A inicios del año 2020, se registraron 4,300 asegurados a EsSalud diagnosticados con Enfermedad Renal Crónica Terminal (ERCT) en el departamento de Lima, quienes han venido recibiendo sesiones de hemodiálisis en el Centro Nacional de Salud Renal (CNSR) y clínicas contratadas para este servicio, según lo reportado por la IAFAS antes mencionada. Por parte de los asegurados al SIS, el Fondo Intangible Solidario en Salud (FISSAL) informó que a inicios del 2020 que 6 mil 268 asegurados vienen recibiendo hemodiálisis en centros particulares de salud de Lima Metropolitana y las diferentes regiones del país. El presente proyecto plantea brindar el servicio ambulatorio de hemodiálisis a pacientes con Enfermedad Renal Crónica Terminal afiliados a la IAFAS EsSalud, puesto que tiene una sobredemanda que requieren del servicio de Hemodiálisis, y que actualmente no se encuentra cubierta ni por la oferta propia ni por la subcontratada con otros centros de hemodiálisis.  Nuestra estrategia es de “Liderazgo en costos”, con una propuesta de valor basada en atención personalizada con un equipo multidisciplinario, altos estándares de calidad y un modelo de gestión centrado en el paciente, según los Términos de Referencia (TDR) requeridos por EsSalud. Desde el punto de vista financiero, la inversión total del proyecto es de S/. 447,110.00 presentando un VAN de S/. 2,676,707.15 y un TIR es 86.1%. Los principales riesgos del proyecto son los financieros y económicos, como la falta de liquidez y lograr la contratación por la IAFAS EsSalud. / At the beginning of 2020, 4,300 insured persons were registered with EsSalud diagnosed with Terminal Chronic Kidney Disease (ESRD) in the department of Lima, who have been receiving hemodialysis sessions at the National Renal Health Center (CNSR) and clinics hired for this service, as reported by the aforementioned IAFAS. On the part of those insured to the SIS, the Intangible Solidarity in Health Fund (FISSAL) reported that at the beginning of 2020, 6,268 insured have been receiving hemodialysis in private health centers in Metropolitan Lima and the different regions of the country. This project proposes to provide the outpatient hemodialysis service to patients with Terminal Chronic Kidney Disease affiliated to IAFAS EsSalud, since it has an over-demand for them that require the Hemodialysis service, and which is currently not covered even by its own offer nor by the one subcontracted to other hemodialysis centers. Our strategy is “Cost Leadership”, with a value proposition based on personalized attention with a multidisciplinary team, high quality standards and a patient-centered management model, according to the Terms of Reference (TOR) required by EsSalud. From a financial point of view, the total investment of the project is S /. 447,110.00 presenting a NPV of S /. 2,676,707.15 and an IRR is 86.1%. The main risks of the project are financial and economic, such as lack of liquidity and being hired by IAFAS EsSalud / Trabajo de investigación

Våld i nära relationer (VNR) är ett utbrett samhällsproblem som kan få förödande konsekvenser, både för den utsatta individen och för samhället i stort. Många som utsätts för VNR är tveksamma till att söka hjälp och upprätta en polisanmälan. Hälso- och sjukvården besöks vid olika typer av problem och vårdcentraler kan vara en av de få instanser individer utsatta för VNR söker sig till. Syftet med studien är att undersöka personal på vårdcentralers möjligheter och förutsättningar att identifiera och hantera VNR genom sin yrkesroll utifrån kunskap om Region Skånes vårdprogram mot VNR med förhoppningen att styrka vårdcentralers brottspreventiva arbete mot VNR. Intervjuer har genomförts med personal på vårdcentral och resultatet visade att kännedom och användning av Region Skånes vårdprogram mot VNR varierade mellan studiens informanter. Många informanter kände till att ett vårdprogram mot VNR existerar men hade endast lite kunskap om innehållet. Gemensamt för alla informanter var dock att vårdprogrammet ofta inte användes som ett stöd i arbetet. Det fanns möjligheter till identifiering och hantering av VNR på vårdcentraler då frågan om utsatthet ofta ansågs lätt att ställa, men det var svårt för informanter att avgöra vem som skulle tillfrågas. Informanter kände sig även osäkra gällande hanteringen av identifierad VNR. Det uppgavs dock finnas goda möjligheter för detta arbete men hinder sågs i form av tidsbrist, otillräcklig kunskap om VNR, otillräckliga riktlinjer för hanteringen av VNR och osäkerhet kring dokumentation av VNR. Informanter menade att de ser arbetet med VNR som en del av deras ansvar men inte uttalat tänkt på vårdcentraler som en del av samhällets brottsprevention. / Violence in close relationships (VCR) is a widespread societal problem that may have devastating consequences for the victim and the society. Many victims of VCR are hesitant to seek help. The Swedish healthcare system is widely visited by the public and primary health centers (PHC) can be one of the few places victims of VCR visit. The aim of the study was to examine the possibilities and barriers medical professionals working in PHC have to be able to identify and manage VCR with the basis in the knowledge of Region Skåne’s care program against VCR. The results showed that many informants know that the care program exists but have little knowledge of the contents and rarely use the program. There were possibilities to identify and manage VCR in PHC as the question regarding patient’s victimization is seen as easy to ask but it was difficult to determine who should be asked. Informants felt insecure regarding the management of VCR and barriers were identified in the form of lack of time, inadequate knowledge about VCR, inadequate guidelines for the management of VCR and uncertainty regarding the documentation of VCR. The informants saw identification and management of VCR as part of their responsibility, however they did not outspokenly think about PHC as part of society’s crime prevention.

Esta tesis surge de la preocupación por las condiciones actuales que deben atravesar los cuidadores de pacientes con enfermedad de Alzheimer en el Perú, quienes en algunos casos llegan a padecer el síndrome del cuidador, lo que impacta significativamente en su capacidad para realizar su trabajo de manera eficiente. Reforzando las preocupaciones, el Instituto Nacional de Estadística e Informática (INEI) prevé que para el 2050 habrá alrededor de 8,7 millones de adultos, la mayoría de los cuales padecerá la enfermedad de Alzheimer. Esta situación no solo es un problema para los pacientes, sino también para sus familias, cuidadores y su entorno social. Así, este proyecto representa una oportunidad para resaltar esta enfermedad y las complejidades que se originan en las familias afectadas al brindar una solución a través de la creación de la primera unidad de memoria integral del país. Este trabajo se desarrolló en diferentes etapas: análisis de contexto y contenedor, diagnóstico, análisis de usuario y función, planteamiento de estrategias de diseño, levantamiento de la preexistencia, propuesta de master plan, detalles del sector y visuales. / This thesis stems from the concern for the current conditions that caregivers of patients with Alzheimer’s disease in Peru must go through, who in some cases come to suffer from caregiver syndrome, which significantly impacts their ability to perform their work efficiently. Reinforcing the concerns, the National Institute of Statistics and Informatics (INEI), foresees that by 2050 there’ll be around 8.7 million adults, most of whom will suffer from Alzheimer’s disease. This situation isn’t only a problem for the patients but also for their families, caregivers, and their social environment. Thus, this project represents an opportunity to spotlight this disease and the complexities that originate in the affected families by providing a solution through the creation of the first integral memory unit in the country. This work will be implemented in different stages: context and container analysis, diagnosis, user and function analysis, approach to design strategies, pre-existence drawings, master plan proposal, details of the sector and visuals. / Trabajo de investigación

Between 2013 and 2016, 8.1% of U.S. adults 20 years and older suffered from depression, but only 29% of them sought help. This project addressed the low depression screening rate in a Federally Qualified Health Center (FQHC) that supported integrated care. The purpose of the project was to evaluate the integration of behavioral health into primary care in an FQHC through the rate of depression screenings. Two theoretical frameworks, the find-organize-clarify-understand-select/plan-do-study-act model and the Centers for Disease Control and Prevention's framework for program evaluation in public health were combined into a list of questions and data validity tests that were used to conduct the evaluation. This quality improvement (QI) project evaluated an existing QI initiative. Findings revealed that 75% of the patients seen, and not the initially reported 53%, received depression screenings, which indicated an improved outcome. Other findings were inadequate use of theoretical frameworks, poor data quality, and suboptimal effectiveness of QI team processes. The strategies and tools recommended in this project could be used by organizational leaders and QI teams to evaluate and improve QI initiatives. The project's contribution to awareness about depression through integrated care could increase patients' access to care, quality of life, and life expectancy, and positively impact social change.

BACKGROUND: Despite large investments in maternity care services, perinatal health outcomes in the U.S. are among the worst compared to other industrialized countries, with documented perinatal health disparities disproportionately impacting racial and ethnic minorities. Midwifery-led freestanding birth centers (FSBC) have emerged as an underutilized model for the safe and cost-effective care of women with low-risk pregnancies. Despite approximately 85% of all US pregnancies being considered low-risk, only 0.5% of all US births occurred in a FSBC in 2016. The goal of the study is to elucidate strategies used to develop and sustain freestanding birth centers (FSBCs) that are seeking to serve high proportions of publicly-insured women and women of color. METHODS: I conducted an embedded unit case study, including semi-structured in-depth interviews and focus groups with 49 stakeholders from three exemplary FSBCs. Supplemental interviews were led with five key informants from three additional FSBCs and a relevant national membership organization. Additional data sources used to complete this case study include, where relevant and permitted, observations of maternity care settings, patient-provider encounters, management meetings, community events, and review of pertinent documents. Qualitative analysis methods were used to identify common themes and variations. FINDINGS: Midwifery-led birth center care can improve the experience and outcomes of maternity care among publicly insured women of color. The study revealed persistent multi-level challenges, as well as the use of common approaches to overcome these organizational, financial, and cultural barriers, resulting in greater, yet still fragile, access to family-centered intrapartum care within the communities in which these FSBCs operate. CONCLUSIONS: The careful integration of FSBCs into health systems such as a Federally Qualified Health Center (FQHC) may contribute to the broad scale-up of this underutilized model of care. While integrating FSBCs into FQHCs may be helpful in expanding equitable access to birth center care, it is not necessary, and also not sufficient. Expansion efforts should include additional deliberate processes and strategies to ensure equitable uptake and sustainability of birth center care. / 2020-10-23T00:00:00Z

A large part of Swedish medical care is expected to be provided from the primary health centers. However, these centers are experiencing challenges in terms of shortages of personnel, an increased volume of patients, higher workload, increasing queue lengths, and increasing costs. Addressing these issues at the primary health centers is important for both improving the operation at the local centers and the functionality of the Swedish healthcare system. This thesis aims to explore the primary health center operation, focusing on a typical public primary health center in Stockholm. This is done to find parameters that affect the flow of patients and develop a graphical model that serves as a foundation for further model development, simulations and optimization of good health. To address the complex and dynamic primary health center system, a system dynamics approach is adopted. A literature review was conducted to gain an understanding of the primary health center environment and to identify parameters that impact the primary health centers ability to operate and/or affect the quality of service towards patients. The model development involved constructing cases and extracting parameters that change over time. The parameter relationships were determined through interpretation and are supported by literature. The model was qualitatively validated with the assistance of expert feedback. The presented result is determined to capture the basic operation of the primary health center and the model can be used as a foundation for further simulations. / En stor del av den svenska sjukvården förväntas levereras från vårdcentraler. Vårdcentralerna står dock inför utmaningar när det gäller brist på personal, ökad patientvolym, högre arbetsbelastning, ökade kölängder och ökande kostnader. Att hantera dessa problem på vårdcentralerna är viktigt både för att förbättra den lokala verksamheten och funktionaliteten i svensk hälso- och sjukvård. Syftet med detta arbete är att undersöka vårdcentralens verksamhet och fokuserar på en typisk offentlig vårdcentral i Stockholm. Detta görs för att hitta parametrar som påverkar patientflödet, för att utveckla en grafisk modell som utgör en grund för vidare modellutveckling, simuleringar och optimering av god hälsa. För att adressera det komplexa och dynamiska vårdcentral-systemet antas ett system dynamiskt tillvägagångssätt. En litteraturgenomgång genomfördes för att få en förståelse för vårdcentralens miljö och identifiera parametrar som påverkar vårdcentralens förmåga att driva verksamheten och/eller påverkar kvaliteten på vården för patienter. Modellutvecklingen innebar att konstruera fall och extrahera parametrar som förändras över tid. Parametrarnas relationer bestämdes genom tolkning och stöds av litteratur. Modellen genomgick en kvalitativ valideringsprocess baserad på expertutlåtanden. Resultatet, den grafiska modellen, som presenteras anses fånga vårdcentralens grundläggande funktion och kan användas som grund för vidare simuleringar.

本研究以城鄉差異觀點，評估台灣鄉村型社區心理衛生中心之服務需求，具體目的有(1)分析台灣縣市及雲林縣鄉鎮與心理衛生有關之各項社會指標，以驗證社區心理衛生相關問題的城鄉差異性；(2)瞭解雲林縣及其鄉鎮關鍵訊息提供者對高度農業地區各項社區心理衛生問題嚴重程度、問題型式、地理分佈與相關在地服務資源之看法；(3)瞭解雲林縣高度農業人口鄉鎮社區居民對其村落各項相關心理衛生問題嚴重程度、問題型式、社區壓力源、因應方式與求助情形之看法；(4)由社區居民調查結果，抽取鄉村心理衛生相關問題之共同因素，並歸納諸項調查研究與指標分析結果，初步擬定出一「台灣鄉村心理衛生指標系統目錄」。 研究方法採用多方法評估策略。社會指標分析方面，共計分析台灣地區23個縣市24項及雲林縣20個鄉鎮市16項心理衛生相關問題，以比較不同農業人口分群其發生率或盛行率之差異。關鍵訊息提供者調查方面，使用自編問卷分別調查雲林縣30位與二崙與水林兩鄉69位政府單位、民間機構或專業個人等。社區居民調查方面，二崙與水林兩鄉共發出2049份問卷，回收1074份(52.4%)，有效問卷為967份(41村、97.6%)。統計方法有描述統計、集群分析、t考驗、單因子變異數分析、皮爾森積差相關分析、因素分析等。 研究主要發現如下：(1)高度農業人口地區之老年、低教育程度、喪偶、外籍配偶、身心障礙、意外事故死亡、醫事人員平均服務人口數等比例明顯較高，離婚、全般刑案、竊盜、強盜搶奪、暴力犯罪、強制性交等比例則較低。(2)台灣縣市心理衛生相關嚴重問題社會指標之地理分佈概況不明顯，但雲林縣心理衛生相關嚴重問題比例則以高度農業人口的二崙與麥寮兩鄉明顯較高。(3)雲林縣與二崙、水林兩鄉關鍵訊息提供者皆認為人口外移與老化、老人問題(獨居、貧窮、安養等)、電話詐騙等問題比例較高。雲林縣關鍵訊息提供者主觀覺得口湖、台西與四湖為最亟需心理衛生服務的農業鄉鎮。二崙鄉關鍵訊息提供者主觀覺得大庄、楊賢與港後為該鄉最亟需心理衛生服務的村落。水林鄉關鍵訊息提供者主觀覺得水北、塭底與大山為該鄉最亟需心理衛生服務的村落。(4)二崙與水林兩鄉社區居民認為電話詐騙、人口外移、農產經營影響、人口老化、家庭經濟壓力等問題比例較高，青少女母親(含未婚懷孕)、家庭人數眾多、親友與鄰居死亡頻傳、自殺、性侵害、精神疾病、家庭暴力、家庭虐待等比例較低。(5)二崙與水林兩鄉居民認為「社區孤立與無望感」來自人口老化、多孤獨貧窮老人、人口外流嚴重、生活無聊、缺乏休閒娛樂等因素較多，「犯罪被害擔憂與恐懼」來自竊盜、詐騙、嗑藥吸毒等問題較多，「社區憂鬱現象」來自個人與家庭經濟壓力、失業、農業損害或收益等因素較多。(6)二崙與水林兩鄉居民認為其感受社會壓力源以治安惡化為主，農業壓力源以農產收益與自然災害為主，社區壓力源以治安不佳、衛生環境不良、缺乏休閒娛樂等較多，學校壓力源以城鄉差距大、教育與學習資源不足、課業或升學壓力、教育政策多變等較多，家庭壓力源以經濟收入與子女教養為主，個人壓力源以經濟收入、身體健康、工作壓力等較多。(7)二崙與水林兩鄉居民指出習慣(或主要)抒解或因應壓力方法，以「找人聊天」居首，只有6.5%曾求助於親友之外的專業人員。(8)雲林縣現有7個單位或機構(衛生局─社區心理衛生中心與長期照護管理示範中心、社會局─各課、家庭教育中心、台大醫院雲林分院精神科、雲林區心理衛生諮詢服務中心與生命線協會)共提供37個鄉村心理衛生相關服務項目。 本研究由社區居民調查結果，共抽取出七個因素構面並分別命名為「一般社區心理衛生問題」、「農業社區心理衛生問題」、「環境污染」、「經濟壓力」、「居住生活風險」、「犯罪」與「家庭婚姻特性」，並歸納諸項調查研究與指標分析結果，初步擬定出一「台灣鄉村心理衛生指標系統目錄」(5大指標向度，14個指標項目)。 文末，研究者並根據研究結果與國內外相關文獻，分別提出鄉村居民心理健康政策、鄉村心理衛生指標系統、農業危機服務、老人心理衛生、社區孤立與無望感、犯罪被害恐懼、環境污染心理影響、鄉村性別與族群心理議題、鄉村學校之預防功能、鄉村心理衛生服務模式等10項建議。 / The purposes of this thesis were: (1) to analyze the differences of some social indicators related to mental health of Taiwan (23 cities/counties) and Yunlin county (20 townships). (2) to understand the opinions of the key informants about community mental health problems. (3) to survey community residents of agricultural areas about the subjective perceptions of their mental health. (4) to set up a summative index of Taiwan Rural Mental Health indicators System. This research used a multi-method strategy. Data collected in the spring of 2005 included 24 social indicators of 23 cities/counties in Taiwan, and 16 social indicators of 20 cities/township in Yunlin, and questionnaires of 99 key informants and 967 community members of Erh-lun and Shui-lin Township of Yunlin County. Major findings of this study were as follows: (1)Significant differences were found in the social indicators about the numbers of older population, the lower educational status, the widowed, the foreign spouse, and the disabled, the accidental injury-related deaths in agricultural counties. In contrast, urbanized areas had higher rates of the divorced, all criminal case, larceny, robbery and forceful taking, violent crime, rape, and the average number of people serviced by per medical personnel . (2)The geographic analysis in terms of the mental health status and service needs of residents revealed no significant differences among 23 cities/counties, but significant differences among 20 cities/township (Yunlin County), Erh-lun and Mailiao had much more problems. (3)Yunlin County’s key informants indicated that the areas of Kou-hu, Tai-si and Sih-hu have high needs for mental health services. Erh-lun’s key informants indicated that 3 villages have high needs for mental health services. Shui-lin’s key informants indicated that 3 villages have high needs for mental health services. (4)Most respondents of resident sample ranked the following mental health problems as serious: fraudulent telephone calls, out-migrant, farm crisis, being elderly, and family economic hardship. (5)Most respondents of resident sample employed “chatting with others” as stress-relieving or coping method. Besides “family and friends”, only about 6.5% of respondents reported that they sought help from mental health professionals or specialists. (6)To set up the initial rural mental health indicator systems of Taiwan: a summative index consists of 14 items and is divided into five dimensions The recommendations for rural mental health policies, indicator systems, program strategies and rural mental health service delivery issues were also suggested.

The master's thesis is elaborated on the basis of the project of the Sport and Health Center Olomouc. The project consists of two main buildings – the object of NH Hotel and the Sports Center Omega. The hotel also includes a conference center with three conference halls and covered parking. The object of Omega Sports Center is composed of sports halls for squash, badminton and tennis, along with changing rooms, wellness area and operational background of the object itself. The sports center also incorporates outdoor tennis courts and an underground tunnel connecting the Omega center and the NH Hotel. This thesis deals with the civil technological project of the building site and involves mainly the technical report of civil technological project, the study of realization of the main technological stages of the building object, the project of organization of construction, time schedule of aforementioned two main buildings, the technological standard with test and execution plans for the execution of underground construction by the impermeable concrete technology and for execution of variant solution of tennis hall roofing. Further, a comparison of the alternative roofing technology with current used roofing technology is performed, including the drawing documentation of new roofing alternative.

Diploma thesis designs a barrier free new building of medical devices – policlinic (health center) with 14 medical workplaces. Object has three floors and basement. The building is covered by a vegetation flat roof. Building of policlinic is based on strip foundations and load-bearing walls are made from sand-lime blocks. Horizontal systém is created like reinforced concrete ceiling and in the same way internal staircase. The building is design at passive architecture – have compact form, thick layer of insulation and airtight cover. The main glass facade is oriented to the sout. There is used heat recovery air conditioning and heat pumping for heating in building. Health center satisfy currently legislation.

Indiana University-Purdue University Indianapolis (IUPUI) / This thesis analyzes the relationship between Flanner House, an African American settlement house, and Planned Parenthood of Central Indiana to determine why Flanner House director Cleo Blackburn would not allow a birth control clinic to be established at the Herman G. Morgan Health Center in 1951. Juxtaposing the scholarship of African Americans and birth control with the historiography of black settlement houses leads to the conclusion that Blackburn’s refusal to add birth control to the health center’s services had little to do with the black Indianapolis community’s opinions on birth control; instead, Flanner House was confined by conservative limitations imposed on it by white funders and organizations. The thesis examines the success of Blackburn and Freeman B. Ransom, Indianapolis’s powerful black leaders, in working within the system of limitations to establish the Morgan Health Center in 1947. Ransom and Blackburn received monetary support from the United Fund, the Indianapolis Foundation, and the U.S. Children’s Bureau, which stationed one of its physicians, Walter H. Maddux, in Indianapolis. The Center also worked as a part of the Indianapolis City Board of Health’s public health program. These organizations and individuals did not support birth control at this time and would greatly influence Blackburn’s decision about providing contraceptives. In 1951, Planned Parenthood approached Blackburn about adding birth control to the services at Morgan Health Center. Blackburn refused, citing the Catholic influence on the Flanner House board. While acknowledging the anti-birth control stance of Indianapolis Catholics, the thesis focuses on other factors that contributed to Blackburn’s decision and argues that the position of Flanner House as a black organization funded by conservative white organizations had more impact than any religious sentiment; birth control would have been a liability for the Morgan Health Center as adding contraceptives could have threatened the funding the Center needed in order to serve the African American community. Finally, the position of Planned Parenthood and Flanner House as subordinate organizations operating within the limitations of Indianapolis society are compared and found to be similar.