Magister Public Health - MPH / Objectives: To document the distribution of medical doctors between the National Health System (NHS), NGOs and the Private Sector over the period 2000-2010; (2) To explore the perceptions of medical doctors (MDs) and human resources managers (HRMs) regarding factors that influence MD internal brain drain in Maputo city, Mozambique, more specifically, the movement of doctors from the Mozambican NHS to NGOs and the private sector within Mozambique.

An examination of developments between 1970-1990 demonstrate a substantial restructuring of relations between the state and nonprofit societies within Vancouver's mental health system. While helping to establish and support the growth of nonprofit societies, the state, during the 1970's, maintained a "hands off" relationship with the nonprofit sector. Throughout the 1980's and early 1990's, state intervention into the affairs and aspirations of nonprofit societies dramatically increased, primarily through the establishment of corporatist arrangements. Such arrangements necessitated the establishment of non-aligned intermediary organizations to regulate and monitor activities within the nonprofit sector. The establishment and development of nonprofit societies and the subsequent restructuring of relations between the state and nonprofit societies is explored through an examination of corporatism. This examination includes a detailed case study of two nonprofit societies operating in the city of Vancouver between 1972 to the present, the Coast Foundation Society and The Greater Vancouver Mental Health Services Society. The methodology utilized includes analysis of secondary data, archival and documentary materials, and personal interviews with a number of key informants previously or currently employed within the mental health system. Analytic themes from the literature on pluralism and corporatism, along with Claus Offe's theoretical examination of state-interest group relations, are used to explain the construction of corporatism during this period. While the inquiry provides a detailed account of developments within Vancouver's mental health system through a case study approach, broader issues are also explored. The impact of macro economic changes, especially the effect of the recessionary period during the 1970's, is crucial in understanding changing state priorities and the subsequent construction of corporatism. An understanding, therefore, of the way in which corporatism relates to the broader reconstruction of consensus within late capitalist societies is an important focus of this study. / Arts, Faculty of / Sociology, Department of / Graduate

Population ageing has been taking place all over the world, being estimated that 2.1 billion people will be aged 60 or over in 2050. Healthcare Supportive Home (HSH) Systems have been proposed to overcome the high demand of remote home care for assisting an increasing number of elderly people living alone. Since a heterogeneous team of healthcare professionals need to collaborate to continually monitor health status of chronic patients, a cooperation of pre-existing e-Health systems, both outside and inside home, is required. However, current HSH solutions are proprietary, monolithic, high coupled, and expensive, and most of them do not consider their interoperation neither with distributed and external e-Health systems, nor with systems running inside the home (e.g., companion robots or activity monitors). These systems are sometimes designed based on local legislations, specific health system configurations (e.g., public, private or mixed), care plan protocols, and technological settings available; therefore, their reusability in other contexts is sometimes limited. As a consequence, these systems provide a limited view of patient health status, are difficult to evolve regarding the evolution of patients health profile, do not allow continuous patients monitoring, and present limitations to support the self-management of multiple chronic conditions. To contribute to solve the aforementioned challenges, this thesis establishes HomecARe, a reference architecture for supporting the development of quality HSH systems. HomecARe considers HSH systems as Systems-of-Systems (SoS) (i.e., large, complex systems composed of heterogeneous, distributed, and operational and managerial independent systems), which achieve their missions (e.g., improvement of patients quality of life) through the behavior that emerges as result of collaborations among their constituents. To establish HomecARe, a systematic process to engineer reference architectures was adopted. As a result, HomecARe presents domain knowledge and architectural solutions (i.e., architectural patterns and tactics) described using conceptual, mission, and quality architectural viewpoints. To assess HomecARe, a case study was performed by instantiating HomecARe to design the software architecture of DiaManT@Home, a HSH system to assist at home patients suffering of diabetes mellitus. Results evidenced HomecARe is a viable reference architecture to guide the development of reusable, interoperable, reliable, secure, and adaptive HSH systems, bringing important contributions for the areas of e-Health, software architecture, and reference architecture for SoS. / O envelhecimento da população é um fenômeno mundial e estima-se que no ano 2050, 2,1 bilhões de pessoas terão 60 anos ou mais. Sistemas de casas inteligentes para o cuidado da saúde (em inglês Healthcare Supportive Home - HSH systems) têm sido propostos para atender a alta demanda de serviços de monitoramento contínuo do número cada vez maior de pacientes que vivem sozinhos em suas residências. Considerando que o monitoramento do estado de saúde de pacientes crônicos requer a colaboração de equipes formadas por profissionais de várias especialidades, é fundamental que haja cooperação entre sistemas eletrônicos de saúde (por exemplo, sistemas de prontuário eletrônico ou sistemas de atenção de emergência), sendo eles externos ou internos à residência. Entretanto, as soluções de HSH existentes são comerciais, monolíticas, altamente acopladas e de alto custo. A maioria delas não considera a interoperabilidade entre sistemas distribuídos e exteriores ou internos à residência dos pacientes, como é o caso de robôs de companhia e monitores de atividade. Além disso, os sistemas de HSH muitas vezes são projetados com base em legislações locais, na estrutura do sistema de saúde (por exemplo, público, privado ou misto), nos planos de cuidados nacionais e nos recursos tecnológicos disponíveis; portanto, a reusabilidade desses sistemas em outros contextos é não é uma tarefa trivial. Em consequência, os sistemas de HSH existentes oferecem uma visão restrita do estado de saúde do paciente, são difíceis de evoluir acompanhando as mudanças no perfil de saúde do paciente, impossibilitando assim seu monitoramento contínuo e limitando o suporte para o paciente na autogestão de suas múltiplas condições crônicas. Visando contribuir na resolução dos desafios apresentados, esta tese estabelece a HomecARe, uma arquitetura de referência para apoiar o desenvolvimento de sistemas de HSH de qualidade. A HomecARe considera os sistemas de HSH como Sistemas-de-Sistemas (do inglês Systems-of-Systems - SoS) (ou seja, sistemas grandes e complexos formados por outros sistemas heterogêneos, distribuídos e que apresentam independência em seu gerenciamento e operação), que cumprem suas missões (por exemplo, melhoria da qualidade de vida do paciente) mediante o comportamento que emerge resultante da colaborações entre seus sistemas constituintes. Para estabelecer a HomecARe, foi adotado um processo sistemático que apoia a engenharia de arquiteturas de referência. Como resultado, a HomecARe contém o conhecimento do domínio, bem como soluções arquiteturais (por exemplo, padrões arquiteturais e táticas) que são descritas usando os pontos de vista conceitual, de missão e de qualidade. A HomecARe foi avaliada por meio da condução de um estudo de caso em que a arquitetura de referência foi instanciada para projetar o DiaManT@Home, um sistema de HSH que visa apoiar pacientes diagnosticados com diabetes mellitus na autogestão de sua doença. Os resultados obtidos evidenciaram que a HomecARe é uma arquitetura de referência viável para guiar o desenvolvimento de sistemas de HSH reusáveis, interoperáveis, confiáveis, seguros e adaptativos, trazendo importantes contribuições nas áreas de saúde eletrônica, arquitetura de software e arquiteturas de referência para SoS.

Método: Trata-se de uma pesquisa qualitativa de cunho documental utilizando o audiovisual como lócus de instalação de depoimentos de lideranças indígenas do Estado do Acre, Brasil. O objetivo é analisar registros de vivências de lideranças indígenas sobre suas condições de vida, como contribuição às políticas públicas do SUS. E apresentar uma proposta interventiva a partir das potencialidades do vídeo documentário. Resultados: A população indígena, por uma série de motivos, certamente é a parcela da população brasileira sobre a qual menos existem dados específicos que permitam o estabelecimento de políticas de saúde pública eficazes. Embora tenham ocorrido avanços significativos no conhecimento das questões indígenas e um crescente empoderamento das lideranças indígenas na luta por seus direitos básicos de cidadania, a situação ainda está aquém do esperado. Temas relevantes abordados: 1. Participação nas instâncias do poder público/ direitos indígenas. 2. Medicina tradicional exterioridade da doença. 3. Dificuldades com o SUS. 4. Cuidados de saúde nas aldeias. 5. Segurança Alimentar e desnutrição. 6. Qualidade da água e saneamento básico. 7. Logística. 8. Cobertura vacinal. 9. Saúde das mulheres indígenas. 10. Ecologia e biodiversidade. 11. Morte de crianças indígenas. Conclusões: 1. A omissão sistemática dos governos em qualificar agentes de saúde indígenas no tocante às intervenções em saúde individual e coletiva e no exercício dos direitos sociais. 2. Falta de empenho do SUS em contratar profissionais com formação especializada para compor as equipes e direções do Sistema de Saúde que atuam nas aldeias e nos postos avançados de saúde no interior do território. 3. Dificuldades de comunicação entre as equipes do SUS e os povos indígenas. Há barreiras de idioma, de cultura e de percepção do processo saúde-doença / Method: This is a qualitative research that uses the documentary audio-visual like a place of installation register statements of native indigenous leaders of Acre, Brazil. The objective is to analyze records of indigenous leaders from experiences about their living conditions as a contribution to public SUS policies. And present an interventional proposal from the documentary video potentiality. Results: The indigenous population, for a number of reasons, it is certainly the Brazilian population, on which there is less specific data that allow the establishment of effective public health policies. Although there have been significant advances in knowledge of indigenous issues and a growing empowerment of indigenous leaders in the struggle for their basic rights of citizenship, the situation is still below expectations. Relevant topics approached:1. Participation in public authoritys instances / indigenous rights. 2. Traditional medicine - externality of the disease. 3. Difficulties with SUS. 4. Health care in villages. 5. Food security and malnutrition. 6. Water quality and basic sanitation. 7. Logistics. 8. Vaccination coverage. 9. Indigenous women\'s health. 10. Ecology and biodiversity. 11. Death of indigenous children. Conclusions: 1. the systematic omission of governments in qualify indigenous health workers with regard to the individual and collective health interventions and the exercise of social rights. 2. Lack of commitment of the SUS in hiring professionals with specialized training to compose the teams and directions of the Health System that work in the villages and in the outposts of health in the territory. 3. Difficulties in communication between SUS teams and indigenous peoples. There are barriers to language, culture and perception of the health-disease process

Maternal and newborn health is one of the main indicators of a good health system. The study wished to develop a strategy to improve the referral system for maternal and newborn care. To identify issues for improvement, the researcher explored the appropriateness of referrals, referral pathways and challenges, and provider costs for maternal and newborn care at health centres and hospitals levels. The researcher selected a sequential explanatory mixed method research design. Two primary hospitals and six health centres were purposively selected for participation. The first phase collected quantitative data by reviewing the health facilities’ medical records for services provided and health service costing, respectively. Data collection covered one Ethiopian fiscal year (8 July 2017 to 7 July 2018). Based on the existing human resource arrangement and care needs, the health service costing found that a single midwife at health centre level spent half of the expected time for delivery care. The cost estimates of various types of care delivery care indicated that delivery care at health centre and hospital levels cost $27.5 to $30.2, and $34.7 to $37.8, respectively. The primary hospitals incurred four times the cost for newborn intensive care units and Caesarean sections compared to normal delivery care. In the second phase, the researcher collected qualitative data from 26 purposively selected key informants in interviews. The findings indicated that the selected hospitals and health centres had a referral system, but several factors impeded its effective implementation. Knowledge of referral pathways determined the referral practices at the lower level of the system. The number of inappropriate referrals to primary hospitals indicated a need to mobilize and educate the community on the services available and protocols of care. In general, most referrals could have been managed at health centre level. Emergency medical transportation is a critical component of the referral system; delays in transportation determine the outcome of care at hospital level. Ambulance management was generally poor, lacked a tracking system, and was negatively affected by confusion and lack of coordination between facilities. The available ambulances were not well equipped or well-staffed for emergency management. Moreover, there were frequent breakdowns due to limited budget for maintenance and running costs. The quality of maternal care depends on the quality of the labour monitoring. However, partograph utilization was not consistently practised. Admitted cases were not properly monitored because of the high caseload and limited supervision support. In many cases, healthcare professionals tended to “treat charts” rather than promote evidencebased practice while providing care. The quality of practice was challenged by insecurity in the working environment but strengthened by good teamwork and available consultation support. The implementation of the existing referral system depended on the people involved; the use of performance indicators; follow up by management, and an accountability framework. The findings of the two phases of the study and review of other countries’ experiences on the identified problems, led to the development of draft strategy and then a consultation with relevant experts produced the final strategy. The strategy includes interventions to improve the practices at the sending and receiving facilities as well as suggestions to improve the communication, transportation and overall governance system. Then, taking into consideration all the phases of the study, the researcher makes recommendations for practice and further research. / Health Studies / D. Litt. et Phil. (Healht Studies)

The investigator undertook a study of the status of the area of health, physical education, and recreation in the colleges and universities of Texas primarily for Negro students during the session of 1953-54.

Objective: To examine health services use on the basis of alcohol consumption. Material and Methods: A cross-sectional study was carried out on patients visiting the Primary Health Care (PHC) settings in Catalonia during 2011 and 2012; these patients had a history of alcohol consumption. Information about outpatient visits in the PHC setting, hospitalizations, specialists’ visits and emergency room visits for the year 2013 was obtained from 2 databases (the Information System for the Development of Research in PHC and the Catalan Health Surveillance System). Risky drinkers were defined as those who consumed more than 280 g per week for men or more than 170 g per week for women, or any amount of alcohol while being involved in a high risk work activity, or taking medication that significantly interferes with alcohol or when being pregnant. Binge drinkers (>60 g in men or >50 g in women in a short amount of time more than once a month) were also considered risky drinkers. Results: A total of 606,948 patients reported consuming alcohol (of which 10.5% were risky drinkers). Risky drinkers were more likely to be admitted to hospitals or emergency departments (range of ORs 1.08–1.18) compared to light drinkers. Male risky drinkers used fewer PHC services than male light drinkers (OR 0.89, 95% CI 0.87–0.92). In general, risky alcohol users used services more and had longer hospital stays. When stratifying by socioeconomic level of the residential area, we found that risky drinking failed significance, while current or past cigarette smoking was associated with higher healthcare use. Conclusions: Risky drinkers use more expensive services, such as hospitals and emergency rooms, but not PHC services, which may suggest that prevention strategies and alcohol interventions should also be implemented in those settings.

Community-Based Health Insurance (CBHI) in Rwanda was promulgated as the best alternative to address the financial barriers for accessibility to health care services for the poor population and the informal sector. The purpose of this study was to investigate whether CBHI reduce Out-of-pocket health expenses for their members as compared to non-members and to what extent CBHI provide financial protection for the poorest population. This research based itself on secondary source of data primarily collected for a prospective quasi-experimental design which evaluated the impact of Performance-Based Financing. The primary study had reported on the Out-Of-Pocket expenses for health by members and non-members of CBHI; residing in a sample of 1961 households; in addition to their demographics and socio-economic characteristics. The findings indicate that insured individuals were about 2.6 times more likely to utilize health care services than respondents without health insurance. It is also worth noting that households with health insurance coverage were less likely to experience a catastrophic health expenditure than households without health insurance (aOR: 0.744; 95% CI:[0.586 - 0.945]), and that the effect of health insurance coverage was higher in people living in poor households than in people living in middle or richer households / Health Studies / M.A. (Public Health)

Bakgrund: I Sverige år 2015 fanns det ungefär 18 000 högstadieelever med ogiltig upprepad frånvaro. Det finns samband mellan skolfrånvaro och sämre självupplevd hälsa och inom elevhälsan har skolsköterskan kompetens att identifiera och förhindra ohälsa. Skolsköterskor har en viktig roll att stödja elever med ohälsa. Därför är det viktigt att beskriva skolsköterskors erfarenheter av arbetet med högstadieelever med omfattande skolfrånvaro.Syfte: Syftet var att beskriva skolsköterskors erfarenheter av arbetet med högstadieelever med omfattande skolfrånvaro.Metod: En kvalitativ induktiv design. Ett ändamålsenligt urval gjordes och nio skolsköterskor verksamma på nio olika skolor i Sverige deltog. Individuella semistrukturerade intervjuer genomfördes och intervjuernas manifesta innehåll analyserades med kvalitativ innehållsanalys. Resultat: Ett tidigt initierat teamarbete där eleven är en viktig del i teamet är betydelsefullt i arbetet med att stödja högstadieelever med omfattande skolfrånvaro. Att skolsköterskan är närvarande genom att vara fysiskt tillgänglig och genom att bry sig om eleven är viktigt för att stödja eleven. Slutsats: Ett fungerande teamarbete där elevens berättelse är central är betydelsefullt. Genom att arbeta personcentrerat och använda arbetsmodellen gemensam problemlösning erhålls en arbetsstruktur där teamarbete möjliggörs och där eleven blir en viktig medlem i teamet. / Background: In Sweden in 2015, there were approximately 18 000 high school students with repeated invalid absence. There is a connection between school absence and poorer self-perceived health and in student health, school nurses have competence in identifying and preventing illness. School nurses have an important role in supporting students with ill health. Therefore, it is important to describe school nurses' experiences of working with high school students with extensive school absence.Aim: The aim was to describe school nurses’ experiences of working with high school students with extensive school absenteeism.Method: Purposive sampling was made and nine school nurses working at nine different schools in Sweden participated. Individual semistructured interviews were conducted and the manifest content of the interviews was analyzed with qualitative content analysis. Result: An early initiated teamwork where the student is an important part of the team is important in the work of supporting high school students with extensive school absence. That the school nurse is present by being physically accessible and by caring for the student is important to support the student.Conclusion: A functioning team work where the student's story is central is important. By working person-centered and using the work model collaborative problem solving, a work structure is obtained where teamwork is made possible and where the student becomes an important member of the team.

The strong emphasis placed on improving equality and well-being for all in the Sustainable Development Goals underscores the importance of tackling persistent within-country disparities in maternal mortality and poor health outcomes. Addressing maternal healthcare access barriers is, thus, crucial, particularly in low-resource settings. Numerous studies investigating determinants of maternal healthcare service use in Ethiopia exist but are limited by their focus on individual and household factors, and by methodological weaknesses. A nuanced understanding of the role of socioeconomic and geographic context in influencing access to care is needed to respond effectively. Maternity waiting homes (MWHs) are a potential strategy to address geographical barriers that delay women’s access to obstetric care. However, in addition to concerns about service quality, there is limited evidence on their effectiveness and on what models meet women’s needs. My research goals were, therefore, to contribute to the understanding of what contextual factors influence maternal healthcare service use in general; and to determine whether or not upgraded MWHs operating in an enabling environment could improve delivery care use in rural Ethiopia. My primary data sources were household surveys conducted as part of a cluster-randomized controlled trial evaluating MWHs and local leader training in Jimma Zone, Ethiopia. Random effects multivariable logistic regression analysis of survey data brought to light the social and financial resources that facilitate MWH use, highlighting the need for complementary interventions to make access more equitable. Spatial analyses identified subnational variation in service use at a finer scale than routinely reported and unmasked local variation in the relevance and magnitude of associations between individual-, interpersonal-, and health system factors and maternal healthcare use. These findings have implications for relying upon homogenous national responses to improve equality in access to care and health outcomes. Finally, analysis of trial data found a non-significant effect of interventions on delivery care use likely due to implementation issues and extraneous factors. The need to generate strong evidence of effectiveness of MWHs in improving maternal healthcare service use using sustainable and equitable MWH models using methods appropriate for complex intervention evaluation remains.