Submitted by Raquel Vergara Gondran (raquelvergara38@yahoo.com.br) on 2016-03-09T01:00:32Z No. of bitstreams: 1 cynthia.pdf: 1044887 bytes, checksum: 467a79ec31cdc26531cdd2a5ba95a3de (MD5) / Approved for entry into archive by Lilian M. Silva (lilianmadeirasilva@hotmail.com) on 2016-03-13T15:51:35Z (GMT) No. of bitstreams: 1 cynthia.pdf: 1044887 bytes, checksum: 467a79ec31cdc26531cdd2a5ba95a3de (MD5) / Made available in DSpace on 2016-03-13T15:51:35Z (GMT). No. of bitstreams: 1 cynthia.pdf: 1044887 bytes, checksum: 467a79ec31cdc26531cdd2a5ba95a3de (MD5) Previous issue date: 2013 / A Atenção Primária em Saúde associada à estratégia Saúde da Família consolida a proposta de reorganização da atenção primária elencando com enfoque na comunidade, indivíduo e coletividade, apreendendo o ambiente de inserção dos sujeitos logo, a saúde socioambiental. No qual visualiza-se grupos organizados da comunidade com a finalidade de amenizar fatores determinantes à integralidade da saúde. Nesta abordagem, este estudo tem como objetivos: Caracterizar como a saúde ambiental encontra-se estudada na produção científica da enfermagem em saúde pública, para o desenvolvimento da saúde comunitária; Compreender a responsabilidade acerca da saúde da comunidade, por meio dos princípios da Atenção Primária Ambiental, na relação dos trabalhadores da saúde da família e dos participantes dos grupos organizados da comunidade; Apreender a contribuição mútua (mutualidade) para a saúde da comunidade, com foco na integralidade da saúde expressa pela base teórica dos Determinantes Sociais da Saúde, na relação dos trabalhadores da saúde da família e dos participantes dos grupos organizados da comunidade. O método constitui-se em duas etapas com a finalidade de alcançar os objetivos: revisão integrativa e; estudo qualitativo, exploratório e descritivo. A revisão foi realizada com o período de 1992 a 2012, em cinco bases de dados de impacto internacional, na temática em estudo, e utilizando-se das palavraschave Environmental Health, Public Health Nursing e Community. O estudo qualitativo, aprovado pelo Comitê de Ética sob parecer nº52/2008, foi conduzido por meio da entrevista e observação realizada com 70 participantes dos grupos organizados da comunidade e 58 trabalhadores da saúde. Para análise os dados foram transcritos e transferidos ao software NVIVO7.0, que mostrou a intensidade das citações para os princípios que fundamentam a APA: Participação da comunidade(222), lntegralidade(79), Organização(74), Prevenção e proteção ambiental(39), Solidariedade e equidade(20), e Diversidade(139) – associado à responsabilidade pela saúde da comunidade e participação coletiva na produção da saúde socioambiental; bem como destacou as categorias de análise delineadas pelo suporte teórico dos Determinantes Sociais de Saúde na abrangência da integralidade da saúde, as quais estão divididas em: Proximais(91), Intermediários(66); Distais(166). A produção internacional apresenta a relevância das relações na saúde pública, carregada de competências teóricas e práticas e compromisso social para minimizar iniquidades. Ratificada pelos princípios da atenção primária, que vem se consolidando na aproximação equipe-comunidade permite atuar na relação saúde e ambiente, o que fortalece responsabilidades e co-participação dos sujeitos à saúde socioambiental. A contribuição entre os trabalhos da equipe e grupos organizados proporcionam a geração da integralidade na saúde, fortalecida a partir da mutualidade no trabalho, visando minimizar os diferenciais determinantes. Desta forma, o conhecimento da enfermagem e sua atuação na produção da saúde socioambiental, favorecem a saúde na geração de sua integralidade, fortalecida a partir da mutualidade no trabalho. / The Primary Health Care Strategy associated with the Family Health consolidates the proposed reorganization of primary care enumerating focusing on community, individual and group, learning environment logo insertion of subjects, environmental health. In which visualizes organized community groups in order to mitigate the completeness determinants of health. In this approach, this study aims to characterize how environmental health is studied in the scientific literature of public health nursing for the development of community health; Understand the responsibility about the health of the community through the principles of Primary Environmental, the relationship of family health workers and participants of organized groups in the community; Apprehending the mutual contribution (mutuality) for community health, focusing on health completeness expressed by theoretical base on Social Determinants of Health, in relation health workers and family of the participants of organized groups in the community. The method consists in two steps in order to achieve the objectives: an integrative review and; qualitative study was exploratory and descriptive. A review conducted in the period from 1992 to 2012, in five databases of international impact, the thematic study, and using the keywords Environmental Health, Public Health and Community Nursing. The qualitative study, proved by the Ethics Committee under Opinion No 52/2008, was conducted by interview and observation conducted with 70 participants in organized groups and 58 community health workers. To analyze the data were transcribed and transferred to NVIVO7.0 software that showed the intensity of the citations to the principles underlying the APA: Community Participation (222), lntegralidade (79), organization (74), prevention and environmental protection ( 39), Solidarity and equity (20), and diversity (139) - associated with responsibility for the health of the community and collective participation in the production of environmental health, as well as highlighted the analysis categories outlined by the theoretical support of the Social Determinants of Health in scope comprehensiveness of health, which are divided into: Proximal (91), Intermediates (66); Distal (166). The production presents the relevance of international relations in public health, full of theoretical and practical skills and social commitment to minimize inequities. Ratified by the principles of primary care, which has been consolidating in the team approach enables communityoperate in relation health and environment, strengthening co-responsibility and participation subject to environmental health. The contribution of the work of organized groups and staff provide the generation of integral health, strengthened from the mutuality at work, aiming to minimize the differential determinants. Thus, knowledge of nursing and its role in the production of environmental health, health in favor of his generation, strengthened from the mutuality at work. / La Estrategia de Atención Primaria de Salud asociados con la salud de la familia se consolida la propuesta de reorganización de la enumeración de la atención primaria centrada en la comunidad, individual y grupal, el aprendizaje de inserción ambiente logotipo de los sujetos, la salud del medio ambiente. En la cual visualiza los grupos organizados de la comunidad con el fin de mitigar los factores determinantes de la exhaustividad de la salud. En este enfoque, el presente estudio tiene como objetivo caracterizar cómo la salud ambiental se estudia en la literatura científica de la enfermería de salud pública para el desarrollo de la salud de la comunidad; Comprender la responsabilidad por la salud de la comunidad a través de los principios de Primaria Ambiental, la relación de los trabajadores de salud de la familia y de los participantes de los grupos organizados de la comunidad; Aprehender la contribución mutua (mutualidad) para la salud de la comunidad, centrándose en la integridad de la salud expresado por la base teórica sobre los Determinantes Sociales de la Salud, en relación trabajadores de la salud y familiares de los participantes de los grupos organizados de la comunidad. El método consiste en dos pasos con el fin de lograr los objetivos: una revisión integradora y, estudio cualitativo fue exploratorio y descriptivo. Un análisis realizado en el período de 1992 a 2012, en cinco bases de datos de impacto internacional, el estudio temático, y el uso de las palabras clave de la Salud Ambiental, Salud Pública y Enfermería Comunitaria. El estudio cualitativo, organizado por el Comité de Ética bajo Dictamen n º 52/2008, se llevó a cabo mediante entrevistas y observación llevó a cabo con 70 participantes en grupos organizados y 58 trabajadores comunitarios de salud. Para analizar los datos se transcribieron y se transfiere a NVIVO7.0 software que muestra la intensidad de las citas de los principios que subyacen a la APA: Participación de la Comunidad (222), lntegralidade (79), la organización de protección (74), prevención y medio ambiente ( 39), la solidaridad y la equidad (20), y la diversidad (139) - relacionado con la responsabilidad de la salud de la comunidad y la participación colectiva en la producción de la salud ambiental, así como destacó las categorías de análisis esbozados por el soporte teórico de los Determinantes Sociales de la Salud en el ámbito exhaustividad de la salud, que se dividen en: proximal (91), intermedios (66); distal (166). La producción presenta la relevancia de las relaciones internacionales en materia de salud pública, llena de conocimientos teóricos y prácticos y el compromiso social para minimizar las inequidades. Ratificado por los principios de la atención primaria, que se ha ido consolidando en el trabajo en equipo permite operar en la comunidad en la salud y el medio ambiente respecto, el fortalecimiento de la corresponsabilidad y la participación sujeto a la salud del medio ambiente. La contribución del trabajo de los grupos organizados y el personal proporcionan la generación de la salud integral, el fortalecimiento de la reciprocidad en el trabajo, con el objetivo de minimizar los factores determinantes de diferenciales. Así, el conocimiento de la enfermería y su papel en la producción de la salud ambiental, la salud en favor de su generación, el fortalecimiento de la reciprocidad en el trabajo.

INTRODUÇÃO: O conceito de equidade enfatiza a diversidade como condição humana e propõe que a diferença seja tratada como princípio orientador das políticas públicas. O objetivo dessa investigação foi verificar a equidade na atenção à saúde de pessoas com indicativos de transtornos mentais comuns (TMC) na cidade de São Paulo. Foram analisadas a procura e utilização dos serviços de saúde, bem como o gasto com saúde no último mês de pessoas com indicativos de TMC, que referiram morbidade quinze dias precedentes à entrevista domiciliar, segundo características sociodemográficas e de condições de saúde. MÉTODOS: Foi realizado um estudo de corte transversal e utilizados os dados do Inquérito de Saúde no Município de São Paulo (ISA - Capital) de 2008. Foram selecionados sujeitos com 16 anos ou mais e com indicativos de transtornos mentais comuns; estes foram avaliados por meio do instrumento Self Reporting Questionnaire (SRQ-20). Foram analisados a procura e utilização de serviços de saúde, e o gasto com saúde no último mês, correlacionando com aspectos sociodemográficos e de condições de saúde. RESULTADOS: A procura pelo serviço de saúde foi menor entre as mulheres, maior na faixa etária dos 30 aos 44 anos e na faixa etária de 60 anos ou mais. A proporção de pessoas que procuraram pelo serviço e obtiveram atendimento foi elevada, o mesmo ocorreu para aquelas que procuraram por médico e foram atendidas por meio de consulta. A procura pelo SUS foi menor entre as pessoas de cor branca, de renda per capita elevada, com união estável e entre as pessoas com ensino superior. A cobertura pelo SUS foi menor para as pessoas das faixas etárias de 45 a 59 anos e de 60 anos ou mais, com renda per capita elevada, com Ensino Médio ou Técnico e Ensino Superior. As pessoas que gastaram mais com a saúde da família foram aquelas com idade igual ou superior a 60 anos, de cor branca, das faixas de renda per capita mais elevadas, com união estável e com Ensino Superior. Em relação à posse de plano de saúde, pessoas de cor branca, com renda per capita elevada e indivíduos com doença crônica apresentaram maiores chances de possuir este serviço. CONCLUSÕES: Foi observado, na população com indicativos de TMC, que não houve desigualdades no acesso e utilização dos serviços entre as pessoas que buscaram por ajuda diante de morbidade. Verificou-se que o SUS atende e cobre os gastos majoritariamente dos mais pobres, denotando uma cobertura desigual que favorece os mais necessitados, porém, considerando o fator idade, ficou explícita uma situação de iniquidade, pois foi constatado que o SUS oferece maior cobertura para a população mais jovem e não contempla as necessidades da população mais idosa. Além disso, verificou-se também uma demanda reprimida de pessoas que não acessaram o serviço, indicando barreiras que antecedem à busca / INTRODUCTION: The equity concept emphasizes diversity as a human condition and proposes this aspect as a guiding principle of the public policy. The objective of this investigation was to verify the equity in health care of people with signs of common mental disorders (CMD) in the city of São Paulo. We analyzed the demand and use of health services and the expenses on health in the last month of people with signs of CMD who reported morbidity 15 days before the home interview, according to socio-demographic characteristics and health conditions. METHODS: We developed a cross-sectional study and used the data from São Paulo\'s health survey (ISA - Capital) of 2008. We selected subjects with 16 years of age or older and with signs of common mental disorders; who were evaluated using the Self Reporting Questionnaire (SRQ-20). We analyzed the demand and the use of health services, and the health expenses in the last month, correlating them with sociodemographic and health condition aspects. RESULTS: The demand for health services was lower among women, higher in the age group from 30 to 44 years old and in the age group of 60 years old or more. The proportion of people who sought the service and were cared for was high, and the same thing happened to those who sought medical attention and had an appointment. The demand for SUS was lower among white people with high per capita income, married and among people with higher education degrees. The coverage of SUS was significantly lower for people aged between 45 and 59 years old and those aged 60 years old or more, with high per capita income, with high school, technical or college degree. The people who spent more on Family health were those with 60 years old or more, white, with high per capita income, married and with college degree. Regarding health care insurance ownership, white people with high per capita income and individuals with chronic diseases presented higher chances of owning a health care insurance. CONCLUSIONS: We observed, among people with signs of CMD, that there were no inequalities in the access and use of health services for those who sought for help faced with morbidity. We verified that SUS serves and covers the expenses mainly of the poorer, denoting an unequal coverage that favours the ones who need it the most, however, taking the age factor into account, a situation of inequity was explicit, since it was verified that SUS offers a wider coverage to the younger population and does not contemplate the needs of the elderly. In addition, there was also a repressed demand of people who could not access the health service, indicating barriers that precede the search

Foi realizado estudo caso-controle de base hospitalar, envolvendo pacientes diagnosticados com câncer de cabeça e pescoço e que participaram do \"Estudo Multicêntrico Latino-americano de Fatores Ambientais, Vírus e Câncer da Cavidade Oral e Laringe\" do projeto \"Genoma Clínico do Câncer\". Foram incluídos pacientes atendidos no Hospital Heliópolis, no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo e no Instituto do Câncer Arnaldo Vieira de Carvalho entre novembro de 1998 e dezembro de 2005. Consideraram-se casos os pacientes com diagnóstico histologicamente confirmado de câncer de boca, faringe ou laringe e controles pessoas atendidas nos mesmos hospitais por outros motivos que não neoplasia maligna e doenças associadas com os fatores de risco do câncer de cabeça e pescoço. A análise empregou regressão logística não-condicional baseada em modelo hierárquico de determinação. No nível mais distal foram incluídas as variáveis demográficas (sexo, cor de pele e idade), seguidas pela escolaridade (série mais elevada que a pessoa cursou) e ocupação (exercida por mais tempo). No nível mais proximal, foram considerados o consumo de tabaco e de álcool. Também foi investigado se a associação de instrução e ocupação com câncer de cabeça e pescoço se mediava apenas por padrões diferenciais de consumo de álcool e tabaco entre os estratos sociais, ou se havia variação residual que excedia esses dois fatores. Todas as análises conduzidas para câncer de cabeça e pescoço foram replicadas de modo específico para as localizações topográficas da boca, faringe e laringe em separado. O estudo foi aprovado pelo Comitê de Ética da Faculdade de Odontologia da Universidade de São Paulo sob parecer no. 68/07 e os procedimentos estatísticos foram realizados no programa Stata 9. A amostra foi composta por 1017 casos e 951 controles. A análise hierárquica identificou maior chance de câncer de cabeça e pescoço entre os homens (OR=2,01; IC95% 1,57-2,59), pessoas entre 48 e 55 anos (OR=1,82; IC95% 1,42-2,33), pessoas sem estudo ou apenas alfabetizados (2,48; IC95% 1,73-3,52), entre pessoas com primeiro grau completo ou incompleto (1,31; IC95% 1,05-1,63) e entre as pessoas que exerceram durante mais tempo profissão manual (1,38; IC95% 1,10-1,74). Além disso, fumantes e consumidores de bebidas alcoólicas apresentaram maior razão de chances em relação àqueles que nunca consumiram os produtos. No modelo não hierárquico, mesmo após o ajuste por tabagismo e ingestão de álcool, maior chance foi verificada para o grupo de menor escolaridade em todas as localizações topográficas (exceto para os tumores de boca), e para pessoas com ocupações manuais (exceto para os tumores de boca e faringe). A identificação desse efeito residual indica haver fatores adicionais, além da exposição ao álcool e tabaco, operando na distribuição desigual do câncer de cabeça e pescoço entre os estratos sociais. / This is a hospital-based case-control study involving patients diagnosed with head and neck cancer. Such patients have participated in the \"Latin American Multicentric Study from Environmental Factors, Virus and Oral Cavity and Larynx Cancer\", and in the \"Clinical Genome of Cancer Project\", from November 1998 to December 2005, and were attended at the Hospital Heliópolis, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo and Instituto do Câncer Arnaldo Vieira de Carvalho. The case group comprised patients histologically diagnosed with mouth, pharynx or larynx cancer; the control group comprised patients treated at the same hospitals for other diseases than malignant neoplasms or conditions related to head and neck cancer risk factors. Data analysis used non-conditional logistic regression based on a hierarchical model of determination. At the most distal level, demographic variables were included (e.g. sex, skin color and age), followed by education level (e.g. highest grade or degree completed) and occupation (i.e. the one performed the longest period). Alcohol and tobacco consumption were included at the most proximal level. The investigation also assessed whether the association between education level and occupation with mouth and neck cancer was only mediated by differential patterns of alcohol and tobacco consumption among social strata, or there was residual variation that exceeded those two factors. All analyses for mouth and neck cancer were specifically replicated for each topographic location (mouth, pharynx and larynx). The study was approved by the University of Sao Paulo School of Dentistry\'s Ethics Committee, report number 68/07, and statistical analyses used the Stata 9 program. The sample was composed of 1017 cases and 951 controls. Hierarchical analysis identified a greater chance of head and neck cancer for men (OR=2,01; CI95% 1,57-2,59), patients aged 48 to 55 years old (OR=1,82; CI95% 1,42-2,33), uneducated or semi-literate patients (2,48; CI95% 1,73-3,52), subjects with elementary education (8 years) (1,31; IC95% 1,05-1,63) and those performing manual occupations (1,38; CI95% 1,10-1,74). In addition, tobacco smokers and alcohol users presented a higher odds than those non-exposed to these conditions. In the non-hierarchical model, even after the adjustment for tobacco and alcohol use, a higher odds was identified for the less-schooled strata in every topographic location (except for mouth tumors), and for subjects with manual labor occupations (except for mouth and pharynx tumors). Identification of such residual effect indicates that there are other factors than alcohol and tobacco consumption, which mediate the uneven distribution of head and neck cancer across the socioeconomic strata.

Um terço dos casos de carcinoma cervical ocorre no período reprodutivo. Sendo que, cerca de 3% dos diagnósticos são realizados durante a gravidez. Evidências atuais indicam que as gestantes apresentam maior chance de terem diagnosticadas lesões iniciais. Pois a gravidez é uma excelente oportunidade para o rastreio desta neoplasia, já que faz parte da rotina pré-natal o exame ginecológico. No entanto, na prática esta oportunidade parece não estar sendo aproveitada na sua totalidade. Com este estudo objetivou-se avaliar o conhecimento das puérperas sobre a prevenção do carcinoma cervical, descrever características associadas a não realização do citopatológico nos últimos três anos e comparar a cobertura da citologia no início e no final do pré-natal. Trata-se de uma avaliação transversal realizada na cidade de Rio Grande-RS, entre maio e junho de 2007. A amostra foi calculada pelo programa Epi-Info 6.04, totalizando 224 puérperas. Durante a internação hospitalar foi aplicado às puérperas um questionário estruturado e pré-codificado. Os dados foram digitados no Epi-Info 6.04, sendo a analise bruta realizada no software SPSS e a multivariada pela Regressão de Poisson no programa Stata. Das 230 puérperas entrevistadas 96,5% referiram conhecer o exame preventivo do câncer do colo uterino. Apesar disso, a prevalência de citopatológico nos últimos 36 meses era de 32,6% no inicio da gestação, chegando a 55,2% no puerpério. Mostrando a associação positiva do pré-natal na cobertura do citopatológico (p>0,001). Mesmo assim, 74 puérperas (32,2%) permaneceram sem nunca terem coletado o citopatológico e 29 (12,6%) continuaram com a citologia desatualizada. Na análise bruta, o grupo de puérperas com idade igual ou inferior a 19 anos, não brancas, de escolaridade igual ou inferior a oito anos, com renda familiar per capita inferior a um salário mínimo, início da vida sexual aos 15 anos ou menos, com inicio do pré-natal no 2º e 3º trimestres, que realizaram cinco consultas ou menos e que fizeram o acompanhamento no SUS, apresentaram diferenças estatísticas significantes para uma menor cobertura do exame citopatológico ao final do pré-natal. Após a análise ajustada, o grupo que consultou no Hospital Universitário da Fundação Universidade Federal do Rio Grande - FURG (IC95%: 0,18 0,82) e as puérperas com idade entre 25 a 29 anos (IC95%: 0,29 0,90), mostraram-se significativamente associadas à melhora da cobertura do citopatológico nos últimos três anos. Portanto, evidenciou-se neste estudo que apesar do pré-natal ter melhorado a cobertura do exame citopatológico. O serviço local de saúde mostra-se pouco efetivo pois cobriu menos mulheres do que o preconizado, e desigual porque o acesso ao exame variou conforme algumas características das usuárias. Além disso, os critérios epidemiológicos de risco para o carcinoma cervical não foram priorizados pela assistência médica. Os resultados revelam a necessidade de aumentar a cobertura do citopatológico e melhorar a qualidade da atenção pré-natal oferecida em Rio Grande. Motivando e capacitando os profissionais de saúde quanto à importância dos procedimentos da rotina pré-natal, pois apenas as gestantes que consultaram no Hospital Universitário da FURG tiveram a cobertura do citopatológico próxima do preconizado pela Organização Mundial da saúde. / One third of the cases of cervical carcinoma occur during the reproductive period and approximately 3% of the diagnoses are made during pregnancy. Current evidence indicates that pregnant women have a better chance of having early lesions diagnosed. Thus, pregnancy represents an excellent opportunity for the screening for this neoplasia, since gynecological examination is part of routine prenatal care. However, in practice this opportunity does not seem to be fully explored. The objective of the present study was to assess the knowledge of puerperae about the prevention of cervical carcinoma, to describe the characteristics associated with the lack of cytopathological examination during the last three years, and to compare the cytology coverage at the beginning and at the end of the prenatal care period. This was a cross-sectional evaluation performed in the city of Rio Grande-RS from May to June 2007. Sample size was calculated using the Epi-Info 6.04 software and corresponded to 224 puerperae. A structured and pre-coded questionnaire was applied to the puerperae during hospitalization. The data were entered in the Epi-Info 6.04 and crude analysis was performed using the SPSS software and multivariate analysis using Poisson regression and the Stata software. Of the 230 puerperae interviewed, 96.5% reported that they knew about the preventive exam for cancer of the uterine cervix. Nevertheless, the prevalence of cytopathological examination in the last 36 months was 32.6% at the beginning of pregnancy, reaching 55.2% during the puerperium, showing a positive association of prenatal care with cytopathological examination (p>0.001). Even so, 74 puerperae (32.2%) had never been submitted to cytopathological examination and 29 (12.6%) had out of date cytology. Crude analysis revealed that the group of puerperae aged 19 years or younger, non-white, with schooling of eight years or less, with a per capita income of less than one minimum wage, with the beginning of sex life at 15 years of age or less, with the beginning of prenatal care in the 2nd and 3rd trimester, who had received five visits or less and who had been followed up at the Unified Health System (SUS) differed in a statistically significant manner regarding a lower cytopathological examination coverage at the end of prenatal care. After adjusted analysis, the group seen at the University Hospital of Fundação Universidade Federal do Rio Grande FURG (95% CI: 0.18 0.82) and the puerperae aged 25 to 29 years (95% CI: 0.29 0.90) showed a significant association with better cytopathology coverage over the last three years. Thus, the present study demonstrated that, even though prenatal care improved the coverage of cytopathological examination, the local health service proved to be poorly effective since it covered fewer women than recommended, and unequal since access to the exam varied according to some characteristics of the users. In addition, the epidemiological criteria of risk for cervical carcinoma were not a priority for the providers of medical care. These results reveal the need to expand the coverage of cytopathological examination and to improve the quality of the prenatal medical care offered in Rio Grande. There is a need to motivate and qualify the health professionals regarding the importance of routine prenatal procedures since only the pregnant women seen at the University hospital of FURG received cytopathological coverage similar to that recommended by the WHO.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-10-05T15:24:46Z No. of bitstreams: 1 mariocirionogueira.pdf: 2341743 bytes, checksum: 751ca181e6b626c41d8a9be1725de0a9 (MD5) / Approved for entry into archive by Diamantino Mayra (mayra.diamantino@ufjf.edu.br) on 2016-10-06T12:30:12Z (GMT) No. of bitstreams: 1 mariocirionogueira.pdf: 2341743 bytes, checksum: 751ca181e6b626c41d8a9be1725de0a9 (MD5) / Made available in DSpace on 2016-10-06T12:30:12Z (GMT). No. of bitstreams: 1 mariocirionogueira.pdf: 2341743 bytes, checksum: 751ca181e6b626c41d8a9be1725de0a9 (MD5) Previous issue date: 2009-02-04 / As doenças do aparelho circulatório (DAC) são as principais causas de morte em Juiz de Fora, no Brasil e na maioria dos países do mundo. A distribuição espacial da mortalidade por DAC em grandes cidades não é homogênea: regiões com piores condições sociais têm maiores taxas de mortalidade. A mortalidade precoce por estas doenças também está relacionada às condições socioeconômicas da região de moradia. As técnicas de análise espacial em saúde permitem estudar os fatores socioambientais como possíveis determinantes de doenças no nível populacional. Dentre estes fatores, os mais utilizados são indicadores de renda, escolaridade, saneamento básico e estrutura do domicílio, obtidos dos censos demográficos decenais do IBGE. O indicador sintético Índice de Desenvolvimento Social (IDS) foi criado para comparar o desenvolvimento social de áreas geográficas de mesma natureza, sendo composto pela média aritmética de dez indicadores do censo demográfico. O objetivo deste trabalho foi analisar a distribuição espacial da mortalidade por DAC nas regiões urbanas (RU) de Juiz de Fora e sua relação com fatores socioeconômicos, especialmente o IDS. Utilizou-se delineamento ecológico, do tipo análise espacial em saúde, com as 81 RU como unidades de análise. Foram usadas técnicas exploratórias de análise de dados espaciais, como medidas de autocorrelação espacial e estimadores bayesianos empíricos. Para investigar a desigualdade na mortalidade por doenças cardiovasculares foram aplicadas as técnicas estatísticas: teste t, teste de Mann-Whitney, análise de variância, análise de correlação e análise de regressão. A relação entre mortalidade por DAC e os indicadores foi investigada com a aplicação de modelos lineares generalizados de Poisson. Devido à presença de super-dispersão, foram ajustados também modelos de quase-Poisson e binomiais negativos. Os resultados indicam que a mortalidade cardiovascular no espaço urbano de Juiz de Fora está associada às condições socioeconômicas do local de residência. A diminuição das desigualdades socioeconômicas em cidades de porte médio pode levar a reduções importantes nas iniquidades em saúde. / The cardiovascular diseases (CVD) are the main causes of death in Juiz de Fora, in Brazil and in most countries. The spatial distribution of CVD mortality in large cities is not homogeneous: regions with worse social conditions have bigger mortality rates. Premature CVD mortality is also related to socioeconomic conditions of neighborhood. The techniques of spatial analysis in health allow to study socioambiental factors as possible determinants of diseases at the population level. Amongst these factors, the most used are education, income and sanitation indicators from national census. The synthetic indicator Índice de Desenvolvimento Social (IDS) was created to compare the social development of similar geographic areas and is composed by the arithmetic mean of ten indicators of national census. The objective of this work was to analyze the spatial distribution of mortality due to CVD in urban regions (RU) of Juiz de Fora and its relationship with socioeconomic factors, especially the IDS. The design of study was ecological, subtype spatial analysis in health, with the 81 RU as units of analysis. It was employed exploratory techniques like measures of spatial autocorrelation and empirical bayesian estimators. To investigate inequalities in CVD mortality were aplied the statistic tests: t test, Mann-Whitney test, variance analysis, correlation analysis and regression analysis. The relationship between CVD mortality and socioeconomic indicators was investigted by Poisson generalized linear models. Due to over-dispersion of data, quasi-Poisson and negative binomial models were also fitted. Results indicate that CVD mortality in urban space of Juiz de Fora is associated with socioeconomic conditions of neighborhood. The reduction of socioeconomic inaqualities in middle cities could induce important reductions in health iniquities.

Background Migrants in many European countries including Germany tend to utilize preventive measures less frequently than the majority population. Little is known about the dental health of migrants as well as about their oral health behaviour, particularly in the adult population. The aim of this study was to examine differences in the uptake of annual dental check-ups in adult migrants and non-migrants in Germany. Methods We used data from the cross-sectional survey ‘German Health Update 2010’ conducted by the Robert Koch Institute (n = 22,050). Data from 21,741 German-speaking respondents with information on the use of dental check-ups was available, of which 3404 (15.7%) were migrants. Multiple logistic regression models were applied to adjust for demographic and socioeconomic confounders, including the place of residence as well as type of health insurance. Results Migrants were generally younger, had a lower socioeconomic status and showed a lower utilization of dental check-ups. The unadjusted odds ratio (OR) for utilization was 0.67 (95%-CI = 0.61–0.73). After adjusting for demographic and socioeconomic confounders the chance only increased slightly (adjusted OR = 0.71; 95%-CI = 0.65–0.77). Conclusions The analysis shows that migration status is associated with a reduced chance of attending dental check-ups, independently of demographic and socioeconomic factors. The influence of other factors, such as type of health insurance and place of residence had also no influence on the association. Migrants are exposed to different barriers in the health care system, comprising the patient, provider and system level. Further studies need to examine the relevant barriers for the uptake of preventive dental services in order to devise appropriate migrant- sensitive measures of dental prevention.

Cette thèse de doctorat met l’emphase sur les défis rencontrés par les patients atteints de maladies rares. Elle est structurée en trois parties, chacune d’entre elles dédiée aux enjeux d’un acteur au cœur de l’Odyssée diagnostique et thérapeutique des patients atteints de maladies rares. La première partie de la thèse s’intéresse au patient et à son réseau social. Le chapitre 1 considère les sources de délai à l’accès au diagnostic, et explore notamment l’effet du capital social sur le délai d’obtention du diagnostic. Le chapitre 2 évoque les externalités négatives sur la santé maternelle d’un diagnostic d’une maladie chronique chez l’enfant. La seconde partie de la thèse est dédiée à l’industrie pharmaceutique et s’intéresse aux décisions d’investissements de R&D ciblant les maladies rares. Le chapitre 3 évalue l’effet causal de l’Orphan Drug Policy sur l’effort de recherche, et le chapitre 4 envisage les inégalités d’allocation des investissements de R&D entre les maladies rares. La partie 3 est dédiée aux décideurs publics et discute des enjeux d’évaluation des bénéfices de l’innovation thérapeutique et de la définition des conditions d’accès à cette innovation. Le chapitre 5 évalue l’effet causal de l’innovation thérapeutique sur la longévité des patients atteints de maladies rares. Le chapitre 6 est une discussion critique relative à l’utilisation d’outils. / This dissertation emphasizes the challenges raised by the management of rare diseases and is structured around three key actors of the diagnostic and therapeutic “odyssey” of patients with rare diseases. Part I is devoted to patients and their social networks. Chapter 1 considers demand-side sources of delay in receiving a diagnosis; Chapter 2 explores the health spillover effects from patients’ health to their direct support structure. Part II considers pharmaceutical firms and examines how firms’ decisions to allocate R&D investment to rare diseases are impacted by innovation policies in rare arenas. Chapter 3 evaluates the causal impact of the EU Orphan Drug policy on R&D efforts in orphan drugs, while Chapter 4 investigates the inequality in allocation of R&D investment within rare diseases. Part III focuses on policymakers and addresses the issues in measuring pharmaceutical innovation benefits along with costs in rare disease arenas, while considering the opportunity cost of healthcare expenditures. Chapter 5 measures the causal impact of pharmaceutical innovation in rare diseases on longevity, while Chapter 6 is a critical discussion of decision-making tools for rational allocation of healthcare resources, and the use of a cost-effectiveness threshold.

Objectifs. Pour augmenter l’activité physique populationnelle et réduire les inégalités relatives à l’environnement bâti, on doit identifier le rôle des profils sociodémographiques individuels dans les niveaux d’activité physique et d’exposition aux environnements bâtis favorables au mode de vie actif. Méthodes. Cette étude combine des données d’accélérométrie et de GPS collectées auprès de 820 participants durant 10 à 30 jours entre 2018 et 2020 dans les études INTErventions urbaines, Recherche-Action, Communautés et sanTé (INTERACT) et Réseau Express Métropolitain (REM). Différents modèles de régressions multiniveaux ‒journées nichées dans des individus‒ testent les associations et les interactions entre les profils sociodémographiques, les niveaux d’exposition à des facteurs environnementaux susceptibles de favoriser le mode de vie actif (infrastructures de transports, commerces, densité bâtie et espaces verts) et la proportion journalière de minutes actives. Les résultats sur l’échantillon de l’application EthicaData sont comparés à ceux sur l’appareil SenseDoc. Résultats. Les participants plus âgés, universitaires ou sans emploi ainsi que les femmes sont moins actifs. Les participants plus âgés, non-universitaires, sans emploi ou à haut revenu ainsi que les hommes sont moins exposés à l’environnement bâti favorable à l’activité physique. Discussion. Les niveaux d’activité physique et d’exposition à l’environnement bâti ainsi que les effets de l’exposition environnementale ne varient pas systématiquement en défaveur des groupes désavantagés systémiquement. Des associations sont inattendues entre l’exposition à l’environnement bâti et le mode de vie actif. Les résultats basés sur le GPS sont concordants entre EthicaData et SenseDoc, mais discordants pour ceux basés sur l’accélérométrie. / Aim. To increase population levels of physical activity and reduce inequalities related to built environment, we must identify the role of individual-level sociodemographic profiles in physical activity levels, and in levels of exposure to built environment that may contribute to active living. Method. This study combines accelerometry and GPS data collected among 820 participants during 10 to 30 days between 2018 and 2020 within the INTErventions, Research, and Action in Cities Team (INTERACT) and Reseau Express Metropolitain (REM) studies. Multiple multilevel models ‒days nested within individuals‒ test associations and interactions between socio demographic profiles, levels of exposure to environmental factors susceptible to promote active living (transport infrastructures, shops, built density and green spaces) and the daily proportion of active minutes. Results on the EthicaData application subset are compared to those on the SenseDoc device subset. Results. Participants who are older, have a university profile or are unemployed, along with women, are less active. Participants who are older, don’t have a university profile, are unemployed or have a higher income, along with men, are less exposed to built environment that may contribute to physical activity. Discussion. The levels of physical activity and exposure to built environment, and the effects of environmental exposure on physical activity, do not vary systematically in disfavor of systemically disadvantaged groups. Some associations between exposed built environment and active living are unexpected. Results based on the GPS are consistent between EthicaData and SenseDoc, but inconsistent for those based on accelerometry.

No description available.

Problématique : Alors que l’on connaît depuis plusieurs décennies les conséquences dramatiques des injustices sociales sur la santé, il existe un profond problème d’application des connaissances pour informer les pratiques et/ou les politiques. Au-delà d’un manque de prise en compte des connaissances pour l’action, il semblerait que la difficulté à lutter contre les inégalités soit plutôt liée à l’enracinement des systèmes de production et d’utilisation des connaissances dans des structures injustes. Approche théorique et cadre conceptuel : Cette thèse s’inscrit dans la quatrième vague de recherche sur le transfert de connaissances qui consiste à mieux comprendre les caractéristiques sociales des connaissances. En d’autres mots, il s’agit d’intégrer une approche d’épistémologie sociale dans la recherche sur le transfert de connaissances. Nous nous intéressons spécifiquement au concept d’oppression épistémique qui consiste en la répétition dans la durée de trois degrés d’exclusions épistémiques. L’exclusion de troisième degré représente un mode de vie épistémique qui est dirigé par des groupes sociaux dominants, qui ne permet pas de prendre en compte d’autres systèmes de pensée et de connaissances que les leurs. L’exclusion de second degré est le fait, pour des individus déjà opprimés socialement, de devoir utiliser des ressources qui ne sont pas les leurs, pour pouvoir participer à la construction de nouvelles ressources communes dans ce système. L’exclusion de premier degré concerne l’impossibilité, pour des individus, d’être considéré comme des « connaisseur·ses » du fait de préjugés à leur encontre. Cette thèse vise à analyser comment les pratiques quotidiennes et le contexte de la santé mondiale favorisent une oppression épistémique. Méthodologie : Nous étudions trois phénomènes correspondant aux trois degrés d’exclusion épistémique, en suivant une échelle d’analyse à trois niveaux (macroscopique, mésoscopique, microscopique) qui rappellent les trois branches de l’épistémologie sociale (système, groupe, individus). Pour cela, nous étudions en premier lieu la construction d’une ressource épistémique commune en santé mondiale à un niveau macroscopique : la couverture santé universelle (CSU) grâce à une revue critique des écrits. En deuxième lieu, nous étudions l’appropriation de cette ressource épistémique à un niveau mésoscopique, et la manière dont un groupe de scientifiques prend ou non en compte des voix dissidentes, en promouvant une définition différente de la CSU. Pour cela, nous réalisons une étude de cas d’un programme de recherches interventionnelles sur la CSU. En troisième lieu, nous étudions le rôle de la source des connaissances sur leur perception grâce à une expérimentation en santé mondiale. Résultats : À travers l’avènement de la CSU, nous observons la présence d’un pouvoir productif qui, tout en donnant l’impression d’une approche ancrée dans les droits humains et inclusive, favorise une conception marchande de la santé, menée par un « centre » de la santé mondiale. Nous avons également observé que l’appropriation de la CSU dans un programme de recherches interventionnelles n’a pas permis de créer une définition dissidente de la CSU. Plusieurs alliances épistémiques, c’est-à-dire des affiliations entre membres partageant la même orientation des études pour analyser la CSU sont apparues : une alliance santé publique, une alliance économique, une alliance anthropologique et une alliance critique. Cette dernière, qui proposait une réflexion globale sur la déconstruction et la gouvernance de la CSU, a été manquée, du fait d’inégalités concomitantes. Enfin, nous avons pu voir à un niveau microscopique que le « messager » peut être plus important que le « message » et participer à invisibiliser ou diminuer certaines voix dans la gouvernance globale en santé. Discussion et valeur ajoutée de la thèse : Les trois degrés d’exclusion épistémiques peuvent s’entrevoir de façon complémentaire. Du fait de la proximité des mondes scientifique et politique, et de la volonté de produire des connaissances pour l’action en santé mondiale, l’avènement de la CSU peut influencer la manière dont les scientifiques s’approprient ce concept. Cela peut limiter les possibilités de diversité épistémique et favoriser l’exclusion de certaines voix. À l’inverse, le sentiment d’exclusion peut conduire à se limiter dans sa contribution intellectuelle. Partant du postulat dont chacun·e de nous peut participer à changer les structures qui créent les injustices, en résistant à l’oppression épistémique, nous proposons un continuum d’actions pour lutter contre les inégalités dans la gouvernance globale en santé. / Background: The dramatic consequences of social injustice on health have been known for several decades, but social injustice also has an impact on knowledge translation. Rather than relating to a lack of knowledge uptake for action, the difficulty in addressing inequalities connects to knowledge production and use systems rooted in unjust structures. Theoretical approach and conceptual framework: This thesis aims to better understand the social characteristics of knowledge, and explores the integration of a social epistemology approach into knowledge translation research. We specifically focus on epistemic oppression, which consists of the repetition over time of three types of mutually reinforced epistemic exclusion. One type applies to an epistemic way of life led by dominant social groups, who prevent new systems of thought and knowledge, different from their own, to surface. A second type relates to socially oppressed individuals who must use resources they do not own to contribute to the construction of new common resources within the dominant system. The last type of epistemic exclusion consists of the impossibility of individuals being recognized as "knowers" because of prejudices that make them appear illegitimate. This thesis aims to analyze how everyday practices and the global health context foster epistemic oppression. Methodology: We study three processes, each related to a type of epistemic exclusion and following a three-level scale of analysis (macroscopic, mesoscopic and microscopic), which also covers the three branches of social epistemology (system, group and individual). First, we focus on the construction of an epistemic resource in global health at a macroscopic level, namely, universal health coverage (UHC), through a critical review of the literature. Secondly, we study the appropriation of this epistemic resource at a mesoscopic level, and how a group allows or does not allow dissenting voices, thus promoting a different definition of UHC. To this end, we conduct a case study of an interventional research program on UHC. Finally, we elaborate on the role of knowledge sources on the perception of knowledge through an experiment in global health. Results: The case of UHC demonstrates the existence of a productive power that, while giving the impression of an inclusive human approach, favours a market-based conception of health led by a global health "centre". We also observed that the appropriation of UHC in an interventional research program did not create a dissident; unorthodox definition of UHC. Several epistemic alliances (i.e. affiliations between members sharing the same orientation of studies to analyse UHC), emerged: a public health alliance, an economic alliance, an anthropological alliance, and a critical alliance. The latter, which suggested a global reflection on the deconstruction and governance of the UHC, did not occur because of concomitant inequalities. Finally, at a microscopic level, we showed that the "messenger" can be more important than the "message" when disseminating knowledge. Discussion and research value: The three types of epistemic exclusion can be read complementarily. Due to the proximity of the scientific and political worlds, and the desire to produce knowledge for action in global health, the social construction of UHC may influence how scientists appropriate this concept. It may limit the possibilities of epistemic diversity, and thus promoting the exclusion of some voices and points of view. A feeling of exclusion can, in turn, lead to self-limitation. Based on the premise that everyone can contribute to changing the structures that create injustice by resisting epistemic oppression, we propose a continuum of actions to address inequalities in global health governance.