Introdução: A medida da qualidade de vida relacionada à saúde vem se tornando um modelo importante de avaliação em muitos estudos clínicos. Especial consideração deve ser dada à doença cerebrovascular por ser freqüente e de graves conseqüências físicas, sociais, familiares e econômicas. No Brasil não dispomos de um instrumento específico de avaliação da qualidade de vida validado para uso em pacientes com doença cerebrovascular isquêmica. Este estudo avaliou as medidas psicométricas do instrumento de avaliação da qualidade de vida específico para a doença cerebrovascular do tipo isquêmico, adaptado transculturalmente para a língua portuguesa (Stroke specific quality of life scale, SS-QOL). Metodologia: Foram avaliados 50 pacientes com história de doença cerebrovascular do tipo isquêmico, com idade superior a 45 anos e com evolução clínica superior a 3 meses da data do íctus, assistidos no Centro Catarinense de Reabilitação em Florianópolis, Santa Catarina. O instrumento SS-QOL foi aplicado em duas entrevistas com intervalo médio, entre elas, de 2 a 4 semanas. Paralelo a esta medida, foram aplicados, na primeira entrevista, os instrumentos: índice Barthel, inventário de depressão de Beck, escala de doença cerebrovascular do Instituto Nacional de Saúde dos Estados Unidos da América (NIHSS) e o estudo de resultados médicos - versão curta de 36 itens (SF-36). A avaliação da confiabilidade (estabilidade e consistência interna) do SS-QOL foi testada por meio da análise do coeficiente de confiabilidade, com o modelo teste-reteste, e do valor alfa de Cronbach. A validação do constructo e de critério foi estabelecida através da correlação linear entre os resultados obtidos para cada domínio e os resultados obtidos nas medidas escolhidas como padrão ouro para aquele domínio medido pelo coeficiente de correlação de Pearson (r). A capacidade discriminativa do constructo foi testada comparando o escore médio do SS-QOL entre os pacientes que referiam alteração da qualidade de vida e os pacientes que não referiram alteração da qualidade de vida em relação à época antes do infarto cerebral. Ela também foi avaliada comparando o escore médio do SS-QOL em relação à gravidade clínica da doença medida pela escala NIHSS e pelo grau de incapacidade funcional avaliado pela escala de Rankin modificado. Resultados: O SS-QOL, versão para a língua portuguesa, apresentou boa aceitabilidade, não tendo informações perdidas nem porcentagem aumentada de respostas com efeito teto ou solo. A confiabilidade do instrumento foi considerada excelente, com coeficiente de correlação intraclasse de 0,95 (p < 0,001) e o valor alfa de Cronbach de 0,98 (p < 0,001). O grau de correlação linear dos domínios do SS-QOL com as demais medidas escolhidas para cada domínio foi considerado de razoável a moderadamente elevado, com valor de r variando de 0,42 a 0,91 (p < 0,01). O SS-QOL mostrou capacidade discriminativa adequada ao detectar diferenças estatisticamente significantes no escore médio dos pacientes que referiram alteração da qualidade de vida e dos que não alegaram alteração da qualidade de vida em relação a antes de a doença ter ocorrido e no escore médio dos pacientes com doença considerada leve em relação aos pacientes com doença considerada moderada (p < 0,001). A análise de variância revelou diferenças estatisticamente significantes no escore médio dos pacientes estratificados pelo grau de incapacidade funcional (p < 0,01). Conclusão: O SS-QOL, adaptado para a língua portuguesa, apresentou medidas psicométricas consideradas satisfatórias, estando adequado para a utilização como uma ferramenta de avaliação da qualidade de vida em pacientes com doença cerebrovascular na prática médica diária ou em estudos clínicos. / Introduction: Measurement of health related quality of life has become an important evaluation model in many clinical studies. Special consideration must be given to the cerebrovascular disease because it is frequent and has serious physical, social, familial and economic consequences. We do not have, in Brazil, a specific instrument to evaluate health related quality of life validated for stroke patients. This study evaluates psychometric measures of the stroke specific quality of life scale cross-culturally adapted to Portuguese language (SS-QOL). Methodology: We evaluated 50 stroke patients, admitted to the Centro Catarinense de Reabilitação in Florianópolis, Santa Catarina, older than 45 years old with time of lesion superior to 3 months. The SS-QOL was applied in two interviews with average interval, between them, of 2 to 4 weeks. Parallel to the instrument, we applied, in the first interview, the Barthel index, Beck depression inventory, National Institute of Health stroke scale (NIHSS) and the Medical outcome study - short version of 36 items (SF-36). The SS-QOL reliability evaluation (stability and internal consistency) was tested with the analysis of the stability coefficient with test-retest model, and the Cronbach?s alpha value. The construct and criterion validation was established by comparing the linear correlation between the results for each domain and the results of the chosen gold standard measures for that domain measured with Pearson correlation coefficient (r). The discriminant capacity was tested comparing the SS-QOL mean scores of patients who referred changes in the quality of life and those that did not refer it in relation to the prestroke period. It was also evaluated comparing the SS-QOL mean score in relation to disease clinical gravity measured with the NIHSS and the degree of functional incapacity evaluated by Rankin modified scale. Results: The SS-QOL, Portuguese language version has good acceptability. It does not have missing data or increased percentage of ceiling or floor effect. The stability was considered excellent with intraclass correlation coefficient of 0,95 (p < 0.001) and the Cronbach?s alpha value of 0,98 (p < 0,001). The degree of linear correlation of the SS-QOL domains with the chosen measures for each domain was considered reasonable to moderately high with r values varying from 0,42 to 0.91 (p < 0,01). The SS-QOL presented suitable discriminant capacity detecting differences, statistically significant, in the mean score of patients who had referred changes in the quality of life and those that did not refer it in relation to the prestroke period and in the mean score of patients with mild stroke and those with moderate stroke. The variance analysis showed statistically significant differences in the mean score of patients stratified by the functional incapacity degree (p < 0.01). Conclusion: The SS-QOL, adapted to Portuguese language, had psychometric measures considered satisfactory. It is suitable to use as a tool of quality of life evaluation in patients with stroke in the daily clinical practice or clinical studies.

Os tumores pediátricos diagnosticados em apresentação avançada necessitam de tratamentos mais intensivos, que causam morbidade aguda e tardia, acrescido de redução das chances de cura. O objetivo deste estudo foi o de avaliar a associação entre variáveis sociodemográficas com o estadiamento de tumores malignos. Foi realizada uma análise retrospectiva de casos com diagnóstico de tumores malignos admitidos no Hospital Sarina Rolim Caracante (HSRC), entre janeiro de 1998 a dezembro de 2008. A variável dependente foi o estadiamento do tumor. Foram consideradas variáveis independentes: idade, sexo, procedência, tempo de sintomatologia, diagnóstico histológico, idade materna, escolaridade materna, número de irmãos, empregabilidade dos pais, disponibilidade de serviço de emergência pediátrica, urbanização, distância, Índice de Desenvolvimento Humano (IDH) e Índice de Exclusão Social (IES) dos municípios de origem do paciente. Foram avaliados 246 casos com exclusão de 25 pacientes por não preencherem os critérios de inclusão. A maioria foi do sexo masculino (61,6%), com média de idade de 7,3 anos. O percentual dos estádios III e IV foi de 60,1% dos casos. O tempo médio de sintomatologia foi de 103,25 dias. Os tipos histológicos mais comuns foram: linfoma de Hodgkin, neuroblastoma e linfoma não Hodgkin. Os neuroblastomas, carcinomas e retinoblastomas apresentaram maior percentual de doença avançada. Não foi observada associação estatisticamente significante do estadiamento dos tumores malignos com as variáveis: idade, sexo, procedência, tempo de sintomatologia, diagnóstico histológico, idade materna, escolaridade materna, número de irmãos, empregabilidade dos pais, disponibilidade de ix serviço de emergência pediátrica, urbanização, distância, Índice de Desenvolvimento Humano (IDH) e Índice de Exclusão Social (IES) / The early diagnosis of cancer is a fundamental goal in pediatric oncology because it allows an opportunity for timely treatment while the disease is still in its earliest stages. The aim of this study was to evaluate the association between sociodemographic variables and stage disease. Retrospective analysis was performed in malignant tumors patients admitted in the Hospital Sarina Rolim Caracante (HSRC) between January 1998 and December 2008. Dependent variable was considered the stage of the disease at diagnosis. Independent variables were age, gender, referral geographic region, lag time, histological diagnosis, mothers education level, number of siblings, employ status, pediatric emergency unit availability, urbanization, distance, Human Developing Index (HDI) and Social Exclusion Index (SEI). Two hundred and forty six cases were evaluated. Twenty-five were excluded because of missing data. Sixty-one per cent were male and 7.3 years median age. Sixty per cent were stage III and IV and the median lag time of all patients was 103.25 days. The commonest histological subtypes were: Hodgkins lymphoma, neuroblastomas and non-Hodgkins lymphoma. Neuroblastoma, carcinoma and retinoblastoma had the highest percentual of advanced disease. There was no statistical correlation between lag time and stage (p=0.49). The patient and parent variables such as age, gender, mothers age, mothers education level, parental employee status were not associated with risk of advanced disease. Variables related with the place of residence: region, distance, pediatric emergency unit availability, urbanization, SEI and HDI were not associated with increased risk of advanced stage either. Despite a high incidence of advanced disease in xi these small series we could not demonstrate that sociodemographic factors are responsible for advanced disease

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-05-06T17:58:43Z No. of bitstreams: 1 lucianadossantostirapani.pdf: 1416883 bytes, checksum: 1a79bea047bbedac18db6f9798555854 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-06-08T14:41:23Z (GMT) No. of bitstreams: 1 lucianadossantostirapani.pdf: 1416883 bytes, checksum: 1a79bea047bbedac18db6f9798555854 (MD5) / Made available in DSpace on 2016-06-08T14:41:23Z (GMT). No. of bitstreams: 1 lucianadossantostirapani.pdf: 1416883 bytes, checksum: 1a79bea047bbedac18db6f9798555854 (MD5) Previous issue date: 2013-08-02 / Introdução: O Serviço social entra oficialmente para o rol de profissões da saúde com a resolução do ministério da saúde nº 218/97. Esse reconhecimento da profissão perpassa um processo histórico, marcado pelas condições históricas nas quais a saúde pública se desenvolveu no Brasil e pelo reconhecimento social da profissão. Dentro da intervenção do Serviço Social na saúde, encontramos um novo campo de atuação que é o da nefrologia, uma atuação que, nos centros de Terapia Renal Substitutiva (TRS), possui um respaldo legal, sendo um reconhecimento da importância dos assistentes sociais na composição das equipes mínimas de atenção ao usuário com Doença Renal Crônica (DRC) em TRS. A associação entre fatores socioeconômicos e incidência e prevalência de DRC está bem determinada na literatura. Indubitavelmente, a etnia é o fator social mais estudado no que diz respeito à incidência e prevalência da DRC. Apenas recentemente, fatores educacionais têm sido abordados com relação à DRC, analisando a importância do autoconhecimento da patologia e a melhora dos desfechos. Um problema frequentemente abordado é a dificuldade de acesso aos serviços de saúde, tanto em países desenvolvidos, com modelos de sistemas de saúde que não são universais, como nos Estados Unidos, quanto em países em desenvolvimento, com populações com baixo nível socioeconômico, como o Brasil. Fatores como o gênero também tem sido abordados em poucos estudos, com mulheres tendo maior incidência de DRC. Quando avaliamos a influência desses mesmos fatores na progressão da DRC, há apenas escassos e fragmentados estudos que avaliam a questão, e vemos claramente que os estudos que avaliam a progressão da DRC abordam prioritariamente fatores biológicos. O objetivo deste estudo foi caracterizar o perfil social dos usuários com doença renal crônica pré-dialítica nos estágios 3, 4 e 5, como também avaliar o impacto das variáveis socioeconômicas na progressão da DRC pré-dialítica nos estágios estudados. Usuários e Métodos: Foi feito um estudo de coorte retrospectivo, período de acompanhamento de janeiro de 2002 a dezembro de 2009. As variáveis analisadas foram sociodemográficas, clínicas e laboratoriais. Os critérios de inclusão: usuários com mais de 18 anos de idade, DRC estágios 3A, 3B, 4 e 5, acompanhados por mais de três meses. Análise Estatística: Os usuários foram divididos de acordo com a vulnerabilidade social (VS). Para calcular a VS, foram utilizadas três técnicas estatísticas em seqüência, análise fatorial, análise de cluster (Cluster) e análise discriminante. Os dados sociodemográficos, clínicos e laboratoriais foram avaliados para cada grupo de VS. Foi realizada uma análise descritiva dos dados, expressos em média ± desvio padrão, mediana ou percentagem, de acordo com a característica da variável. Para avaliar a normalidade, utilizamos o teste de Kolmogorov-Smirnov. Diferenças entre os grupos foram analisadas pelo teste t para amostras independentes ou o teste de Wilcoxon para as comparações não-paramétricas. Um teste de χ2 foi usado para variáveis categóricas. A sobrevida foi analisada com curvas de sobrevida de Kaplan-Meier. O desfecho foi mortalidade ou iniciar a terapia renal substitutiva (TRS), analisadas por uma regressão de Cox. Resultados: Foram avaliados 209 usuários, acompanhados por um período de 7 anos, 29,4% foram classificados como vulneráveis. Não observamos diferença na mortalidade entre os usuários vulneráveis e não vulneráveis (log rank: 0,23), o que também ocorreu quando o resultado foi TRS (log rank: 0,17). No modelo de regressão de Cox, risco relativo (RR) e intervalo de confiança (IC) para o impacto da VS sobre a mortalidade, não ajustado foi RR: 1,87 (IC: 0,64-5,41) e, após RR ajustado: 1,47 (C1: 0,35-6,0). Quando analisamos o impacto da VS em TRS, observamos o R RR não ajustado: 1,85 (IC: 0,71-4,8) e RR ajustado: 2,19 (CI :0.50-9 0,6). Conclusão: A VS não apresentou impacto nos desfechos óbito e TRS. O acesso aos cuidados de saúde, no Brasil, apesar de suas características universais, tem barreiras sociais no acesso ao tratamento especializado. Acreditamos que os usuários passaram pelas barreiras sociais impostas para o 7 acesso a cuidados especializados (viés de seleção). Nosso estudo apresenta limitações, já que não nos permite comprovar a eficácia de uma intervenção interdisciplinar, uma vez que o desenho do estudo adotado (coorte retorspectiva) não nos permite avaliar o impacto da aborgadem interdisciplinar, pois a coleta dos dados ocorreu após a intervenção da equipe.No entanto, o presente estudo é o primeiro a avaliar a VS em usuários com DRC em pré-diálise, por um período de acompanhameto de sete anos. / Introduction: The Social Work officially enter the ranks of health professions with the resolution of the Ministry of Health No. 218/97. This recognition of the profession goes through a historical process marked by the historical conditions in which public health was developed in Brazil and the social recognition of profession. Inside Social Service Health, found a new playing field that is nephrology, a performance that, in the centers of Renal Replacement Therapy (RRT), has a legal backing, and a recognition of the importance of social workers in the composition teams minimal attention to patient with Chronic Kidney Disease (CKD) in TRS. The association between socioeconomic factors and incidence and prevalence of CKD is well established in the literature. Undoubtedly, the ethnicity is the most studied social factor with regard to the incidence and prevalence of CKD. Only recently, educational factors have been addressed with respect to CKD, analyzing the importance of self-pathology and improves outcomes. An issue often discussed is the difficulty of access to health services, both in developed countries, with models of health systems that are not universal, as in the United States and in developing countries with populations with low socioeconomic status, as Brazil. Factors such as the genre has also been addressed in a few studies, with women having higher incidence of CKD. When we evaluated the influence of these same factors in the progression of CKD, there is only scarce and fragmented studies evaluating the issue, and we see clearly that studies evaluating the progression of CKD deal primarily biological. The aim of this study was to characterize the social profile of users with chronic kidney disease pre-dialysis stages 3, 4 and 5, as well as assess the impact of socioeconomic variables on the progression of CKD pre-dialysis stages studied. Patients and Methods:: We conducted a retrospective cohort study, follow-up period from January 2002 to December 2009. The variables were sociodemographic, clinical and laboratory. Inclusion criteria: users over 18 years of age, CKD stages 3A, 3B, 4 and 5, accompanied by more than three months. Statistical Analysis: The users were divided according to social vulnerability (SV). To calculate the VS, we used three statistical techniques in sequence, factor analysis, cluster analysis (Cluster) and discriminant analysis. The demographic data, clinical and laboratory data were evaluated for each group of VS. We performed a descriptive analysis of the data, expressed as mean ± standard deviation, median, or percentage, according to the characteristic of the variable. To assess normality, we used the Kolmogorov-Smirnov test. Differences between groups were analyzed by t test for independent samples or the Wilcoxon test for nonparametric comparisons. A χ2 test was used for categorical variables. Survival was analyzed with survival curves of Kaplan-Meier. Cox regression was performed to examine the impact of SV on the outcomes. Results. We evaluated 209 patients cared for a period of 7 years, 29.4% were classified as vulnerable. There were no differences in mortality among the vulnerable and non-vulnerable users (log rank: 0.23), which also occurred when the result was TRS (log rank: 0,17). In the Cox regression model, hazard ratio (HR) and confidence interval (CI) for the impact of VS on mortality was not adjusted HR: 1.87 (CI: 0.64 to 5.41) and after adjusted HR: 1.47 (C1: 0.35 to 6.0). When we analyze the impact of VS on TRS, observe the HR and CI, unadjusted HR: 1.85 (CI: 0.71 to 4.8) and adjusted HR: 2.19 (CI:0.50-9 0.6) . Conclusion: VS showed no impact on mortality outcomes and TRS. Access to health care in Brazil, despite its universal features, have social barriers in access to specialized treatment. We believe that users spent by social barriers imposed for access to specialized care (selection bias). Our study has limitations, as it does not allow us to prove the effectiveness of an interdisciplinary intervention, since the method adopted (retrospective cohort) did not allow us to evaluate the impact of an interdisciplinary approach, because data collection occurred 9 after the intervention team. However, the present study is the first to evaluate the VS in users with CKD pre-dialysis, for a follow-up period of seven years.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-07-21T12:05:52Z No. of bitstreams: 1 raylaamarallemos.pdf: 8200511 bytes, checksum: 926302d3ee9c6ade88a5409db88a3c45 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-07-22T15:28:27Z (GMT) No. of bitstreams: 1 raylaamarallemos.pdf: 8200511 bytes, checksum: 926302d3ee9c6ade88a5409db88a3c45 (MD5) / Made available in DSpace on 2016-07-22T15:28:27Z (GMT). No. of bitstreams: 1 raylaamarallemos.pdf: 8200511 bytes, checksum: 926302d3ee9c6ade88a5409db88a3c45 (MD5) Previous issue date: 2011-02-28 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / O avanço no cuidado obstétrico e neonatal tem proporcionado a sobrevivência de crianças com altos graus de prematuridade e baixo peso ao nascer, que apresentam marcada susceptibilidade para alterações em seu desenvolvimento. O objetivo deste estudo foi avaliar os efeitos em longo prazo da prematuridade e do baixo peso ao nascimento sobre as habilidades funcionais e a independência de crianças entre 2 e 7 anos de idade acompanhadas em um serviço de follow-up. Foi realizado estudo de caráter transversal, utilizando o Inventário de Avaliação Pediátrica de Incapacidade – PEDI uma entrevista estruturada com cuidadores de crianças e que avalia as habilidades funcionais e o nível de independência destas. Os 98 participantes (50 do sexo feminino e 48 do masculino), com idade média de 4,3 anos, foram divididos de forma independente em três grupos de acordo com o grau de prematuridade e em outros três grupos de acordo com o peso ao nascer. Foram coletados também dados sociodemográficos e ambientais. Realizaram-se análises estatísticas de variância com um e dois fatores e regressão linear multivariada, com nível de significância α=0,05. Houve atraso de 10,2%, nas habilidades funcionais de autocuidado (HFAC), 12,2% nas de mobilidade (HFM), e de 14,3%, função social (HFFS). Quanto ao nível de assistência recebida do cuidador o atraso foi de 11,2% em autocuidado (ACAC), 19,4% em mobilidade (ACM) e 15,3% em função social (ACFS). A análise bivariada não revelou associação estatisticamente significativa entre os índices de prematuridade e baixo peso ao nascer com nenhum dos domínios do PEDI. As análises de variância mostraram que a interação entre estes fatores e os ambientais como nível socioeconômico, escolaridade, etnia e estado civil do cuidador, número de complicações neonatais, frequência em creche e presença de irmãos, exerceu influência estatisticamente significativa sobre áreas específicas do perfil funcional e independência dos participantes. Com o ajuste das variáveis na regressão linear múltipla mantiveram valores significativos: número de complicações neonatais com o desfecho HFAC quando se considera no modelo a idade gestacional, e peso ao nascer com o desfecho ACAC, no modelo que considera o peso. A interação entre a prematuridade, o baixo peso ao nascer com fatores ambientais parece exercer importantes efeitos sobre o desempenho funcional de crianças pré-escolares. Os achados podem subsidiar políticas públicas e ações voltadas à população com risco biológico para alterações no desenvolvimento. / Introduction: Advances in obstetric and neonatal care has been providing the survival of children with high degrees of prematurity and low birth weight, who are highly susceptible to alterations in their development. The objective of this study was to assess the long-term effects of prematurity and low birth weight on functional abilities and on independence of children between two and seven years old in follow-up service. Methods: Cross-sectional study which used the Pediatric Evaluation Disability Inventory- PEDI, that consists in an interview structured with children caregivers and assesses children’s functional abilities and independence level. The test was accomplished with 98 participants distributed into three groups according to the degree of prematurity, and three groups according to birth weight. It was collected, too, sociodemografic and environmental data. It was accomplished variance statistic analysis and multivariate linear regression, considering significant level α=0,05. Results: There was a delay in the functional abilities in the areas of selfcare (HFAC), mobility (ACM) and social function (ACFS) of 10,2%, 12,2% and 14,3%, respectively and caregivers’ assistance received level of 11,2% in self-care (ACAC) , 19,4% in mobility (ACM) and 15,3% in social function (ACFS). Bivariate analysis do not found significant statistically association between prematurity levels, low birth weight and areas of the PEDI. Variance analysis demonstrated that interaction between those factors and socioenvironmental characteristics, such as socioeconomic status, schooling level, marital status and skin color of caregiver, neonatal complications number, school frequency and brothers, showed statistically significant influence on specific areas of the functional performance and independence of participants. After adjusting the variables through multivariate linear regression, remained associated: the neonatal complications number, in the outcoming of self-care functional abilities (HFAC), when it is considered in the model the gestational age, and birth weight in the outcoming of self-care caregivers assistance (ACAC), when variable weight is into model. Final Considerations: The interaction between prematurity, low birth weight and socioenvironmental factors has important effects on functional performance of pre-school children. Data can subsidize public policies and preventive therapeutic actions favoring children exposed to those conditions.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / The objectives of the present research were to study the correlations between the presence of risk to child development and the interference of socioeconomic, demographic, psychosocial and obstetric variables, and to investigate the association between the presence of risk to child development and children initial speech production from 13 to 16 months of age. The quantitative, descriptive study of comparative nature about the behavioral manifestations of the mother-infant interactive process consisted of the evaluation of an initial sample of 182 mother-child dyads who were followed for 18 months in a cohort study. The final sample for the study of socioeconomic, demographic, psychosocial, and obstetric variables consisted of 64 infants and for the initial speech production study, the sample consisted of 54 infants. The collecting procedures were based on an initial interview, during the first stage of collection (1-4 months), on the application of the Risk Indicators for Child Development Protocol (1-18 months) and on the collection of children speech production between 13 and 16 months of age, by spontaneous observation and maternal report. Statistical analysis was developed through the application of non-parametric tests. The results demonstrated that there is a significantly association between the presence of risk to infant development and socioeconomic, demographic, psychosocial and obstetric variables. It was also verified that the initial language acquisition correlates significantly with the presence of development risks, since infants at risk present initial speech output in numerical magnitude statistically lower compared to infants without risk. Therefore, the risk to child development is multifactorial, being necessary to observe the constitutional aspects of the infant and relational to the environment, especially in relation to who plays the maternal role, in order to analyze and decide on the clinical referral. Keywords: Infant care. Infant. Child development. Risk factors. Language. Socioeconomic factors / Esta pesquisa teve como objetivos analisar as associações entre a presença de risco ao desenvolvimento infantil e variáveis socioeconômicas, demográficas, psicossociais e obstétricas, e investigar a associação entre presença de risco ao desenvolvimento infantil e produção inicial de fala de crianças na faixa de 13 a 16 meses de idade. O estudo quantitativo, descritivo com caráter comparativo sobre as manifestações comportamentais do processo interativo mãe-bebê, constituiu-se da avaliação de uma amostra inicial de 182 díades mães-bebês que foram acompanhadas durante 18 meses em um estudo de coorte. A amostra final para o estudo de variáveis socioeconômicas, demográficas, psicossociais e obstétricas foi de 58 crianças e para o estudo de produção inicial de fala de 54 crianças. Os procedimentos de coleta constaram de uma entrevista inicial, na primeira etapa da coleta (1 a 4 meses), a aplicação do Protocolo de Índices de Risco ao Desenvolvimento Infantil (1 a 18 meses) e da coleta da produção de fala entre 13 e 16 meses, por meio da observação espontânea e relato materno. A análise estatística deu-se pela aplicação de testes não-paramétricos e pela estimação de modelos de regressão logística. Os resultados demonstraram que há uma associação significativa entre presença de risco ao desenvolvimento infantil e variáveis socioeconômicas, demográficas, psicossociais e obstétricas. Também se verificou que a aquisição da linguagem inicial apresenta associação de modo significativo com a presença de riscos ao desenvolvimento, visto que bebês com risco apresentam produção de fala inicial em magnitude numérica estatisticamente inferior em relação aos bebês sem risco. Portanto, o risco ao desenvolvimento infantil é multifatorial, sendo necessário observar os aspectos constitucionais do bebê e relacionais com o ambiente, sobretudo em relação a quem exerce a função materna, para analisar e decidir acerca do encaminhamento clínico.

Abstract Physical activity provides important physical health benefits for young people. However, the information on physical activity in association with various social, educational and mental health factors among adolescents is scarce. This study aimed to evaluate how physical activity is related to adolescents’ emotional and behavioural problems, self-rated health, educational attainment and parental socio-economic position, and how these factors interrelate with each other. The study population consisted of the Northern Finland Birth Cohort 1986 (N = 9432). Data on physical activity, emotional and behavioural problems, self-rated health, educational attainment and parental socio-economic position at age 15–16 years was collected by postal inquiries in 2001–2002. Logistic regression models were used to study the associations between these factors. High parental socio-economic position was associated with being physically active among adolescents. Physical inactivity was related to emotional, social, thought and attention problems, and rule-breaking behaviour. Physical inactivity, emotional, behavioural and social problems, and low parental socio-economic position were related to poor self-rated health. In addition, higher levels of physical activity, fewer behavioural problems, and higher parental socio-economic position were associated with high self-perceived academic performance and future plans for higher education. Physical inactivity during adolescence is associated with several emotional and behavioural problems, and poor self-rated health, whereas being physically active is related to higher educational attainment. Developmentally appropriate and enjoyable physical activity could have an important role in enhancing adolescents’ health, well-being, and educational attainment. / Tiivistelmä Liikunta edistää lasten ja nuorten fyysistä terveyttä. Liikunnan yhteyksistä sosiaalisiin tekijöihin, nuorten koulumenestykseen ja mielenterveyteen on kuitenkin vähän tietoa. Tämän tutkimuksen tavoitteena oli selvittää liikunnan yhteyksiä nuorten tunne-elämän ja käyttäytymisen häiriöihin, koettuun terveyteen ja koulumenestykseen. Lisäksi selvitettiin liikunnan, terveyteen ja koulutukseen liittyvien tekijöiden, sekä perheen sosioekonomisen aseman keskinäisiä suhteita. Tutkimusaineistona oli Pohjois-Suomen syntymäkohortti 1986 (N =  9432). Liikunta-aktiivisuus, perheen sosioekonominen asema, tunne-elämän ja käyttäytymisen häiriöiden esiintyvyys, koettu terveys ja koulumenestys selvitettiin postikyselyllä 15–16-vuotiaana vuosina 2001–2002. Muuttujien välisiä yhteyksiä testattiin logistisella regressioanalyysilla. Vanhempien korkea sosioekonominen asema oli yhteydessä nuorten liikunnalliseen aktiivisuuteen. Vähäinen liikunnan harrastaminen liittyi tunne-elämän häiriöihin, sosiaalisiin ongelmiin, ajatus- ja tarkkaavuushäiriöihin sekä sosiaaliseen käytöshäiriöön. Vähäinen liikunta, tunne-elämän ja käyttäytymisen häiriöt sekä vanhempien alhainen sosioekonominen asema liittyivät huonoon koettuun terveyteen. Lisäksi liikunnallinen aktiivisuus, vähäiset käyttäytymisen häiriöt sekä vanhempien korkea sosioekonominen asema olivat toisistaan riippumatta yhteydessä nuorten hyvään koulumenestykseen ja opintosuunnitelmiin. Tämän tutkimuksen tulokset osoittavat, että vähäinen liikunta on yhteydessä nuorten tunne-elämän ja käyttäytymisen häiriöihin sekä huonoon koettuun terveyteen, kun taas liikunnallinen aktiivisuus liittyy hyvään koulumenestykseen. On mahdollista, että monipuolisen, ikä- ja kehitystasolle sopivan liikunnan avulla voidaan edistää nuorten terveyttä ja hyvinvointia sekä koulutuksellisia edellytyksiä.

Socioeconomically deprived women are at greater risk of adverse pregnancy outcomes. To counteract this, attention tends to focus around access (equality) of services. Yet access may not equate with the meaningfulness (equity) of services for women from different socioeconomic backgrounds. Without understanding equity we are not in a position to plan appropriate and equitable care. This study aimed to determine pregnant women's perceptions of the current antenatal provision and to determine if women from the extremes of socioeconomic background perceived their antenatal care differently. Longitudinal interviews were undertaken with multiple, comparative antenatal case studies between January 2007 and April 2009. Cases were primigravida women from ‘least deprived’ (n=9) and ‘most deprived’ (n=12) geographical areas as identified by the Scottish Index of Multiple Deprivation (SIMD 2006). The data were analysed using case study replication analysis. Analysis of categorical data from the sample groups indicated they were less diverse than might have been expected in terms of age and education. However in the key variables of housing tenure, potential income and socioeconomic status based on area of residence, the groups were indicative of the SIMD target populations. The preliminary analysis showed that the sample groups considered the initial General Practitioner contact to be less than adequate and the subsequent utility of antenatal education to be based on self perceived relevance. The substantive analysis showed little difference in access to antenatal services between the ‘least’ and ‘most’ deprived groups but perception of care differed. A key difference concerned the level of ‘engagement’ (defined as personalisation and active involvement in care, power and relationships and health literacy). Using these concepts, engagement was present in most of the ‘least deprived’ group and almost none of the ‘most deprived’ group. In comparison with women from affluent areas, more deprived women described less evidence of: personal connection to their own care; shared decision making; and perceived value in relation to the written educational aspects of antenatal care. In terms of the preliminary analysis, the results suggest that utility of educational material may need to be reviewed to ensure it is relevant to specific needs. Without this relevance, key information may be missed. The substantive analysis suggests that for women from socioeconomically deprived areas, access may be a less useful indicator than engagement when assessing quality of antenatal services. The lack of engagement perceived by those who are most deprived suggests that equity of service has yet to be attained for those who are most in need. Future research needs to be directed to the potential reasons that may undermine equity and engagement in women from lower socioeconomic areas.

In 2007, the Canadian Paediatric Society (CPS) released a guideline aimed at preventing complications of neonatal jaundice through universal screening and guidelines for follow-up and treatment. This thesis investigates the impact of implementation of the CPS guideline on health services utilization at a population level in Ontario. First, we surveyed all Ontario hospitals providing maternal-newborn services to determine if and when they had implemented universal bilirubin screening, and to gather information about the organization of services to provide follow-up and treatment, and about the factors that influenced screening implementation. Then we conducted two population-based cohort studies using linked administrative health data to evaluate the association between 1) the implementation of universal bilirubin screening and phototherapy use (during and following birth hospitalization) length of stay (LOS), jaundice-related emergency department (ED) visits and readmissions; and 2) universal bilirubin screening implementation and access to recommended follow-up care by socio-economic status (SES). By 2012, the majority of Ontario hospitals had implemented universal bilirubin screening. There is heterogeneity in how hospitals organize services, but a notable trend towards hospital-based post-discharge care. Screening was associated with an increase in phototherapy during hospitalization at birth (relative risk (RR) 1.32, 95% confidence interval (CI) 1.09-1.59), and a decrease in jaundice-related ED visits (RR 0.79, 95% CI 0.64-0.96), but no statistically significant difference in phototherapy after discharge, length of stay, or jaundice-related readmissions after accounting for pre-existing temporal trends in healthcare service use and other patient socio-demographic and hospital characteristics. Implementation of the universal bilirubin screening in Ontario was associated with a modest increase in rates of early follow-up (adjusted RR 1.11, CI 1.0014-1.22, p=0.0468), but most babies were not seen within the recommended timeframe. Babies of lowest SES were least likely to receive recommended follow-up, and disparities in follow-up increased following universal bilirubin screening implementation. En 2007, la Société canadienne de pédiatrie (SCP) a publié une directive visant à la prévention des complications de l'ictère néonatal par le dépistage universel et des lignes directrices pour le suivi et le traitement. Cette thèse étudie l'impact de la mise en œuvre de la directive SCP sur l'utilisation des services de santé à niveau de population de l'Ontario. Tout d'abord, nous avons interrogé tous les hôpitaux de l'Ontario offrant des services de santé maternelle-nouveau-né afin de déterminer si et quand ils avaient mis en œuvre le dépistage universel de la bilirubine, et à recueillir des informations sur l'organisation des services pour assurer un suivi et de traitement, et sur les facteurs qui ont influencé la mise en œuvre de dépistage. Ensuite, nous avons mené deux études de cohorte basée sur la population à partir de données administratives sur la santé pour évaluer 1 ) l'association entre la mise en œuvre du dépistage de la bilirubine universel et la photothérapie utilisation lors de l'hospitalisation à la naissance, la photothérapie après avoir sortie de l'hôpital, la durée du séjour, le service des urgences liées à la jaunisse et des réadmissions liées à la jaunisse; et 2 ) l'association entre la mise en œuvre du dépistage universel et l'accès aux soins de suivi recommandés et si cela différait entre les quintiles de statut socioéconomique. En 2012, la majorité des hôpitaux de l'Ontario a mis en œuvre le dépistage universel de la bilirubine. Il existe une hétérogénéité de la façon dont les hôpitaux organisent des services, mais une tendance notable vers les soins post-décharge en milieu hospitalier. Le dépistage a été associé à une augmentation de la photothérapie pendant l'hospitalisation à la naissance (risque relatif (RR) de 1,32, intervalle de confiance 95 % (IC 95 %) de 1,09 à 1,59), et une diminution des visites à l'urgence liées à la jaunisse (RR 0,79, IC 95 % 0,64 à 0,96), mais aucune différence statistiquement significative dans la photothérapie après la sortie , la durée du séjour , ou réadmissions liées jaunisse - après comptabilisation des tendances temporelles pré- existants dans l'utilisation des services de soins de santé et d'autres caractéristiques socio- démographiques des patients et caractéristiques de l'hôpital. La mise en œuvre de le dépistage universel en Ontario a été associée à une légère augmentation des taux de suivi précoce (RR ajusté 1,11; IC de 1,0014 à 1,22; p = 0,0468), mais la plupart des bébés n'ont pas été vues dans les délais recommandés. Les bébés de statut socioéconomique faibles étaient moins susceptibles de recevoir de soins de suivi recommandés et les disparités dans le suivi ont augmenté suite à la mise en œuvre du dépistage universel de la bilirubine.

L'asthme est une des principales maladies chroniques de l'enfance. Elle a été associée à l'exposition aux polluants de l'air extérieur provenant de sources régionales éloignées et du trafic routier. Les mélanges de polluants provenant de sources industrielles et leurs effets peuvent ne pas être les mêmes que ceux provenant du trafic routier et de sources régionales. Pourtant, contrairement aux associations entre les polluants provenant de sources régionales et liées au trafic et l'asthme chez les enfants, les associations avec l'exposition des communautés aux émissions de polluants atmosphériques industriels n'ont pas été systématiquement évaluées. En outre, bien que des réductions substantielles des émissions industrielles de particules fines (PM2.5) et de dioxyde de soufre (SO2) aient été constatées dans les pays industrialisés au cours des dernières décennies, les associations entre les variations géographiques et temporelles des émissions industrielles de polluants atmosphériques et la variation de la morbidité de l'asthme chez les enfants ont été sous-étudiées. Dans cette thèse, nous avons étudié l'association entre la morbidité liée à l'asthme et les émissions de polluants atmosphériques industriels chez les enfants. Nous avons d'abord évalué l'association entre l'exposition aux émissions industrielles de polluants atmosphériques et l'asthme chez les enfants sur la base des écrits scientifiques. Nous avons ensuite évalué les associations entre les variations spatiales et temporelles des émissions industrielles de polluants atmosphériques et la variation spatiale de la morbidité liée à l'asthme au Québec. Pour le premier objectif, nous avons consulté des bases de données bibliographiques afin d'identifier les études sur l'association entre l'exposition des enfants à la pollution atmosphérique provenant de sources industrielles et l'asthme, en incluant les symptômes d’asthme, la respiration sifflante et la bronchiolite. Lorsque possible, nous avons effectué des méta-analyses des résultats avec effets aléatoires. Pour le deuxième et le troisième objectifs, nous avons effectué des analyses écologiques spatiales et temporelles à partir de données pour de petites zones géographiques (n=1386) dans la province de Québec. Pour le deuxième objectif, nous avons mis en relation les émissions industrielles de PM2.5 et de SO2 obtenues à partir de l'Inventaire national des rejets de polluants et d'autres variables telles que les niveaux régionaux de PM2.5, le revenu annuel médian des ménages et le pourcentage de la population d'enfants exposés à la fumée de tabac secondaire (FTS) avec le nombre total d'admissions à l'hôpital pour asthme chez les enfants de moins de 13 ans par petite région (données de la base MED-ÉCHO: Maintenance et exploitation des données pour l'étude de la clientèle hospitalière), pour les années 2002 à 2011, avec des modèles binomiaux négatifs additifs généralisés. Pour le troisième objectif, nous avons mis en relation les émissions industrielles de PM2.5 et de SO2, ainsi que les autres variables environnementales et sociodémographiques mentionnées ci-dessus, avec le nombre annuel de nouveaux cas d'asthme chez les enfants âgés de <13 ans de la base de données SISMACQ (Système intégré de surveillance des maladies chroniques du Québec) pour les années 2002 à 2011, avec des modèles binomiaux négatifs à effets fixes (modèles statistiques pour les données de panel). Dans ces modèles, les niveaux régionaux de PM2.5 provienaient de données satellitaires, le revenu médian du recensement, la FTS d'une enquête pancanadienne et la pollution atmosphérique liée au trafic a été estimée avec les kilomètres de routes principales dans de petites zones. La revue systématique a montré que la moitié des études publiées sélectionnées utilisaient un devis d'étude transversal, que la proximité binaire écologique était la principale méthode d'exposition utilisée dans 15 des 36 articles, tandis que les résultats de l'asthme étaient divers mais principalement recueillis par questionnaires et à partir des services de santé. Les rapports de cotes (RC) combinés de la méta-analyse des études cas-croisés avec hospitalisation pour asthme et bronchiolite chez les enfants de moins de 5 ans étaient de 1.02 (IC95% : 0.96-1.08; I2 = 56%) par 10 ppb d'augmentation de la concentration moyenne quotidienne de SO2 ; pour les PM2,5, les RC combinés étaient de 1.02 (IC95% : 0.93-1.10; I2 = 56%) par 10 μg/m3 d'augmentation de la concentration moyenne quotidienne. Dans les études transversales sur la prévalence de l'asthme et la respiration sifflante chez les enfants, les RCs combinés, pour la proximité résidentielle à des industries étaient respectivement de 1.98 (IC95% : 0.87-3,09; I2 = 71%) et 1.33 (IC95% : 0.86-1.79; I2 = 65%). Les résultats des analyses écologiques spatiales et temporelles ont suggéré que les émissions industrielles de PM2.5 et de SO2 n'étaient pas liées à la morbidité liée à l'asthme. Le risque relatif (RR) pour les admissions à l'hôpital pour l'asthme selon le modèle spatial multivarié était de 1.0009, par augmentation d'une tonne de PM2.5 (95%IC : 0.9982-1.0037); le RR pour le SO2 par augmentation d'une tonne était de 0.9999 (95%IC: 0.9997-1.0001). En outre, le RR pour les nouveaux cas d'asthme chez les enfants à partir des modèles temporels multivariés était de 0.99 pour 1000 tonnes de SO2 (95%IC : 0.99-1.00) et également de 0.99 pour 100 tonnes de PM2.5 (95%CI : 0.98-1.00). Néanmoins, on a constaté une diminution de 3.29 % du taux de cas d’asthme (95%CI : 2.44-4.14) pour chaque diminution de 1 ug/m3 des niveaux régionaux de PM2.5. Dans l'ensemble, nos résultats suggèrent que les émissions industrielles de polluants atmosphériques ont une influence limitée sur la morbidité liée à l’'asthme. Ceci contraste avec ce à quoi on pourrait s'attendre sur la base de la littérature publiée qui fait état des effets de la pollution atmosphérique provenant de sources autres que les industries. Les résultats suggèrent qu'une meilleure évaluation de l'exposition et de meilleurs devis d'études devraient être adoptés dans les études futures pour évaluer l'association entre la morbidité liée à l'asthme et les émissions industrielles de polluants atmosphériques chez les enfants. / Asthma is a main chronic childhood disease. It has been associated with exposure to outdoor air pollutants from remote regional and traffic sources. Pollutant mixtures from industrial sources and their effects may not be the same as those from traffic and regional sources. Yet contrary to associations between pollutants from these sources and asthma in children, associations with community exposures to industrial air pollutant emissions have not been systematically assessed. Furthermore, although substantial reductions in industrial emissions of fine particles (PM2.5) and sulphur dioxide (SO2) have been noted in industrialized countries over the past decades, associations between the geographic and the temporal variations of industrial air pollutant emissions and the variation of asthma morbidity in children have been understudied. In this dissertation, we aimed to investigate the association between asthma morbidity and industrial air pollutant emissions in children. We first assessed the association between exposure to industrial air pollutant emissions and asthma in children based on available evidence. We then assessed the associations between the spatial and the temporal variations in industrial air pollutant emissions and the spatial and temporal variations in asthma morbidity in Québec. For the first objective, we searched bibliographic databases to identify studies on the association between children's exposure to air pollution from industrial point-sources and asthma-related outcomes, including: asthma, asthma-like symptoms, wheezing and bronchiolitis. Where possible, we performed random-effects meta-analyses of results. For the second and third objectives, we conducted spatial and temporal ecological analyses based on data for small geographic areas (n=1386) in the province of Québec. For the second objective, we related industrial emissions of PM2.5 and SO2 obtained from the National Pollutant Release Inventory and other variables such as regional levels of PM2.5, median annual household income and the percentage of the population of children exposed to Environmental Tobacco Smoke (ETS) to the total count of asthma hospital admissions in children younger than 13 years of age per small area (data from the database MED-ÉCHO: Maintenance et exploitation des données pour l'étude de la clientèle hospitalière), for the years 2002 to 2011, with negative binomial General Additive Models. For the third objective, we related industrial emissions of PM2.5 and SO2, as well as other environmental and sociodemographic variables mentioned above, to the yearly numbers of asthma onset cases in children aged <13 years from the database QICDSS (Québec Integrated Chronic Disease Surveillance system) over the years 2002 to 2011, with fixed effects negative binomial models (statistical models for panel data). In these models, regional PM2.5 levels were from satellite data, the median income from the census, ETS was from a pan Canadian survey and traffic related air pollution was estimated with kilometers of major roads in small areas. The systematic review highlighted that half of the selected published studies used a cross sectional study design, ecological binary proximity was the main exposure method used in 15 out of 36 articles, while asthma outcomes were diverse but mainly collected by questionnaires and healthcare services. The pooled odds ratios (ORs) from the meta-analysis from case-crossover studies with hospitalisation for asthma and bronchiolitis in children younger than 5 years old was 1.02 (95%CI: 0.96-1.08; I2 = 56%) per 10 ppb increase in the daily mean concentration of SO2; for PM2.5, the pooled ORs was 1.02 (95%CI: 0.93-1.10; I2 = 56%) per 10 μg/m3 increase in the daily mean concentration. In cross-sectional studies on the prevalence of asthma and wheezing in children, pooled ORs in relation to residential proximity to industries were 1.98 (95%CI: 0.87-3.09; I2 =71%) and 1.33 (95%CI: 0.86-1.79; I2= 65%), respectively. Results of the spatial and temporal ecological analyses suggested that industrial emissions of PM2.5 and SO2 were not related to asthma morbidity. The relative risk (RR) for asthma hospital admissions from the multivariate spatial model was 1.0009, per increase of one ton of PM2.5 (95%CI: 0.9982-1.0037); the RR for SO2 per increase of one ton was 0.9999 (95%CI: 0.9997-1.0001). Additionally, the RR for new asthma onset cases in children from the multivariate temporal models were 0.99 per 1000 tons of SO2 (95%CI: 0.99-1.00) and also 0.99 per 100 tons of PM2.5 (95%CI: 0.98-1.00). Nonetheless, there was a 3.29% decrease in the rate of cases (95%CI: 2.44-4.14) per 1 ug/m3 decrease in the regional PM2.5 levels. Overall, our results suggest that industrial air pollutant emissions have limited influence on asthma morbidity. This is in contrast with what would be expected based on the published literature that report effects of air pollution from sources other than industries. The results suggest that better exposure assessment and better study designs should be adopted in future studies to assess the association between asthma morbidity and industrial air pollutant emissions in children.

This diploma thesis deals with the topic of health literacy level in the Czech population and its association with sociodemographic and lifestyle factors. The aim was to describe this association in the stages of health information processing, which are the stages of finding, understanding, judging and application of health information. The data from the Czech modification of the HLS-EU survey from 2014 was used. Lower level of health literacy was associated with older age, lower level of education, as well as lower self-assessed social status at all stages of health information processing. Lower self- assessed health condition was also associated with lower level of health literacy, especially in the phases of understanding and application of health information. Regarding the lifestyle factors, the association was determined in case of physical activity, most notably in the phases of understanding and application of health information. The association was also determined in the case of body mass index, but only in phases understanding and judging. Differences in health literacy levels between smoking categories as well as between gender were not been determined. Regarding the difference between phases of health information processing, the judging of health information seems to be the most risk.