The objectives of this thesis are to: 1) obtain a snapshot of callers of 211 Toronto, a free information and referral service, understanding how representative they are of Toronto’s general population; 2) understand how 211 Toronto callers seeking health-related information use the information they obtain when contacting the service and their overall level of satisfaction, and; 3) better understand the experience and information needs of recent immigrants struggling to navigate an unfamiliar health care system. The study had three phases: 1) a cross-sectional phone interview with 211 Toronto callers; 2) a follow-up phone interview of 211 Toronto callers who had asked health-related questions; and, 3) qualitative interviews with callers who were Spanish speakers from Latin American countries. Participants were randomly selected adult callers living within the boundaries of Toronto’s Census Metropolitan Area (CMA). Respondents were compared with the general adult population living in Toronto’s CMA, using 2001 Census data, to identify under- or overrepresented population groups. A sub-set of callers who had asked health-related questions was followed up to understand how they had used the information received and their level of satisfaction with the service. Qualitative interviews were conducted with callers who were recent immigrants and native Spanish speakers from Latin America to explore their post-migration experiences. Recent immigrants experience significant information challenges. Health-related questions reflect the multifaceted nature of the concept of health in the experience of users. Negative experiences with the health care system are common. Recent immigrants have access to disorganized, confusing, often poor quality information. 211 Toronto represents an efficient and effective way to gain access to information but does not achieve its full potential. Newcomers should receive timely, appropriate, and reliable information on existing health and health-related services as soon as possible after they relocate to Canada. Appropriate information should also be made available to potential immigrants in their countries of origin. Information and communication technologies should be used to support newcomers, increasing the efficiency and effectiveness of services such as 211 Toronto.

The objectives of this thesis are to: 1) obtain a snapshot of callers of 211 Toronto, a free information and referral service, understanding how representative they are of Toronto’s general population; 2) understand how 211 Toronto callers seeking health-related information use the information they obtain when contacting the service and their overall level of satisfaction, and; 3) better understand the experience and information needs of recent immigrants struggling to navigate an unfamiliar health care system. The study had three phases: 1) a cross-sectional phone interview with 211 Toronto callers; 2) a follow-up phone interview of 211 Toronto callers who had asked health-related questions; and, 3) qualitative interviews with callers who were Spanish speakers from Latin American countries. Participants were randomly selected adult callers living within the boundaries of Toronto’s Census Metropolitan Area (CMA). Respondents were compared with the general adult population living in Toronto’s CMA, using 2001 Census data, to identify under- or overrepresented population groups. A sub-set of callers who had asked health-related questions was followed up to understand how they had used the information received and their level of satisfaction with the service. Qualitative interviews were conducted with callers who were recent immigrants and native Spanish speakers from Latin America to explore their post-migration experiences. Recent immigrants experience significant information challenges. Health-related questions reflect the multifaceted nature of the concept of health in the experience of users. Negative experiences with the health care system are common. Recent immigrants have access to disorganized, confusing, often poor quality information. 211 Toronto represents an efficient and effective way to gain access to information but does not achieve its full potential. Newcomers should receive timely, appropriate, and reliable information on existing health and health-related services as soon as possible after they relocate to Canada. Appropriate information should also be made available to potential immigrants in their countries of origin. Information and communication technologies should be used to support newcomers, increasing the efficiency and effectiveness of services such as 211 Toronto.

Yes / Background: To contain the spread of COVID-19 within the UK over the past year, there have been a series of local and national lockdowns. These restrictions are likely to have impacted upon the health and well-being of marginalised groups who rely on now closed social and community support services to stay healthy. An understanding of the experiences of marginalised people is important; therefore, this study aimed to explore the impact of the COVID-19 restrictions on the health and well-being of marginalised groups in the UK. Methods: In summer 2020, a rapid telephone survey was conducted by trained, trusted volunteers with 76 participants who were from marginalised groups. As part of this survey, 64 participants consented to describe their experience of lockdown. These case studies were thematically analysed to identify patterns of meaning. Results: Findings indicate that lockdown led to the deterioration of health of participants, impacted adversely on their socio-economic positions and affected access to food and essential supplies. In addition, government public health messaging was considered confusing and inadequate. Conclusions: This study highlights the need for pathways into services which support marginalised groups to remain accessible during periods of restrictions and essential supplies and food to be mapped and protected for marginalised individuals within our local communities. / NHS England; Improvement

Since the early 1990s, the Estonian health sector has been undergoing a number of reforms. At the same time, a number of legislative acts have also been established, forming a new legal basis for the health system. The introduction of a social health insurance in 1992 was the first reform in the Estonian health sector reorganisation, followed by a primary health care (PHC) reform, a hospital reform and a number of public health reforms. The aim of this thesis is to analyse these health sector reforms in Estonia, focusing on the outcomes of the health system from the population’s perspective. Proceeding from this general aim, the specific objectives of the thesis are as follows: 1) To analyse the PHC reform in terms of the access to the health services and the acceptability and satisfaction with these services. 2) To analyse the health insurance reform in terms of the acceptability and satisfaction with the new system. 3) To analyse the public health reforms and their impact on the health of the population. The empirical data were gathered with the following research methods: reviews of official health statistics and population surveys in 1998, 2002 and 2005 based on face-to-face interviews using structured questionnaires. The main results can be summarised in relation to the objectives of the thesis: 1) The primary health care reform has been implemented and most of the objectives have been achieved. In general, people accept the changes in the PHC system and the satisfaction with the family doctors has increased. Access to the PHC services is good. Based on the results of a population study in 2002 and 2005, more than half of the respondents could see the family doctor on the same day they made an appointment. Almost a half of the respondents (49%) were satisfied with the access to the health services. Satisfaction with the PHC services and family doctors were found to have positive effects on satisfaction with access to health services. Although people with chronic conditions were less satisfied with the access to the health services they did not experience organisational barriers in their access to such services. 2) The health insurance reform has been implemented and a high level of financial protection has been maintained. The solidarity principle of the health insurance system guarantees access to health services for all the insured people. About half of the population is satisfied with the present system. Compared to 2002, the percentage of satisfied people has increased in 2005, while the percentage of very dissatisfied persons has decreased. The most important predictor of satisfaction with the health insurance was the satisfaction with the existing PHC system. The satisfaction with the health insurance was higher in 2002 as well as 2005 among those respondents who had visited a family doctor or a specialist or were admitted in a hospital during the last 12 months before the survey, but lower among those who had visited a dentist. A small majority preferred the solidarity principles and comprehensive financing of health service by health insurance. The attitudes regarding financing principles were related to the personal contacts with the health services. The respondents who had used the PHC or ambulance services preferred a more comprehensive financing of health services, while those who had had contacts with a specialists or dentists would prefer less comprehensive financing if the waiting lists were short. More than three quarters of the respondents were informed about their rights concerning the access to the health services. Personal contacts with family doctors and specialists had positive impact on the level of awareness. 3) Some progress has been made in connection with the public health reforms. A number of national programs and projects to prevent the most essential health risks have been initiated. As a result, there is some evidence of a positive impact on the health of the population – positive trends in dietary habits and decreasing infant mortality, number of abortions, and incidences of sexually transmitted infections and tuberculosis. At the same time, however, the proportion of smokers and consumers of strong alcohol has not decreased. Moreover, there has been an explosive increase of new cases of HIV-infections in 2000, which is one of the most serious public health problems today. Greater progress has been achieved in the areas where health promotion and health education activities have been supported by political decisions to make a healthy choice for the population easier. However, a comprehensive national health policy and strategy is still lacking in Estonia. In public health, this is evidenced by a lack of long-term planning and understanding of the significance of intersectoral co-operation. Discussion. Up to now, the major reforms in the Estonian health system have been implemented. However, the environment is changing and the health system has to respond to these changes. The next step should therefore be to reach a public agreement about the common values of the health system and setting long-term health policy goals. To improve the effectiveness of policy implementation and reform, the importance of systematic research and evaluation should also be stressed.

O Sistema Único de Saúde estabelece a Unidade Básica de Saúde como porta de entrada para o atendimento aos problemas/demandas de saúde. É nesse espaço, tradicionalmente conhecido como recepção e, mais recentemente como acolhimento, que as demandas dos usuários devem ser apresentadas e confrontadas com as possibilidades do serviço em responder a elas. O estudo teve como objetivo geral, caracterizar a atividade de recepção dos usuários do setor Saúde da Criança de uma Unidade Básica de Saúde, e como específicos, identificar e analisar as demandas por assistência à saúde que emergem na atividade de recepção e caracterizar e analisar as respostas oferecidas pelo serviço. Trata-se de um estudo de caso, com abordagem qualitativa que integrou um projeto mais amplo aprovado por Comitê de Ética em Pesquisa, desenvolvido em um Centro de Saúde Escola. A observação livre foi utilizada para a coleta dos dados, realizada durante duas semanas típicas de agosto de 2007, por observadores treinados que conheciam o serviço. A amostra foi constituída por 42 observações, conduzidas na recepção do setor saúde da criança. Os sujeitos da pesquisa foram os trabalhadores de enfermagem que desempenhavam a atividade de recepção e os respectivos usuários que demandavam o atendimento. Para a análise, os dados registrados nas observações foram digitados e inseridos no software para pesquisa qualitativa N-Vivo 8, que ajudou a sistematizar a análise. Os textos foram submetidos à análise de conteúdo que resultou nas seguintes categorias: cumprimentos, demandas apresentadas pelos usuários, investigação por parte do trabalhador, respostas oferecidas pelos trabalhadores, supervisão e queixa do serviço. Os resultados evidenciaram que os usuários demandavam o serviço com diferentes necessidades, porém destacaram-se as demandas de ordem biológica, seguida de acesso a cuidado programado, que em sua maioria relacionava-se à solicitação de consulta médica. A investigação do trabalhador de enfermagem limitou-se à própria queixa, restringindo-se ao âmbito biológico. Entretanto, houve investigações ampliadas para além do biológico. Em relação à resposta do trabalhador, as mais expressivas referiram-se a 23 encaminhamentos para atendimento fora do dia (atendimento médico equivalente ao pronto atendimento), nove agendamentos para consulta de enfermagem e quatro para consulta médica. Apenas um caso foi encaminhado para atendimento de enfermagem e um caso para grupo de aleitamento materno. A supervisão ocorreu somente em quatro casos. Constatou-se um esforço do trabalhador em oferecer a consulta de enfermagem como alternativa para a resolução da demanda apresentada, além da tentativa de garantir a entrada da criança ao serviço por meio da queixa clínica. Entretanto, várias queixas relacionadas à dificuldade de acesso foram evidenciadas. A investigação evidenciou que a equipe de enfermagem basicamente desenvolveu como atividade de recepção encaminhamentos que prioriza o atendimento individual. Permanece, portanto, como desafio, a reorganização do serviço, com vistas à real implantação do acolhimento como diretriz para a atuação da equipe, no sentido de cumprir os princípios do Sistema Único de Saúde / The Brazilian National Health System sets the Primary Care Services as a gateway for attending the problems/needs of health. Its in this place, traditionally known as reception and, more recently as welcoming, that users needs must be presented and confronted to the possibilities of the service to answer for them. This study had as the overall objective to characterize the activity of reception for the users of Child Health Sector of the one Primary Care Service. The specifics objectives were to identify and analyze the needs for healthcare presented in the reception and to characterize and analyze the answers offered by the service. Its a study of case, with qualitative approach, which was part of a broader Project approved by the Ethical Committee in Research, developed in a Health-School Center. Data were collected through free observation during two typical weeks of August 2007, by trained observers who knew the service. The sample consisted of 42 observations, conducted at the reception area of Child Health Sector. The subjects were nursing workers who performed the reception activity and the respective users who needed the attendance. For the analysis, registered data of the observations were typed and inserted in the N-Vivo 8 software program for the qualitative research, which helped to systematize the analysis. The texts were submitted to content analysis, which resulted in the following categories: greetings of the worker, problems presented by users, inquiry and answer provided by the workers, supervision and complaint of service. The results showed that users demanded services with different needs. The biological problems were predominant, followed by access to care programs, which mostly related to the request for medical appointment. The inquiry of nursing worker was limited to the complaint itself, getting restricted to the biological scope. However, there were some inquiries beyond the biological. Regarding to the workers answer, the most expressive ones were related to 23 referrals for unscheduled attendance (medical attendance equivalent to the emergency attendance), nine appointments for nursing consultation and four for the medical one. Only one case was referred to nursing attendance as an alternative for solving the problem. The supervision occurred only in four cases. There was an effort of the workers to provide consultation to nursing as an alternative to resolving the demands presented in addition to trying to ensure the child\'s access to the service through clinical complaint. However, several complaints related to the difficulty of access were evidenced. This research showed that the nursing staff basically carried on activity of reception, referrals that prioritizes individual care. Therefore, it remains as challenge, the reorganization of service, for the implementation of welcoming as a guideline for the performance of team of nurse, to meet the principles of the Brazilian National Health System

Objetivos: O objetivo deste estudo foi avaliar o acesso ao diagnóstico e ao tratamento de doentes com Tuberculose e coinfectados pelo HIV, no município de São José do Rio Preto- SP. Materiais e Métodos: Trata-se de uma pesquisa avaliativa, de abordagem quantitativa que utilizou o modelo de estudo transversal. Foram entrevistados 106 doentes no período de junho de 2006 a julho de 2007, que estavam em tratamento nas Unidades de Saúde que desenvolvem o Programa de Controle da Tuberculose (PCT) do município. Utilizou-se o instrumento \"Primary Care Assessment Tool,\" adaptado para atenção à tuberculose. Para análise dos dados foram usadas técnicas de estatística descritiva como análise de freqüência, média, desvio-padrão, intervalo de confiança, teste t de Student e teste de Mann-Whitney Resultados: Dos 106 doentes entrevistados, 11 foram excluídos por não terem sido submetidos ao teste de anti HIV Desta forma 95 doentes participaram deste estudo, sendo que 76,8% apresentavam TB e não-coinfecção pelo HIV e 23,2% apresentavam TB e coinfecção pelo HIV. A maioria (66,3%) era do sexo masculino, 69,5% possuia ensino fundamental, 50,5% declarou residir em casa própria e 98,9% possuia casa de alvenaria. A partir dos dados observados houve diferenças estatisticamente significativas quanto as variáveis acesso ao diagnóstico cujos doentes com TB e coinfectados quase nunca ou às vezes procuram o posto de saúde mais próximo da residência e os doentes com TB quase sempre procuram o posto de saúde mais próximo da residência. Como também, houve diferenças estatisticamente significativas no acesso ao tratamento sendo que, o profissional da saúde visita mais vezes os doentes acometidos pela coinfecção quando comparados com os doentes que não apresentam a coinfecção e os doentes coinfectados quase nunca realizam o tratamento da doença em um posto de saúde perto da residência. Considerações finais: Os resultados do estudo apontam para a necessidade de maior integração e comunicação entre o PCT e o DST/Aids, fator este, considerado como facilitador tanto no acesso dos doentes ao diagnóstico quanto ao tratamento da doença. / Objetives: The aims of this study were to characterize the patients with Tuberculosis and coinfected with AIDS as to their sociodemographic aspects (gender, schooling, place of living and type of residence); to analyze the access to the diagnose and treatment of these patients; to identify the disagreements among groups of patients with TB and those co-infected with TB/AIDS regarding the access to diagnose and treatment and in this way to evaluate the access to diagnose and treatment of persons with Tuberculosis and co-infected with HIV living in São José do Rio Preto, São Paulo State. Material and Methods: This is an evaluative research with a quantitative approach using a cross-sectional study model developed at the Health Units developing the Tuberculosis Control Program (TCP) in São José do Rio Preto. The patients received medical attention from June 2006 to June 2007. Techniques of descriptive analysis were used to analyze the data, such as frequency analysis, mean (average), standard deviation, and confidence interval. Results: Of the 106 patients interviewed 11 were excluded because they have not done the anti-HIV test. Therefore, the study population was composed of 95 patients. Of these, 76.8% presented TB and not coinfection with HIV, and 23.2% presented both TB and co-infection with HIV. The majority (66.3%) was male, 69.5% have Elementary Education, 50.5% reported to be homeowners, and 98.9% live in a brick-made house. From these results, we can imply that there were statistically significant differences as to the variables access to diagnose of those patients with TB and those co-infected who hardly ever or sometimes seek for the nearest Health Unit, and the patients with TB who most of the time seeks for the nearest Health Unit. There have been also statistically significant differences as to the access to treatment once the health professional visits more times the patients with co-infection in comparison to the patients who did not present co-infection and those co-infected. The co-infected patients hardly ever receive treatment at the nearest Health Unit. Final Comments: The study results point out to the necessity of a greater integration and communication between both programs TCP and sexually transmitted disease - aids (STD/AIDS). This factor is considered as a facilitator to both the access of patients to diagnose and treatment of the disease.

Orientador: Carmen Maria Casquel Monti Juliani / Resumo: INTRODUÇÃO: A regulação de acesso é compreendida como importante ferramenta de gestão do sistema de saúde. OBJETIVO: Conhecer o perfil e demanda de urgência e emer-gência encaminhadas a um serviço de alta complexidade antes e após um sistema de regulação. MÉTODO: Estudo transversal, avaliando, por meio de análise estatística, dois períodos o primeiro de março de 2015 a setembro de 2016 e o segundo de outubro de 2016 a abril de 2018. RESULTADOS: Houve predominância dos moradores de Botucatu sendo 82% adultos e as especialidades mais buscadas foram oftalmologia, clínica médica e ortopedia. 10450 casos foram regulados pela Central de Regulação de Ofertas de Serviços de Saúde, em análise comparativa do período anterior e posterior da implantação da plataforma notou-se aumento na demanda de atendimento dos municípios e na distribuição das especialidades solicitadas. Das solicitações aceitas e encaminhadas ao Hospital das Clínicas prevaleceu o público mascu-lino e as principais hipóteses diagnósticas foram relacionadas à fratura, trauma, afecções car-díacas e acidente vascular cerebral. Após realizou-se um cálculo amostral que evidenciou 12,5% a realização de contrarreferência, analisando a amostra a maioria eram homens com média de idade de 40 anos e o tempo médio de regulação dos casos foi de 1 hora, 43 minutos e 48 segundos com as principais queixas relacionadas à fratura, dor abdominal, infarto agudo do miocárdio e dispneia. CONCLUSÃO: Houve diferença significativa comparando o... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: BACKGROUND: Access regulation is understood as an important health system manage-ment tool. AIM: To know the profile and demand of urgency and emergency sent to a high complexity service before and after a regulation system. METHOD: Cross-sectional study, evaluating, through statistical analysis, two periods from March 2015 to September 2016 and the second from October 2016 to April 2018. RESULTS: Population of Botucatu was predo-minantly 82% and specialties most sought were ophthalmology, medical clinic and orthope-dics. 10450 cases were regulated by the Central of Regulation of Health Service Offerings, in a comparative analysis of the period before and after the implementation of the platform, there was an increase in the demand for care of the municipalities and in the distribution of the spe-cialties requested. Of the requests accepted and sent to Hospital das Clínicas, the male public prevailed and the main diagnostic hypotheses were related to fracture, trauma, cardiac affecti-ons and stroke. After a sample calculation that showed a 12.5% counterreference, the sample was mostly men with a mean age of 40 years and mean time to regulate the cases was 1 hour, 43 minutes and 48 seconds with the main complaints related to fracture, abdominal pain, acute myocardial infarction and dyspnea. CONCLUSION: There was a significant difference comparing the two periods, evidencing the increase after the insertion of the platform, contri-buting to the regulation and flow of the patien... (Complete abstract click electronic access below) / Mestre

Introdução: O escorpionismo é reconhecido como um problema de saúde pública em alguns países em desenvolvimento devido à significativa incidência e gravidade, particularmente entre crianças e idosos com comorbidades. No Brasil, estima-se que ocorram cerca de 58.000 acidentes com mais de 80 óbitos por ano, o que representa uma incidência anual aproximada de 30 casos/100.000 habitantes/ano. Justifica-se, portanto, o presente estudo, tendo em vista que, no Município de Santarém-PA, na Amazônia, há dificuldade de acesso aos serviços de saúde pela população local, devido à extensão territorial da região. Objetivo: Analisar como se processa a ocorrência de acidente escorpiônico no Município de Santarém-PA. Método:O estudo foi observacional, exploratório, prospectivo, descritivo e qualitativo. Foram sujeitos do estudo, 19 pacientes vítimas de acidente escorpiônico atendidos no PSM, no período de Novembro de 2016 a Fevereiro de 2017. Dados relativos às características pessoais, de condições de vida e de trabalho foram extraídos dos prontuários e confirmados por ocasião das entrevistas realizadas enquanto estiveram internados na unidade hospitalar. Também foram levantados dados clínicos. Utilizou-se de instrumento para a captura dos dados. Os procedimentos éticos foram resguardados.Resultados: Em relação à caracterização dos sujeitos, verificou-se que dos 19 entrevistados 14 (73,7%) eram do sexo masculino. Quanto à faixa etária, 5 (26,3%) tinham idade entre 5 e 10 anos, e 2 (10,6%) entre 11-20 anos, os demais eram adultos ente 21 e 60 anos. Em relação ao tempo de estudo, mesmo levando em consideração os sujeitos menores de idade, alguns dos sujeitos adultos possuíam baixa escolaridade, sendo o maior número de anos de estudo entre 8 e 10 anos, em 7 (36,8%) dos entrevistados. A maior parte dos acidentes ocorreu na zona rural: 13 (68,5%). Quanto aos sintomas, a dor local foi relatadapor 18 (94,7%); a sensação de choque por 18 (94,7%). O tempo de chegada à unidade hospitalar, após a picada, foi maior que uma hora em 15 (78,9%) dos casos. A análise qualitativa dos depoimentos revelou cinco Temas: Situação em que ocorreu o acidente escorpiônico; Trajetória percorrida pelo paciente até o tratamento;Providências após a ocorrência do acidente; Manifestações clínicas apresentadas pelas vítimas dos acidentes escorpiônicos; O que foi feito com o escorpião (lacrau).Estes temas evidenciam a experiência dos sujeitos no manejo do agravo; a forma como se processa o percurso até a unidade de atendimento, evidenciando falhas no acesso e vulnerabilidade programática; e algumas características relacionadas ao modo de vida dos indivíduos. Conclusão: Verificou-se dificuldade no acesso aos serviços de saúde, relacionada à distância geográfica entre as comunidades rurais e o Município de Santarém, onde há o tratamento específico para o acidente escorpiônico, além da necessidade de percorrer várias unidades de saúde até a obtenção do tratamento adequado; a severidade das manifestações locais e sistêmicas; o desconhecimento da população local acerca do manejo apropriado do agravo escorpiônico; e afalta de informações a respeito de ações de prevenção e de tratamento correto. Propõe-se, portanto, uma cartilha para ser utilizada junto às comunidades, para instrumentalizá-las sobre as melhores ações a serem adotadas na prevenção e por ocasião do acidente. / Introduction: Scorpionism is recognized as a public health problem in some developing countries due to its significant incidence and severity especially among children and elderly with comorbidities. It is estimated that about 58,000 accidents occur in Brazil with over 80 deaths per year, representing an approximate annual incidence of 30 cases/100,000 inhabitants per year. The present study is justified since in the Municipality of Santarém-PA, in the Amazon region, there is great difficulty of access to health services by the local population due to the territorial extension. Objective: Analyze how the scorpion accident occurs in the municipality of Santarém-PA. Method:The study was observational, exploratory, prospective, descriptive and qualitative. Nineteen patients who were victims of scorpionic accidents were included in the study. They were treated at the PSM during November 2016 through February 2017. Data on personal characteristics and living and working conditions were extracted from the medical records and confirmed at the time of the interviews while the patients were at the hospital. Clinical data was also collected. An instrument was used to collect the data. The ethical procedures were preserved. Results: In relation to the characterization of the subjects, it was verified that 14 out of the 19 interviewed (73.7%) were male. As for the age group 5 (26.3%) were aged between 5 and 10 years old and 2 (10.6%) between 11 and 20 years old. The others were adults ranging from 21 and 60 years. Regarding the schooling, taking into consideration even the underage subjects, the majority of the adult subjects had low schooling and 7 (36.8%) with the greatest number of years of schooling ranged only from 8 to 10 years. Most accidents occurred in the rural area 13 (68.5%). Regarding to the symptoms, the local pain was pointed out by 18 (94.7%); the shock sensation by 18 (94.7%). The time of arrival at the hospital after the accident was over one hour in 15 (78.9%) cases. The qualitative analysis of the testimonies revealed five themes: Situation in which the scorpionic accident occurred; Trajectory traveled by the patient to the treatment site, Measures taken after the occurrence of the accident; Clinical manifestations presented by the patients; What had been done with the scorpion (lacrau). The themes revealed evidence of the experience by which the subjects dealt with the situation; the flow of the trajectory to the service unit evidencing access failures and programmatic vulnerability; and some characteristics related to the way of life of individuals. Conclusion:There was difficulty in accessing health services, related to the geographical distance between rural communities and the Municipality of Santarém, where there is the specific treatment for the scorpionic accident, as well as the need to go through several health units until obtaining the treatment; the severity of local and systemic manifestations; the lack of knowledge of the local population about the proper management of the scorpionism; preventive actions and the lack of information regarding to the correct treatment. Therefore, it is proposed a hornbook to be used at the communities, to instrumentalize the population on the best actions to be taken for prevention and after the accident.

Orientador: Carmen Maria Casquel Monti Juliani / Banca: Sandra Thomé / Banca: Nilce Emy Tomita / Resumo: O Sistema Único de Saúde (SUS) atualmente passa por grandes transformações e conquistas, acompanhadas por algumas dificuldades na consolidação dos seus princípios. O funcionamento do sistema de referência e contrarreferência em saúde, proposto para contribuir com a garantia dos princípios de integralidade, equidade e universalidade, é um desafio que enfrentamos. Faz-se necessário um sistema de referência e contra-referência que funcione de forma a promover a integração entre os serviços, para que em rede possam oferecer uma assistência de qualidade ao usuário. O objetivo desta pesquisa foi compreender a organização do sistema de referência e contra referência no contexto do Sistema Único de Saúde na Estratégia Saúde da Família no município de Bauru/SP, a partir da experiência dos gestores que vivenciam essa prática. A pesquisa, qualitativa, utilizou o referencial da fenomenologia. Foram entrevistados gestores da ESF do município e chefias das unidades, totalizando seis entrevistados. Emergiram dos depoimentos três categorias: Categoria A: O sistema de saúde, com os temas: política de Saúde, não garantia da integralidade, resolubilidade, lógica/modelo dominante no sistema e cultura da população; Categoria B: O funcionamento do sistema de referência e contra-referência, cujos temas foram a visão do sistema de referência e contrareferência, operacionalização da referência no município, importância da reorganização da referência, importância da contrarreferência e desafios da comunicação entre os níveis de atenção e usuários; Categoria C: Fatores estruturais do sistema local de saúde. abrangendo os temas demanda reprimida, organização dos serviços, atenção básica insuficiente, priorização das vagas urgências/emergências, retrabalho e custos para o sistema, perspectivas de melhoria da rede de atenção a saúde, perspectivas... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The Unified Health System (SUS) has undergone great changes. It has also made great achievements that have been accompanied by difficulties in the consolidation of its principles. The functioning of the health referral and counter-referral system, which has been proposed in order to contribute so as to ensure the principles of integrality, equity and universality, is a challenge that has been faced. A referral and counter-referral system that works so as to promote integration between the services is necessary in order to provide quality care to users in the form of a network. This study aimed at understanding the organization of the referral and counter-referral system in the context of the Unified Health System in the Family Health Strategy in the city of Botucatu/SP based on the experience of managers who live such practice. The qualitative research used the phenomenology framework. ESF managers in the city as well as health unit managers were interviewed, totaling 06 respondents. Three categories emerged from their statements: Category A: The health system, with the following themes: health policy, non-guarantee of integrality, resolubility, logic/dominant model in the system and the population's culture; Category B: the functioning of the referral and counter-referral system, whose themes were the view of the referral and counter-referral system, referral operationalization in the city, importance of referral re-organization, importance of counter-referral and communication challenges between care levels and users; Category C: structural factors of the local health system, including the following themes: repressed demand, service organization, insufficient primary care, prioritization of places for emergencies, re-work and costs for the system, perspectives of improvement in the health care network, perspectives for matrix-based strategies. The data show a system that... (Complete abstract click electronic access below) / Mestre

Atà 2000, o controle da hansenÃase no Brasil foi verticalizado. Desde entÃo, o processo de descentralizaÃÃo dessa doenÃa deu inÃcio a aÃÃes que priorizaram o nÃvel primÃrio de atenÃÃo à saÃde. Entretanto, a assistÃncia ainda permanece centralizada em algumas unidades de saÃde, como o Centro Nacional de ReferÃncia em Dermatologia SanitÃria D. LibÃnia (CDERM), em Fortaleza, CearÃ. O referido centro responde por 84% da detecÃÃo dos casos de hansenÃase do MunicÃpio. O objetivo deste estudo foi investigar os fatores associados à demanda excessiva de casos, em nÃvel secundÃrio de atenÃÃo, representado por esse centro de referÃncia. Um estudo transversal foi realizado com 600 usuÃrios, selecionados aleatoriamente nos ambulatÃrios do CDERM. Foram coletados dados socioeconÃmicos e demogrÃficos sobre o conhecimento da doenÃa e a percepÃÃo dos serviÃos. Oitenta e dois por cento dos participantes tinham baixa situaÃÃo socioeconÃmica, 90% vieram encaminhados por outras unidades de saÃde e 87% tinham a forma multibacilar. Sessenta e nove por cento receberam atendimento prÃvio em outras unidades de saÃde, 49% jamais ouviram falar de hansenÃase, 24% referiram sentir medo da doenÃa ou terem sofrido discriminaÃÃo, 39% dos usuÃrios referiram que o atendimento ininterrupto no horÃrio do almoÃo favorece a permanÃncia no CDERM, 57% e 27%, respectivamente, referiram que a medicaÃÃo complementar nunca faltou no CDERM e nas Unidades BÃsicas de SaÃde (UBS). Sessenta e um por cento consideraram que o compromisso dos profissionais no CDERM foi Ãtimo, contra 14% nas UBS. Os atores relatados pelos usuÃrios, especialmente logÃsticos e de qualidade de atendimento e dos profissionais, poderiam explicar a concentraÃÃo de usuÃrios nesse centro de referÃncia. / Until 2000, the Leprosy control in Brazil was a vertically integrated program. After this date, the program was considered a priority for primary care. However, the program remained centralized in some reference centers such as the D. LibÃnia National Reference Center for Sanitary Dermatology, located in Fortaleza, CearÃ, Brazil (CDERM), responsible for 84% of the case detection in this municipality. The goal of this study was to investigate the factors associated with use of these services, and the potential for integration into primary health care. A cross-sectional survey was conducted with 600 users randomly selected in the outpatient clinic of the CDERM with the objective of determining the factors associated with demand for these services. Social, economic and demographic data, knowledge about the disease and perception about the services were collected. Eighty two percent of the participants had low social and economic status, 90% were referred from other health units; 87% had the multibacillary form. Sixty-nine per cent reported previous visits to other health units (HU). Fortynine per cent have never heard about leprosy, 24% reported fear of being discriminated against or suffering discrimination. Complementary medication was never missed for 57% treated in the CDERM and for 27% in other HUs. The commitment of the professionals was considered exemplary by 61% in the CDERM and by 14% in the other HUs. These facts reported by users, especially logistic ones and those related to the quality of the assistance and of the professionals might explain the concentration of users in this reference center.