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Inmates with gender identity disorders (GID) pose special challenges to policy makers in U.S. prison systems. Transgender persons are likely overrepresented in prisons; a reasonable estimate is that at least 750 transgender prisoners were in custody in 2007. Using the Freedom of Information Act, requests were mailed to each state, the District of Columbia, and the Federal Bureau of Prisons in 2007. The requests were for copies of policies, directives, memos, or other documents concerning placement and health care access of transgender inmates. By April 2008, 46 responses were received; 6 states did not reply. Information was qualitatively analyzed and summarized. There was substantial disparity in transgender health care for inmates with GID or related conditions. Most systems allowed for diagnostic evaluations. There was wide variability in access to cross-sex hormones, with some allowing for continuation of treatment and others allowing for both continuation and de novo initiation of treatment. There was uniformity in denial of surgical treatments for GID.

Estudam-se as políticas de enfrentamento da violência contra as mulheres, no município de São Paulo. Os objetivos são mapear as políticas públicas e as propostas de organização institucional de uma rede de atenção integral, assim como conhecer suas implementações nos serviços, com destaque ao setor de Saúde, pelos relatos de gestores e formuladores da política, trabalhando-se a relação da prática da gestão com o enunciado nas políticas públicas, o peso dos valores e da perspectiva pessoal dos gestores e o peso do discurso socialmente dominante nas tomadas de decisão para implementação dessas políticas. A produção dos dados possui entrevistas semiestruturadas com 32 gestores operando em diferentes níveis da organização institucional da Secretaria Municipal da Saúde, dentre eles alguns formuladores das políticas no cenário estadual e nacional. A análise desse corpus de dados será temática de conteúdo, examinando-se cada uma das entrevistas e relacionando-as com a literatura e referencial conceitual utilizado. Conclui-se que os gestores, como agentes de práticas, são influenciados pelas estruturas e crenças vigentes, pela referência ao contexto sócio-histórico a que estão inseridos para tomadas de decisão de gestão. Porém, são também capazes de, ao relacionar-se com tais estruturas, interferir nas formas de produzir e ofertar cuidado às mulheres em situação de violência, em especial ao aproximar-se de processos de formação e sensibilização e de novos paradigmas acerca do reconhecimento dos direitos das mulheres como direitos humanos / Public policies to face (struggle) violence against women In São Paulo are studied. The objectives are mapping public policies and proposals for the institutional organization of a comprehensive health care network, as well as, to understand how they have been implemented in the Health sector based upon managers and health care policymakers\' reports. Health management practice is examined by comparison with public policies contents, as well as whether it has been influenced by managers\' values and personal perspectives, and by the dominant social discourse. Data is comprised of semistructured interviews with 32 health care managers, that work at different government levels: Municipal Health Care Office, State Health Secretariat others at a national level. Data interpretation has been done by Content Analysis, scrutinizing each interview and comparing them with the literature of reference. Analysis showed that health care managers, as practice agents, are influenced by the structural dimension and prevailing beliefs owing to the social context in which they are inserted, when making decisions. Nonetheless, they are able to interact with those structures, in order to intervene to create and offer care to women who were or are victims of violence. This ability is even greater when health managers are offered the opportunity to take contact with new paradigms, such as regarding women\'s rights as part of human\'s rights

Estudam-se as políticas de enfrentamento da violência contra as mulheres, no município de São Paulo. Os objetivos são mapear as políticas públicas e as propostas de organização institucional de uma rede de atenção integral, assim como conhecer suas implementações nos serviços, com destaque ao setor de Saúde, pelos relatos de gestores e formuladores da política, trabalhando-se a relação da prática da gestão com o enunciado nas políticas públicas, o peso dos valores e da perspectiva pessoal dos gestores e o peso do discurso socialmente dominante nas tomadas de decisão para implementação dessas políticas. A produção dos dados possui entrevistas semiestruturadas com 32 gestores operando em diferentes níveis da organização institucional da Secretaria Municipal da Saúde, dentre eles alguns formuladores das políticas no cenário estadual e nacional. A análise desse corpus de dados será temática de conteúdo, examinando-se cada uma das entrevistas e relacionando-as com a literatura e referencial conceitual utilizado. Conclui-se que os gestores, como agentes de práticas, são influenciados pelas estruturas e crenças vigentes, pela referência ao contexto sócio-histórico a que estão inseridos para tomadas de decisão de gestão. Porém, são também capazes de, ao relacionar-se com tais estruturas, interferir nas formas de produzir e ofertar cuidado às mulheres em situação de violência, em especial ao aproximar-se de processos de formação e sensibilização e de novos paradigmas acerca do reconhecimento dos direitos das mulheres como direitos humanos / Public policies to face (struggle) violence against women In São Paulo are studied. The objectives are mapping public policies and proposals for the institutional organization of a comprehensive health care network, as well as, to understand how they have been implemented in the Health sector based upon managers and health care policymakers\' reports. Health management practice is examined by comparison with public policies contents, as well as whether it has been influenced by managers\' values and personal perspectives, and by the dominant social discourse. Data is comprised of semistructured interviews with 32 health care managers, that work at different government levels: Municipal Health Care Office, State Health Secretariat others at a national level. Data interpretation has been done by Content Analysis, scrutinizing each interview and comparing them with the literature of reference. Analysis showed that health care managers, as practice agents, are influenced by the structural dimension and prevailing beliefs owing to the social context in which they are inserted, when making decisions. Nonetheless, they are able to interact with those structures, in order to intervene to create and offer care to women who were or are victims of violence. This ability is even greater when health managers are offered the opportunity to take contact with new paradigms, such as regarding women\'s rights as part of human\'s rights

Cette thèse étudie l'effet des prix sur les décisions des professionnels de santé et l'utilisation des services de santé maternelle dans le contexte de l'Afrique sub-saharienne. Les deux premiers chapitres s'intéressent à l'effet de la rémunération du travail sur les choix d'effort et la pluriactivité des professionnels de santé. En se basant sur des données collectées au niveau périphérique du système de santé Camerounais (Yaoundé et Douala), il apparaît que la rémunération du travail dans l'emploi principal n'a aucun effet significatif sur les choix d'effort et la pluriactivité des professionnels de santé. Une politique de hauts salaires apparaît ainsi insuffisante pour contrôler l'effort au travail et le phénomène d'emploi multiple des professionnels de santé. Le troisième chapitre analyse l'impact à court terme de la gratuité des soins d'accouchement et de césarienne sur l'utilisation des services de santé maternelle au Sénégal. Cette évaluation ne permet pas à court terme de mettre en évidence à un quelconque impact positif de la mesure de gratuité sur l'utilisation des services de santé maternelle. La mise à l'échelle précipitée des politiques de gratuité peut dès lors être interrogée dans ce contexte. / This thesis studies the effect of prices on the decisions of health professionals and the use of maternal health services in sub-Saharan Africa. The first two chapters are concerned with the effect of wages on the effort choices and the multiple job holding of health professionals. Based on data collected at the peripheral level of the Cameroonian health system (Yaoundé and Douala), it appears that wages in the main job have no significant effect on the effort choice and the multiple job holding of the health professionals. Thus, a policy of high wages appears insufficient to control the shirking behaviour and the multiple job holding phenomenon of health professionals in the sub-Saharan context. The third chapter analyzes the short-term impact of the free delivery and caesarean program on the use of maternal health services in Senegal. This evaluation does not show in a short-term any positive impact of the free-of-charge measure on the use of maternal health services. The hasty scaling-up of free-of-charge policies can be then questioned in this context.

Cette thèse de doctorat vise à étudier la manière dont les politiques du care agissent sur la mobilité sociale des assistant-e-s maternel-le-s issu-e-s de l’immigration en France et en Allemagne (de l’Ouest). Elle vise aussi à interroger la répartition du travail de care entre les femmes et plus largement la problématique globale du care dans l’État-providence européen. À partir d’entretiens biographiques avec des assistant-e-s maternel-le-s dans les deux pays, sont étudiées les conditions de la sous-traitance des tâches ménagères et de la garde des enfants qui permettent aux mères (et aux pères) d’être actifs-ves. / This research project examines how care policies affect the social mobility of child minders with migrant backgrounds in France and (West) Germany. As an element of modern division of labour among women, the child minders’ situation influences the issue of care in the European welfare state within society as a whole. Taking biographical-narrative interviews with registered family home-based child minders in both countries as a basis, those actors are considered who enable mothers (and fathers) to go to work within the scope of outsourcing domestic housework and day care duties. / Es wird in diesem Forschungsprojekt untersucht, wie care policies auf die soziale Mobilität migrantischer Kindertagespflegepersonen in Frankreich und Westdeutschland einwirken und damit, als Teil der modernen Arbeitsteilung unter Frauen, die gesamtgesellschaftliche Problematik von Care im europäischen Wohlfahrtsstaat beeinflussen. Anhand von biografisch-narrativen Interviews mit registrierten Tageseltern in beiden Ländern werden Akteure in den Blick genommen, die den Müttern (und Vätern) im Prozess des Outsourcings von Haushalts- und Fürsorgearbeit ermöglichen, erwerbstätig zu sein.

Problématique : L’amélioration de l’accessibilité financière aux soins de santé est essentielle pour réduire la morbidité et de la mortalité infantile dans les pays à ressources limitées. Cependant, les preuves disponibles sur la relation entre un accès accru aux soins et l’amélioration la santé infantile, dans le long terme, demeurent insuffisantes et parfois inconnues. Dans le contexte spécifique de la région du Sahel au Burkina Faso où les niveaux élevés de morbidité et de malnutrition coïncident avec un faible recours aux soins, une intervention de santé publique associant la gratuité des soins à l’amélioration de la qualité des soins et à la prise en charge de la malnutrition dans la communauté a été mise en œuvre en septembre 2008. Objectifs : En utilisant des approches statistiques et épidémiologiques appliquées aux données transversales et de séries chronologiques, cette thèse vise à apporter une meilleure compréhension de la façon dont la présence de l’intervention dans les communautés peut augmenter et maintenir l’utilisation des services de santé à long terme et améliorer la santé des enfants de moins de cinq ans. Les objectifs spécifiques sont : 1) évaluer le maintien à long terme des effets de l’intervention sur l’utilisation des services de santé chez les enfants de moins de cinq ans, 2) évaluer l’effet contextuel de l’intervention, quatre ans après le début de sa mise en œuvre, sur la probabilité de survenue d’une maladie et sur la probabilité d’utilisation des services de santé chez les enfants de moins de cinq ans, et 3) évaluer l’effet contextuel de l’intervention, quatre ans après le début de sa mise en œuvre, sur le retard de croissance chez les enfants de moins de cinq ans. Méthodes : Les données proviennent du système national d’information sanitaire, d’une enquête rétrospective sur les services de santé ainsi que d’une enquête de ménages réalisée quatre ans après le début de l’intervention dans 41 villages du district d’intervention et 51 villages du district de comparaison. Nous avons utilisé un plan quasi expérimental à séries temporelles interrompues avec groupe de comparaison pour évaluer les effets immédiats et à long terme de l’intervention sur les taux d’utilisation des services de santé. Ensuite, un plan d’étude transversale post-intervention avec un groupe de comparaison nous a permis d’évaluer l’effet contextuel de l’intervention sur la probabilité de survenue d’une maladie, sur la probabilité d’utilisation des services de santé et sur le retard de croissance chez les enfants de moins de cinq ans. La stratégie analytique a combiné la méthode de pondération par les scores de propension pour équilibrer les covariables entre les deux groupes, la modélisation binomiale négative à effets mixtes, les régressions linéaire et logistique multiniveaux. Résultats : L’intervention de gratuité des soins associée à l’amélioration de la qualité des soins et à la prise en charge de la malnutrition dans la communauté était associée à l’augmentation et au maintien de l’utilisation des services de santé au-delà de quatre ans (ratio des taux d’incidence = 2,33 ; IC 95 % = 1,98 – 2,67). En outre, comparativement aux enfants vivant dans le district de contrôle, la probabilité d’utiliser les services de santé était de 17,2 % plus élevée chez les enfants vivant dans le district d’intervention (IC 95 % = 15,01–26,6) ; et de 20,7 % plus élevée lorsque l’épisode de maladie était sévère (IC 95 % = 9,9–31,5). Ces associations étaient significatives, quels que soient la distance par rapport aux centres de santé et le statut socio-économique du ménage. Par ailleurs, alors que le contexte de résidence expliquait 9,36 % de la variance du retard de croissance (corrélation intraclasse = 9,36 % ; IC 95 % = 6,45–13,38), la présence de l’intervention dans les villages n’explique que 2 % de la variance du retard de croissance. Cependant, nous n’avons pas pu démontrer que la présence de l’intervention dans les communautés était associée à une réduction de la probabilité de survenue d’un épisode de maladie (Différentiel des probabilités = 4.4 ; IC 95% = -1.0 – 9.8), ni à une amélioration significative de l’état nutritionnel des enfants de moins de cinq ans (RC = 1,13 ; IC 95 % = 0,83–1,54). Conclusion : Cette thèse souligne que la gratuité des soins associée à l’amélioration de la qualité des soins et à la prise en charge de la malnutrition dans la communauté est efficace pour augmenter et maintenir l’utilisation des services de santé et réduire les inégalités géographiques de recours aux soins. Cependant, cette intervention n’était pas associée à une amélioration des résultats de santé infantile. Bien que des études longitudinales rigoureuses soient nécessaires pour comprendre pleinement l’influence potentielle de cette intervention sur la morbidité, cette thèse plaide pour la nécessité d’agir simultanément sur les autres déterminants sociaux de la santé et d’intégrer, de manière synergique, des interventions spécifiques à la nutrition pour plus d’impact sur la santé infantile. / Introduction: Improving financial access to health care is believed to be essential for reducing the burden of child morbidity and mortality in resource-limited settings, but the available evidence on the relationship between increased access and health remains scarce and the long-term issues are still unknown. In the specific context of the Sahel region in Burkina Faso where high levels of morbidity and malnutrition coincide with low health care use, a pilot intervention for free health care including quality of care improvement and management of malnutrition at the community level was implemented in September 2008. Objectives: Using statistical and epidemiological approaches applied to cross-sectional and time series data, this thesis aims to provide a better understanding of how the presence of intervention in communities can increase and maintain long-term use of health services and improve the health of children under five years. The specific objectives are: 1) to evaluate the long-term effects of the intervention on the use of health services in children under the age of five, 2) to estimate the contextual effect of intervention on the probability of occurrence of and the likelihood of health services being used by children under five, four years after the start of its implementation, and 3) to evaluate the contextual effect of the intervention on stunting in children under five, four years after the start of its implementation. Methods: The data for the analyses were provided from a variety of sources including the national health information system, a retrospective health services survey, and a household survey conducted four years after the intervention onset in 41 villages in the intervention district and 51 villages in the comparison district. We used a quasi-experimental controlled interrupted time-series design group to analyze the immediate and long-term effects of the intervention on the rate of health services utilization in children under five. Then, a quasi-experimental post-test-only design that included a control group allowed us to evaluate the contextual effect of the intervention on the probability of occurrence of a disease, on the probability of use of health services, and stunting in children under five. The analytic strategy combined the propensity score weighting method to balance the covariates between the two groups, two-level mixed-effects negative binomial, and linear and logistic regression models to account for the hierarchical structure of data. Results: The intervention for free health care including quality of care improvement and management of malnutrition at the community level was associated with an increased and maintained use of health services beyond four years after the onset of intervention (incidence rate ratio = 2.33; 95% CI = 1.98–2.67). In addition, compared to children living in the comparison district, the probability of using health services was 17.2% higher among those living in the intervention district (95% CI = 15.0–26.6); and 20.7% higher when the illness episode was severe (95% CI = 9.9–31.5). These associations were significant regardless of the distance to health centers and the socio-economic status of households. In addition, inequalities in the use of care were less pronounced in the intervention villages compared to those in the control village. Finally, the results also showed that the residence context accounted for 9.36% of the variance in stunting (intra-class correlation = 9.36% ; 95% CI = 6.45–13.38), and only 2% of the variance in stunting was explained by the intervention. However, we could not demonstrate that the intervention in these communities was associated with a reduced probability of an illness occurring (AME=4.4 (95% CI: -1.0 – 9.8), nor with a significant improvement in the nutritional status among children under five (OR = 1.13; 95% CI = 0.83–1.54). Conclusion: This thesis underlines the importance that affordable health care, including quality of care, as well as improving the management of malnutrition at the community level, are effective in increasing and maintaining the use of health services and reduce geographical inequalities in the use of care. However, this intervention was not associated with improved child health outcomes. Although rigorous longitudinal studies are necessary to fully understand the potential influence of this intervention on morbidity, this thesis highlights the need to simultaneously act on other social determinants of health and to synergistically integrate nutrition-specific interventions for greater impact on child health.