarian distributive principles. Finally, we are dedicated to developing an argument about justice and health centred on the issues of social determinants of health and the social gradient in health. We shall argue, drawing on the empirical literature on the issue, that public health policies should be based on an ideal of democratic equality and should take the elimination of existing health inequities between social groups as a central guideline, as well as combatting present structural injustices in contemporary societies.

Introdução - O trabalho com a determinação social da saúde no âmbito do Programa Saúde da Família (PSF) é abordado pelo Ministério da Saúde como estratégia de reorganização da atenção básica no sentido da integralidade. Ao mesmo tempo, a filosofia holística do programa é tida pelos profissionais da promoção da saúde como força sinérgica para o empoderamento comunitário e a eqüidade social. No entanto, sabe-se ainda pouco sobre o trabalho com determinantes sociais de saúde (DSS) no âmbito do PSF. A investigação desta prática apresenta-se como importante estudo de caso sobre a integralidade de serviços de atenção primária à saúde de base comunitária, além de representar um estratégico foco de avaliação para o PSF. Objetivo - Analisar o estado atual do trabalho com DSS no âmbito do Programa Saúde da Família do município de São Paulo e discutir a viabilidade e a pertinência de seu desenvolvimento. Metodologia - Adotando uma posição pragmática, o estudo utilizou-se de métodos mistos de pesquisa divididos em duas fases seqüenciais de coleta e análise de dados, ancoradas em uma estratégia seqüencial explanatória. A primeira fase, majoritariamente quantitativa, contempla a coleta de dados quantitativos e qualitativos através de inquérito com a população de gerentes das Unidades de Saúde da Família do município de São Paulo. A segunda fase, unicamente de caráter qualitativo, contempla a coleta de dados por intermédio de entrevistas semi-estruturadas e grupos focais. Resultados - As ações do PSF dirigidas ao cuidado com a doença apresentaram maior índice de freqüência e regularidade do que as demais atividades do programa, porém, todos os grupos de atividades (biomédico, psicológico, comportamental, social e estrutural) estão bem representados no PSF do município. O trabalho com DSS se desenvolve em um contexto de bastante diversidade e pouca regularidade. A variedade e o tipo de determinantes trabalhados em cada unidade seguem um padrão de comportamento pelo qual foram identificados três grupos de unidades (Negativista, Essencialista e Inclusivo) quanto ao trabalho com DSS e dois grupos de DSS (Clássicos e Amplos). Os esforços do programa para com o trabalho com DSS estão dirigidos para os DSS Clássicos. Foi estabelecida relação entre os grupos de trabalho com DSS e as coordenadorias de saúde do município. As principais barreiras para o desenvolvimento de iniciativas de trabalho com DSS no PSF do município são majoritariamente de ordem estrutural e institucional, enquanto os facilitadores são de caráter individual. Todos os DSS mais comumente citados na literatura estão sendo trabalhados no PSF do município de São Paulo. Discussão e Conclusão - O PSF do município é voltado, no ideário, para os problemas e potencialidades da saúde no território, mas é gerido essencialmente para responder questões relativas à prevenção, tratamento e cura de enfermidades. O trabalho com DSS no PSF assume, no município de São Paulo, forma fluida e caráter extraordinário. Sua fluidez abarca de forma oportunista, em uma mesma iniciativa, diferentes conceitos de saúde e diferentes objetivos. Sua caracterização extraordinária define as iniciativas, por um lado, como algo a mais, trabalho extra ordinário, e por outro, como iniciativas admiráveis, importantes, extraordinárias. A naturalização do caráter extraordinário do trabalho com DSS é utilizada, por um lado, como justificativa para o trabalho desinstitucionalizado e, por outro, para mostrar uma suposta incompatibilidade natural de se trabalhar a determinação social da saúde no âmbito do PSF. O trabalho social, principalmente no grupo dos graduados, adquiriu, nas narrativas coletadas, condição santificada, no sentido de que não se deve falar contra ele. Se valoriza o trabalho no âmbito social como forma de exaltar a potencialidade "extraordinária" do PSF para lidar com a ampla determinação do processo saúde-doença. Da maneira como o trabalho com DSS se organiza hoje no PSF do município de São Paulo, ele não é viável ou sustentável. Sua pertinência, entretanto, se coloca para além do contexto atual de sua caracterização fluida e extraordinária, abrangendo singularidades e potencialidades do setor saúde como aliado dos princípios da promoção da saúde. Recomendações - Recomendamos: (1) o debate político/acadêmico sobre a naturalização do caráter extraordinário do trabalho com DSS no PSF e a mitificação do social no âmbito dos movimentos nacionais e internacionais de reforma sanitária, (2) a re-pactuação técnica e política do escopo do trabalho com DSS no âmbito do PSF, (3) a revisão das diretrizes do programa no sentido de incorporar o trabalho com DSS de forma integral, levando a mudanças nas políticas de avaliação, capacitação, financiamento e recursos humanos, (4) o aperfeiçoamento da práxis do trabalho com DSS no âmbito da atenção primária, visando o continuo aprimoramento de estratégias de intervenção e (5) a avaliação do trabalho desenvolvido pelo Grupo Inclusivo e as formas de organização da coordenadoria associada a este grupo, assim como as instituições parceiras relacionadas a esta coordenadoria. / Introduction - The work with social determinants of health (SDH) under the banner of the Family Health Program (FHP) is seen by the Brazilian Ministry of Health as a key strategic lever to reorganize primary health care efforts into integral care. At the same time, this program's holistic approach is considered by the health promotion professionals as a driver for community empowerment and social equality. Little is known, however, about the work with SDH being carried on under the FHP. The investigation of this practice represents a strategic point of evaluation for the FHP, as well as an importance case study of the comprehensiveness of community-based primary health care. Objective - To identify, analyze and discuss the state of work with SDH under the banner of FHP in the city of Sao Paulo. Methodology - Based on a pragmatic approach and making use of a mix methods design, data was collected and analyzed in a two step sequential process that reflected a sequential explanatory strategy. The first step encompassed a mostly quantitative (but also qualitative) survey with the population of FHP unit managers of the city of Sao Paulo. The second step, strictly qualitative in nature, comprehended data collection through semi-structured interviews and focal group discussions with central coordination staff, unit managers and other health professionals of the FHP units. Results - Though FHP actions that deal with disease treatment are not only the most frequent ones as well as the ones that are performed with greater regularity, all types of actions (biomedical, psychological, behavioral, social and structural) are being performed by the FHP units in the city. The work with SDH is characterized by great diversity and low regularity. The particular variety and specificity of SDH work that is performed at each unit follow certain patterns that were identified and grouped together - two sets of SDH (classical and broad) and three sets of units (inclusive, essentialist and negativist) emerged. FHP efforts with SDH are mostly directed towards the classical types of determinants. The nature of the relationship between units that carry on work with SDH and central health coordination bodies of the city was also examined. The main barriers for SDH work under FHP are mostly structural and institutional in nature, while the key facilitator tends to be of an individual nature. The appropriateness of working with SDH under FPH was put to doubt by the program professionals, even by those who were most heavily involved with initiatives related to the social determination of health. Conclusion - The work with SDH in the city of Sao Paulo under the FHP has a fluid form and an irregular character which hamper their feasibility. Discussions over the adequacy of these actions should go beyond the simple normalization of their non-standard character and address the kind of initiatives that would foster their institutionalization and allow for proper evaluation.