By 2020, cancer mortality rates are estimated to increase by 180% in Arab countries, where breast cancer is the most common type of cancer. This thesis explores and evaluates the ‘asabiyya-driven structuration (the cohesive force of the group that gives it strength in facing its struggles for progressive reproduction) of cancer agents, government agents, and the World Health Organization agents for breast cancer prevention and early detection in the Arab region. The layers of the philosophical standing from Ibn Khaldûn’s concept of ‘asabiyya and the theoretical foundation of social systems theory, structuration theory, social network analysis, and social capital theory are peeled in order to explore and evaluate the context, constraints, social networks, autopoiesis, and social capital. Utilizing a qualitative research design, this thesis employs content analysis and in-depth interviews, as well as NVivo as a tool for analysis. Data is collected from 122 publications and knowledgeable informants employed by cancer agencies, ministries of health, and World Health Organization offices in Egypt, Jordan, Morocco, and Oman. The findings are divided into the contextual scope of responsibility and resources, the progressive and hierarchal constraining structure, the optimal and weak social networks, the strong and vulnerable shields of autopoiesis, and the presence and absence of social capital momentum, followed by a discussion on the the struggle for structuration against breast cancer. The findings demonstrate that countries with a national cancer control program witness local strengthening ‘asabiyya and ‘asabiyya-driven structuration, while those without a national cancer control program witness weakening local ‘asabiyya. Ultimately, this thesis proposes strategic recommendations to accelerate the regional ‘asabiyya-driven structuration of breast cancer.

Introdução O Transtorno de Déficit de Atenção/hiperatividade (TDAH) tem sido muito estudado, mas informações econômicas referentes ao seu tratamento com o metilfenidato de liberação imediata (MFD-LI) ainda necessitam ser exploradas. Grande parte da população mundial, principalmente aqueles que vivem em países em desenvolvimento, utiliza essa formulação como principal escolha para o tratamento do TDAH. Esses países, por sua condição financeira, necessitam informações de análises econômicas para administrar de forma eficiente os recursos públicos destinados aos setores da saúde. Objetivos Avaliar a eficácia do MFD-LI através de estudos com tempo superior a 12 semanas, e realizar uma análise econômica para o tratamento do TDAH com MFD-LI para crianças e adolescentes brasileiros. Método O estudo foi planejado em cinco etapas: 1) estimativa de custo do não tratamento do TDAH para o Brasil, e estimativa de economia com tratamento com MFD-LI; 2) revisão sistemática da literatura nas principais bases de dados internacionais onde se buscaram estudos abertos com tratamento do TDAH com MFD-LI por tempo igual ou superior a 12 semanas; também foram feitas metanálises e uma metaregressão 3) estudo naturalístico para obterem-se dados de uma amostra brasileira referentes a probabilidades de uso e sucesso com tratamento com MFD-LI por 12 semanas, e estimar os utilities desses indivíduos; 4) painel Delphi com especialistas em TDAH no Brasil; 5) estudo de custo-efetividade para o tratamento do TDAH com MFD-LI no Brasil, utilizando um Modelo de Markov. A perspectiva adotada será a do sistema público de saúde brasileiro como pagador. Resultados Os resultados principais encontrados para cada uma das etapas foram: 1) a estimativa de custos anuais com o TDAH não tratado no Brasil foi de R$ 1.594 bilhões/ano, e da quantia que poderia ser economizada se tratado, R$ 1 bilhão/ano. 2) na revisão sistemática da literatura, de 4.498 resumos, sete foram incluídos para compor a metanálise. O tempo de tratamento variou entre 13 e 104 semanas. O efeito agregado para desatenção e hiperatividade medida pelos pais, respectivamente, foi 0.96 (95%CI 0.60 - 1.32) e 1.12 (95%CI 0.85 - 1.39), e pelos professores 0.98 (95%CI 0.09 - 1.86) e 1.25 (95% CI 0.7 - 1.81). A metaregressão não mostrou associação entre as variáveis idade, qualidade do artigo e tempo de tratamento com heterogeneidade. 3) no estudo naturalístico, de 171 pacientes avaliados, 73 forneceram informações para o baseline, e 56 para a 12a semana de tratamento com MFD-LI. Os utilities para um paciente com TDAH não tratado (baseline) foram 0.69 (crianças) e 0.66 (adolescentes), e estimaram-se ganhos entre 0.09 a 0.10 utilities/mês, se tratados adequadamente. 4) no painel Delphi, de 26 especialistas, 14 responderam o questionário online, e foi estimado que a probabilidade dos pacientes não tratados se manterem sintomáticos na 12a semana seria de 91%, e 9% a probabilidade de melhora espontânea; 5) no estudo de custo-efetividade, para o caso base, estimou-se que o Incremental Cost Effectiveness Ratio (ICER) seja I$9,103/QALY (Quality Adjusted Life Years) para crianças e I$11,883/QALY para adolescentes em um horizonte temporal de 06 anos. Para os cenários mais desfavoráveis, os ICERS mais elevados foram I$95,164/QALY para 50% de sucesso com o tratamento, e I$15,000/QALY para 70% de adesão em um horizonte temporal de 06 anos. Conclusões O MFD-LI é um tratamento eficaz para crianças e adolescentes, por um período superior a 12 semanas. Entretanto, o Brasil pode estar aumentando os custos referentes à saúde por não estar fornecendo um tratamento eficaz e economicamente acessível para o TDAH. O tratamento mostrou ser uma opção custo-efetiva para crianças e adolescentes brasileiros, mesmo em cenários desfavoráveis para o tratamento. / Introduction Attention-Deficit/Hyperactivity Disorder (ADHD) is a well-known psychiatric disorder, but some economical aspects of the treatment with Methylphenidate Immediate-release (MPH -IR) still need to be explored. A large number of people around the world, most living in Low-Middle Income Countries (LMIC), use this formulation as the first choice for ADHD treatment. These countries, due to their financial condition, need information from health economic analyzes to efficiently manage the public resources allocated to the health sector. Objective To study the efficacy of MPH-IR reviewing studies conducted for more than 12 weeks long, and to perform an economic analysis for the treatment of ADHD with MPH-IR for Brazilian children. Method The study was planned in a five stages process: 1) to estimate the cost of untreated ADHD for Brazil, and to estimate the savings if MPH-IR were adequately provided; 2) systematic review of the literature to identify papers published where young patients with ADHD were treated with MPH-IR for more than 12 weeks, and to perform a meta-analysis and a meta-regression; 3) to conduct a naturalistic study with a Brazilian sample to collect the probabilities of use and success with the MPH-IR treatment for 12 weeks, and to estimate the utilities; 4) to perform a Delphi panel with ADHD Brazilian experts; 5) to conduct a cost-effectiveness analysis for the treatment of ADHD with MPH-IR in Brazil, using a Markov model. The perspective is the one of the Brazilian public health system as the payer. Results The main findings for each step were: 1) the estimated annual expenditures with untreated ADHD in Brazil were R$1.594billon/year, and the estimated amount that could be saved was R$1billion/year; 2) in the systematic review, from 4,498 abstracts, 7 studies were selected. The length of treatment ranged from 13 to 104 weeks. The aggregate effects for inattention and hyperactivity, according to parents evaluations were respectively 0.96 (95%CI 0.60 - 1.32) and 1.12 (95%CI 0.85 - 1.39), and for teachers 0.98 (95%CI 0.09 - 1.86) e 1.25 (95% CI 0.7 - 1.81). There was no evidence of association between heterogeneity and the variables, age, paper quality and length of treatment; 3) in the naturalistic study, from 171 patients assessed, 73 provided information in the baseline, and 56 in the 12th week of MPH-IR treatment. Utilities for an untreated ADHD patient (baseline) were 0.69 (children) and 0.66 (adolescents), and it was estimated a gain ranging from 0.09 to 0.10 utilities/month if subjects were properly treated; 4) in the Delphi Panel, 26 experts were addressed and 14 filled in the online questionnaire. It was estimated the probability of untreated patients to remain symptomatic on the 12th week to be 91%, and the probability of spontaneous improvement, 9%; 5) in the cost-effectiveness analysis, for the base case, it was estimated an Incremental Cost Effectiveness Ratio (ICER) of I$9,103/QALY (Quality Adjusted Life Years) for children and I$11,883/QALY for adolescents, in a time horizon of 6 years. The worst case scenarios were also tested, and the highest ICER were I$95,164/QALY when patient reached 50 % of success with the treatment, and I$15,000/QALY if only 70% of use was observed in a time horizon of 6 years. Conclusions MPH-IR is an efficacious treatment for ADHD children and adolescents for periods longer than 12 weeks. However, Brazil may be probably wasting money due to not provide an efficient and affordable treatment for ADHD such as the MPH-IR. The treatment proved to be cost-effective for children and adolescents living in Brazil, even when the worst case scenarios were tested.

Un requerimiento esencial para las organizaciones de salud es garantizar la privacidad y la óptima distribución de los registros médicos electrónicos (RME) debido a que almacenan toda la información médica sensible de los pacientes. Sin embargo, las organizaciones privadas de salud presentan riesgos y deficiencias en la seguridad e interoperabilidad de los RME afectando la adecuada distribución y autenticación de los registros médicos. Las arquitecturas y soluciones encontradas en la literatura se desarrollan utilizando la tecnología Blockchain; sin embargo, estas no contemplan todas las necesidades requeridas por las organizaciones privadas de salud y no ofrecen al paciente el control completo de toda la información en sus registros médicos. El objetivo de esta investigación es determinar la utilidad e importancia de la tecnología Blockchain en la propuesta de una arquitectura tecnológica para la gestión de los RME en organizaciones privadas de salud. La metodología empleada se basa en el análisis de trabajos y soluciones de diversos autores relacionados con el uso de la tecnología Blockchain para la gestión de los registros médicos en organizaciones de salud. De esta manera, se puede determinar el aporte brindado ante la deficiente gestión y seguridad de los registros médicos, detallar todo el proceso del resultado de la propuesta de una arquitectura tecnológica que use la tecnología Blockchain para garantizar la integridad y confidencialidad de los datos médicos junto con la protección de la privacidad del paciente; y, proponer investigaciones a futuro que complementen la propuesta y su implementación en el sector de salud. / An essential requirement for healthcare organizations is to ensure the privacy and optimal distribution of electronic medical records (EMRs) because they store all sensitive medical information of patients. However, private health organizations present security risks and have deficiencies with the interoperability of EMRs, affecting the proper distribution and authentication of medical records. The architectures and solutions found in the literature are developed using Blockchain technology; however, these do not meet all the needs required by private health organizations and do not offer the patient complete control of all the information in their medical records. The objective of this research is to determine the use and importance of Blockchain technology in the proposal of a technology architecture for the management of EMRs in private health organizations. The methodology used is based on the analysis of works and solutions of various authors related to the application of Blockchain technology for the management of medical records in health organizations. In this way, it is possible to determine the contribution provided to the deficient management and security of medical records, to detail the entire process of the result of the proposal of a technological architecture that uses Blockchain technology to guarantee the integrity and confidentiality of medical data along with protection of patient privacy; and to propose future research that complements the proposal and its implementation in the health sector. / Trabajo de investigación

Masters of Science / The aim of this study was to develop a Stock Control Assessment Tool for use in the public health care sector and then to apply it to identify problems in the stock control system. This would help authorities to optimize the system. The advantages experienced with such a dynamic Assessment Tool were many: The Tool was quick and easy to apply; it was user friendly; it provided an immediate SWOT analysis of a particular facility; it is in line with the SA NDP directives and it provides an indication of which structures are in place and whether they are functioning properly. Furthermore; it could determine the increase or decrease in performance of a facility (therefore identify trends within the functional status of a system) when data is collected over a period of time; and finally, it could also be used to prioritize drug policy directives. The following steps were established in the development of the Tool: A literature review of pharmaceutical stock control and Drug Supply Management was addressed to provide the background information for the motivation of this study and to identify the various elements that could influence stock control at a facility level. Observational studies were applied at selected private and public facilities to observe the impact of these identified stock control elements. An 'ideal' stock control system was then generated from the literature review and observational assessment. A structured questionnaire was developed and surveyed at these facilities to generate key areas of concern of a stock control system. A study and adaptation of the indicator methods used by the World Health Organization (WHO) to monitor drug use in health facilities resulted in the formulation of a practical Stock Control Assessment Tool based on 11 key indicators and a number of sub-indicators, all of which were objectively defined. The Tool was then applied at selected public facilities and the results were analyzed quantitatively, qualitatively and subjectively. Each of the indicators was then applied and results examined closely with a view to possible refinements of the indicator. The refinements were made and the Tool was re-applied at two selected facilities. These two facilities were randomly selected from the original six facilities included for the testing of the Tool. Final conclusions and specific recommendations were generated to improve the stock control systems at the selected public health care facilities.

Cette thèse examine l’apport du travail statistique à la normalisation de la vaccination en France, des années 1950 au milieu des années 1990, une période au cours de laquelle la vaccination a fait l’objet de peu de controverses. Au moyen d’opérations statistiques de rationalisation, de régulation et de justification, l’épidémiologie (entendue comme un ensemble de pratiques plutôt qu’une discipline universitaire autonome) a largement contribué à maintenir cet état de fait – un processus que je qualifie de routinisation. L’enquête est construite sur des archives issues de diverses institutions, nationales et internationales, ainsi que sur une série d’entretiens avec les principaux acteurs du domaine. Elle éclaire le rôle d’un groupe d’épidémiologistes associés au Centre international de l’enfance (1949-1999), qui mit en œuvre un programme de rationalisation et de simplification de la vaccination. Dans cette période coloniale et postcoloniale, l’Afrique subsaharienne était un de leurs terrains de prédilection : ils y réalisèrent de nombreux essais, simultanément à leurs activités métropolitaines. L’implication de l’OMS dans le domaine de la vaccination a conforté la dimension internationale de cette routinisation : les épidémiologistes français se sont appropriés des opérations statistiques popularisées par Genève. À la fin de la période considérée, la controverse de la vaccination contre l’hépatite B a perturbé cette routinisation et mis en évidence un écart croissant entre les logiques de l’épidémiologie et l’expérience des individus vaccinés. Cette recherche éclaire d’une lumière nouvelle la façon dont l’intervention de santé publique la plus courante a été normalisée et gouvernée par des nombres. / This dissertation studies the entanglement between statistical production and the normalization of immunization practices in France from the 1950s to the mid-1990s, a period during which immunization remained largely uncontroversial. By rationalizing, regulating, and justifying immunization, epidemiology (understood as a collection of practices, rather than a discrete academic discipline) has contributed greatly to this normalization – a process I term “routinization.” This research project is based on archival findings, both in France and internationally, as well as a series of interviews with significant actors in the field. It is primarily focused on a group of epidemiologists affiliated with the Centre international de l’enfance (French International Children’s Center, 1949-1999), whose mission was to rationalize and simplify immunization for children. Throughout the institution’s history, which overlaps with the late colonial period and the process of de-colonization, there is a significant engagement with Francophone Africa: numerous trials were carried out simultaneously in Sub-Saharan Africa and the Paris region. The transnational nature of this activity is also due, in part, to the involvement of the World Health Organization in matters of immunization – French epidemiologists appropriated calculations popularized on a global scale. At the end of the period in question, the Hepatitis B vaccine controversy disrupted the routinization process and shed light on the rising gap between the discourse and practice of epidemiology and the experience of vaccinated individuals. This study offers new insights into the role of numbers in the maintenance and governance of the most common public health intervention.

Bakgrund   The Gugging Swallowing Screen - Intensive Care Unit (GUSS-ICU) är ett screeningtest med syfte att fånga upp indikationer på sväljsvårigheter efter långvarig intubering hos inneliggande patienter på intensivvårdsavdelningar (IVA). I dagsläget finns det inget svenskt översatt och validerat screeningtest för omvårdnadspersonalen att använda vid bedömning av sväljförmågan efter extubering på IVA. Syfte Syftet med studien var att översätta det internationella screeningtestet GUSS-ICU till svenska för användning i en svensk intensivvårdspopulation. Vidare syftade studien till att utföra en pilotstudie av den svenska versionen på extuberade patienter på IVA. Metod En framåt-bakåtöversättningsmetod användes vid översättningen av screeningtestet GUSS-ICU. Översättningsprocessen omfattade tre steg: framåtöversättning, granskning och kommentarer från en expertpanel och en bakåtöversättning. I översättningsprocessen deltog två logopedstudenter, två handledare, en expertgrupp och en översättare. Expertgruppen bestod av 10 deltagare med olika professioner inom hälso- och sjukvården. Fem inneliggande patienter från IVA planerades delta i en pilottestning av den svenska översättningsversionen. En innehållsanalys genomfördes för att kunna jämföra samtliga översättningar. Syftet med jämförelsen var att identifiera skillnader i ord och satser samt kulturella och kontextuella skillnader. Resultat       Studien resulterade i en svensk översättning (GUSS-IVA) av screeningtestet GUSS-ICU. Analysen visade på skillnader i val av ord, koncept och satser mellan de olika översättningarna. Flertalet skillnader var ej betydelseskiljande utan analyserades istället som resultat av skillnader i erfarenhet, kunskap och språkbruk. Översättningsmetoden bidrog till språklig, kontextuell och kulturell anpassning av översättningen. Slutsats Den svenska versionen av GUSS-ICU stämmer bra överens med originalversionen och enbart ett fåtal skillnader observerades mellan översättningarna. Skillnaderna mellan bakåtöversättningen och originalversionen var inte betydelseskiljande, vilket tyder på att den svenska versionen mäter det den avser att mäta. Framtida studier behöver pilottesta och validera den svenska versionen av GUSS-ICU, innan testet kan implementeras i en svensk intensivvårdspopulation. / Validering av screeningtest för sväljsvårigheter för användning inom svensk vårdkontext

VOVES, Petr. Úloha Světové zdravotnické organizace v případu epidemie viru eboly na území západní Afriky v roce 2014. Praha, 2017. 95 s. Diplomová práce (Mgr.) Univerzita Karlova, Fakulta sociálních věd, Institut politologických studií. Katedra mezinárodních vztahů. Vedoucí diplomové práce PhDr. Irah Kučerová, Ph.D. Abstract The M.A. thesis deals with the World Health Organization's response to the outbreak of the ebola virus disease in Guinea, Liberia and Sierra Leone in 2014. The spread of the disease is mapped from its very beginning at the end of December 2013 until the creation of UNMEER in September 2014, which was the first international medical mission ever created by UN Security Council. The purpose of this thesis is to evaluate the particular problems, which limit WHO's role in a timely and effective response to the public health threats of international concern (PHEIC) under the reformed International Health Regulations (IHR). The response of WHO representatives to the spread of the disease is evaluated taking into account the available material and competence capacities of the organization as well as its previous practice in this field. The specific misconduct of WHO representatives is explained in the context of longstanding WHO's problems, which are mainly linked to the vertical fragmentation...

Magister Public Health - MPH / The introduction of National Health Insurance (NHI) and the Ideal Clinic Monitoring System have highlighted gaps and challenges with regard to medicine supply management (MSM) at primary health care (PHC) facilities. PHC facilities are the first point of contact communities have for their health needs, however, frequent stock-outs of medicines at PHC facilities in uMkhanyakude district, a rural district in KwaZulu-Natal, and have raised questions as to how medicine stock is managed at these facilities.

Background: Higher protein diets, especially from animal sources, have seen a rise in popularity due to potential metabolic. This may have consequences for kidney function particularly in rising middle class populations who are allocating more income towards meat. The objective of this systematic review and meta-analysis was to evaluate the effects of higher versus lower protein intake on glomerular filtration rate (GFR) in adult populations without renal impairment. Methods: Search strategies were developed and electronic databases searched: MEDLINE and EMBASE. Data were extracted up until June 3, 2015. The main outcome measure was GFR and a random effect model (Cochrane’s Review Manager Version 5.3) was used to pool mean differences in GFR values. Results: Database searches yielded 25 trials from 1914 articles that were eligible for analysis based on inclusion/exclusion criteria. 12 studies were randomized controlled trials and 11 studies were crossover trials. As a result of data presented, 2 crossover studies were treated as 4 trials to result in 25 total trials. A total of 810 subjects from 25 trials were included in this systematic review and meta-analyses. The age of participants was 24-62 years and their BMI was 21-36 kg/m2. Higher protein compared to lower protein-containing diets were associated with increased GFR values [mean difference (MD): 8.33 ml/min (95% CI 4.87 to 11.79), P < 0.00001] but this was less pronounced when assessing change from baseline GFR values [MD: 4.71 ml/min (95% CI 0.06 to 9.36), P = 0.05]. Moreover, significant heterogeneity was present and funnel plot asymmetry indicated potential publication bias in both meta-analyses. Conclusion: Higher protein diets were associated with increased GFR, however, these results were inconclusive due to significant heterogeneity and overestimation by random effect analyses. There is still no clear evidence that high protein diets negatively impact renal function in healthy populations. / Thesis / Master of Science (MSc) / Globally, the leading causes of mortality in industrialized countries are cardiovascular disease (CVD), stroke, and type 2 diabetes (T2D). Deaths from these chronic diseases now outpace deaths due to malnutrition. Being overweight and obese increases the risk of both morbidity and mortality from CVD, stroke, and T2D. Global rates of overweight and obesity have now reached ‘epidemic’ proportions and the World Health Organization has stated that, “… [a] global epidemic of overweight and obesity – ‘globesity’ – is taking over many parts of the world. If immediate action is not taken, millions will suffer from an array of serious health disorders.” Over the past 20-30 years, the popularity of higher protein energy restricted diets have grown due to the potential benefits regarding weight loss, appetite regulation, and maintenance of lean (muscle) mass. Additionally, the expansion of the global ‘middle-class’ has resulted in families allocating more income towards meat products as a primary protein source in their diet. A health concern is that higher protein intake may have an adverse effect on kidney function. In individuals with chronic kidney disease, higher protein diets have been shown to result in further renal impairment. However, the effects of increased protein intake in healthy populations are unclear. The aim of this systematic review and meta-analysis was to compare higher versus lower protein diets on kidney function in healthy populations based on the literature to date. This was accomplished by looking at changes in glomerular filtration rate (the rate at which kidneys filter blood), which is the ‘gold standard’ marker of kidney function.

Study Objective The objectives of this study are: (1) to explore the impact of the national consolidated guidelines for Option B+ PMTCT on the work of healthcare professionals at both clinical and management levels (including nurses, physicians and management) (2) to understand pregnant HIV-positive women views and experiences with ART for life, as a way to better manage the Option B+ PMTCT programme within state hospitals Research Questions The following research questions will be used to explore both perceptions of healthcare professionals and patients: 1.How have the national consolidated guidelines for Option B+ PMTCT affected the work of healthcare professionals? 2.What are pregnant HIV-positive women’s views and experiences about going on lifetime treatment with ARVs? / ABSTRACT Background. South Africa’s National Department of Health has adopted World Health Organization’s (WHO) 2013 consolidated guidelines on the use of ARVs for treatment and prevention of HIV infection. The guidelines include changes for prevention of mother to child transmission (PMTCT) through Option B+. Option B+ aims to reduce the HIV prevalence rate amongst these women by placing them on ART for life, no matter their CD4 count. As a result, in January 2015, these guidelines were implemented for the PMTCT programme at RMMCH. Little is known about the impact of these new guidelines on the work of healthcare professionals in state hospitals. Most importantly, no research has focused on how these changes have affected adherence for the patients. Purpose. The purpose of this research project is (1) to explore the impact of the Option B+ PMTCT programme on the work of healthcare professionals, and (2) to understand pregnant HIV-positive women views and experiences with ART for life, as a way to better manage the Option B+ PMTCT programme. Methods. A qualitative study design is used with a phenomenological approach. The methodology uses demographic questionnaires and semi-structured interviews with healthcare professionals and patients. The study is situated in Johannesburg, South Africa. Findings. The findings demonstrate that work has changed and become difficult to manage for all healthcare professionals because of (1) the need for strengthening indicators for tracking to decrease loss to follow-up (LTFU); (2) inconsistency in delivery of counseling and support services and the need for communication across clinical departments; and (3) the lack of compassion and understanding by service providers. The difficult healthcare environment has affected overall views and experiences of pregnant HIV-positive women going on ART for life. All 55 patient participants responded that they chose to take the fixed-dose combination (FDC) for life to protect the health of the baby and felt ART for life can be stopped after giving birth. Conclusion. Implications for future research include the need to address changes within the healthcare system at both clinical and management levels. It is crucial to incorporate the perspective of patients in policy implementation; uptake and adherence are key indicators in informing whether the Option B+ PMTCT programme is being adapted into state hospitals effectively. There needs to be extensive research on how to strengthen indicators for long term scalability and sustainability of the programme. Future evaluations need to address, will interdisciplinary collaboration within hospitals improve the management and understanding of Option B+? / Thesis / Master of Science (MSc)