Thesis (D.P.H.)--University of Michigan, 1995.

Orientador: Antonio Carlos Pereira / Dissertação (mestrado profissional) - Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba / Made available in DSpace on 2018-08-25T21:48:45Z (GMT). No. of bitstreams: 1 Buges_AndreaFerreiraCaria_M.pdf: 571145 bytes, checksum: fb10029b804f974ffcee3ff9caa687d5 (MD5) Previous issue date: 2014 / Resumo: O sistema de saúde (SUS) tem como objetivo proporcionar acesso universal, cuidado efetivo, qualidade na prestação dos serviços e responder às necessidades da saúde da população. Para isso, utilizam-se ferramentas como a regulação em saúde pública, que controla o equilíbrio entre a oferta de serviços e a demanda de usuários, com a finalidade de corrigir falhas de mercado e garantir o bem-estar social. O presente estudo identificou as barreiras ao acesso à média e à alta complexidade de assistência hospitalar, mediante análise através da central de regulação de leitos da macrorregional do norte do Estado do Paraná (Macro Norte), feita em duas etapas. Na primeira (quantitativa), foram obtidos dados relativos ao cadastro da central de regulação de leitos da Macro Norte, com os respectivos municípios solicitantes e regional executante, acomodação e acesso realizados. De posse dos dados quantitativos, foi realizada a segunda etapa (qualitativa), a qual consistiu em entrevistas com base em duas perguntas semiestruturadas junto aos gestores municipais e estaduais da Macro Norte, onde foram abordados os problemas enfrentados para promoção do acesso. Na primeira etapa, verificou-se que 11% dos casos cadastrados não foram regulados, e que destes casos regulados foi negado o acesso pelos prestadores a 36%. Pode-se constatar que o desempenho e a ocupação dos leitos em cada regional de saúde foram diferentes. Na fase qualitativa, foram apontados como deficiências: infraestrutura assistencial deficitária, fragilidade das pactuações entre os gestores e com os prestadores, fragilidade das redes de atenção à saúde, atuação da regulação na promoção do acesso e interferências nas ações regulatórias. Concluiu-se que a Macro Norte vem atendendo aos propósitos de suprir a demanda de forma espontânea ao garantir o acesso do usuário no momento da urgência, embora não apresente desempenho máximo e otimizado por estar obstruída por problemas organizacionais e estruturais / Abstract: The Unified Health System (SUS) aims to provide universal access, effective care and quality in health care services and to meet the health needs of the Brazilian population. To this end, mechanisms are operated, such as public health regulation, which controls the balance between the supply of services and the demand of users, with the purpose of correcting market failures and promoting social welfare. The present study identified, through a quantitative and qualitative analysis, obstructions to the access in hospital assistance of medium and high complexity, by investigating macro-regional Macro Norte's hospital beds center, and was conducted in two stages. In the first stage (quantitative), data were collected from the hospital beds center of Macro-Norte, with soliciting municipality, performing municipality and executing region, used accommodations and performed access. By analysing quantitative data, the second stage of the study (qualitative) was carried out, which consisted of interviews with municipal and state supervisors of Macro Norte, based on two semi-structured questions, in which the obstacles in promoting access were indicated. In the first part, it was verified that 11% of registered cases had not been regulated and that the access had been denied by providers to 36%. It was confirmed that performance and bed accommodation were different in each health regulation's region. In the qualitative stage of the research, failures were pointed out, such as deficient attendance infrastructure, frailty in contracts between providers and with supervisors, vulnerability of health assistance networks, the role of regulation in promoting access and interference in regulatory actions. In conclusion, Macro North has been serving the purposes of meeting demand spontaneously by providing access to users at emergency times, despite not being able to deliver maximum and optimized performance for being obstructed by organizational and structural problems / Mestrado / Odontologia em Saude Coletiva / Mestra em Odontologia em Saúde Coletiva

This thesis emerged from a long-standing interest in healthcare ethics and professional education and is the result of conceptual and literature-based research. It began with: a nagging doubt about the possibility of teaching professional ethics; with an interest in the gap between what is known and what is done; with an awareness that the A grade ethics student is not necessarily the exemplary nurse or doctor in practice; and with an idea that virtue ethics might be the answer. Two central and related issues are addressed: (1) ethical values and perspectives which are necessary components of healthcare ethics and (2) the implications of, and strategies for, promoting these ethical values and perspectives in the education of health professionals. Changes within healthcare and in society urge an ongoing consideration and reevaluation of ethical values in healthcare and professional education. Contemporary approaches to health professional ethics have, for the most part, focused on duty, consequences, principles and, more recently, on rights. Such obligation-based approaches are primarily concerned with action and the cognitive realm with too little regard for the emotions and character. It will be argued that virtue ethics, which focuses on the character of the professional, goes some way towards correcting the rationalist and externalist bias of predominant approaches to healthcare ethics. A wide array of ethical values, have been described and discussed as characterising healthcare ethics. One of the most well-known perspectives is that of Beauchamp and Childress (2001) who elucidate four biomedical ethical values, what they call principles, of autonomy, beneficence, non-maleficence and justice. Beauchamp and Childress identify but elaborate little on the virtue correlates of these principles: respectfulness, benevolence, non-malevolence and justice. In this thesis, the virtue of respectfulness will be developed. It will be argued that respectfulness and selfrespectfulness are necessary healthcare values. Respectfulness is considered both initself and as respect-for: in relation to dignity and autonomy. Respectfulness also goes some way to reinforcing and encompassing other values: if the dignity and autonomy of people are respected they will be benefited rather than harmed and they will be treated fairly. Whilst self-respectfulness and respectfulness are necessary health professional virtues, they are not sufficient. Two further necessary virtues will be discussed in relation to the health professions: courage and practical wisdom. The more holistic approach to ethics proposed in this thesis requires attention to: technical-rational ('hard, high ground') and professional artistry ('swampy lowlands') perspectives on healthcare; to 'whole person' and common human experience perspectives; to rationality and the emotions; to action or conduct and character; to obligations and virtues; and to empirical and theoretical ethics. These aspects should be considered in professional education. It is argued that the development of ethical competence is the overall purpose of professional ethics education. The model of ethical competence proposed comprises: ethical knowing; ethical seeing; ethical reflection; ethical doing; and ethical being A draft curriculum is suggested regarding how ethical competeiice might be promoted.

No description available.

The health and development of a nation are linked. Health research is a vital element helps bring about improved health and has the potential to serve as an impetus for equitable development. Generally, it is necessary to prioritise needs in order to optimise the use of scarce resources for development. The overall aim of this thesis is an analysis of the setting of health research priorities, with specific reference to South Africa. Other objectives include describing the technical approaches used for priority setting and developing a suitable framework for analysing and classifying health research. Two other objectives concern measurement for priority setting: Specifically, how burden of disease quantification fits into the process of priority setting and a thorough critique of the Disability Adjusted Life Expectancy (DALY). Another objective was to examine priority setting and Essential National Health Research (ENHR) in the South African context. A further important objective is the development of a framework for guiding the analysis of health research priorities. This framework is part of model for health research priority setting that incorporates ENHR strategy and burden of disease methodology. The methods used ranged from an extensive literature review to statistical analysis. The literature review included grey literature and draws on multiple disciplines such as economics, public health policy and economics.

Tobacco use remains a significant issue in the Gulf Cooperation Council countries (GCC), a political and economic union consisting of Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates. Tobacco is responsible for 11.6% and 5.3% of mortalities among men and women, respectively, and causes US$ 34.5 billion financial loss. Tobacco use is expected to slightly decline in GCC countries by 2025, except in Oman, where tobacco use is expected to increase. In GCC countries, tobacco use is influenced by similar socio-cultural and environmental factors acting independently or interacting with other factors. In 2006, the six GCC countries ratified the Framework Convention on Tobacco Control (FCTC) treaty, which was developed by the World Health Organization. The FCTC is composed of evidence-based policies that address environmental and behavioral factors. While FCTC policies have shown a positive effect in many countries, little is known about the impact of the FCTC in GCC countries. Given the past influence of the tobacco industry in culturally and politically connected countries, it becomes necessary to examine tobacco use in the GCC region to prevent the initiation of use and reduce the economic burden associated with tobacco use. The goal of this study was to examine the impact of tobacco control policies on preventing tobacco use among youth in the GCC countries. The study used a mixed-method approach to investigate tobacco control policies. The specific aims of the study were: 1) evaluate the implementation of FCTC measures in the six GCC countries at the national level; 2) examine the relationship between youth susceptibility to initiate tobacco use and key FCTC provisions in five GCC countries; and 3) investigate the occurrence of tobacco use in Arabic media to assess compliance with the FCTC provision on banning tobacco advertisement, promotion, and sponsorship in the GCC region. The longitudinal review of tobacco control measures in the six GCC countries between 2008 and 2020 showed progress in implementing measures related to tobacco packaging, smoking cessation, and tobacco sale to minors in most GCC countries while much less progress in implementing measures related to tobacco prices and taxes and eliminating illicit tobacco trade. Examining the self-reported intention to initiate tobacco use by youth indicated that a person’s susceptibility to begin tobacco use statistically declined over time from the pre- to post-FCTC ratification in Bahrain (15.6% in 2002 to 8.9% in 2015) and Qatar (11.3% in 2004 to 7.3% in 2018), while it increased in the UAE (4.9% in 2002 to 9.3% 2013). Consistent with previous literature, exposure to smoking in public places and tobacco marketing activities increased susceptibility to initiate tobacco use among youth at a statistically significant level. In contrast, exposure to anti-tobacco education in media statistically reduced susceptibility. Finally, the in-depth examination of incidents of tobacco use in Arabic media showed a total of 32,084 incidents of tobacco use in 92 TV series broadcasted between January 2017 and December 2019, suggesting that on-screen tobacco use has not been completely banned in Arabic media. The findings of this study should lead to more collective action in the region. Policymakers should dedicate more efforts to address environmental factors that influence tobacco use, and anti-tobacco advocacy groups should enhance youth engagement in tobacco control activities. Policy surveillance remains the ultimate solution to assess the impact of legal intervention in health outcomes and amend interventions when unintended consequences occur. Future research should continue tracking tobacco control measures at the national and local levels and share policy surveillance data across countries to better assist with the decision-making process. Researchers should examine the implementation process and enforcement activities related to tobacco control policies. Moreover, it is critical to understand the history of the influence of the tobacco industry in the GCC region and examine the current activities of the tobacco industry in order to counter them effectively. Mixed methods research may be an optimal option for researchers to examine the cause-effect relationships and uncover gaps that hinder tobacco control policies from addressing the issue. / Public Health

The U.S. public health system is continually challenged by unexpected epidemiological events that pose significant risks to the health of the community and require a commensurate surge in the public health system capacity to stem the spread of the disease. The complexity and even changing nature of funding and surge events drives agencies to innovate in order to maintain and support a competent workforce as well as update, or evolve the knowledge, skills and abilities (KSA) necessary to prevent, mitigate, or even eliminate the health crisis arising from a disease. This research investigates the capability of an agent-based, online personalized (AOP) intelligent tutoring system (ITS) that adaptively uses aptitude treatment interaction (ATI) to deliver public health training and assure competency. Also, presented is a conceptual model that combines Davis' Technology Acceptance Model (TAM) and the Public Health Service's Health Behavior Model (HBM) concepts to understand actual use of new technology in the public health sector. TAM is used to evaluate the effectiveness and the behavioral intent to use the system. HBM is used to explain and predict the preventative health behavior of actual use of the ITS. Our findings indicate the use of the ITS increases participant performance while providing a high level of acceptance, ease of use, and competency assurance. Without the determination of casual sequence, the TAM/HBM conceptual model demonstrated the best fit for predicting actual use of an ITS with the constructs of attitude, cues to action, and perceived ease of use showing the most influence. However, discussion of our findings indicates limited potential for an ITS to make a major contribution to adding workforce surge capacity unless members are directed to utilize it and technology barriers in the current public health IT infrastructure overcome.

This dissertation argues that there are three basic types of health care systems used in industrial nations: free market (private insurance and provision), universal (public insurance and private provision), and socialized (public insurance and provision). It examines the role of market forces (supply and demand) within the health care systems and their effects on health outcomes by constructing an integrative model of health care markets and policies that is lacking within the scientific and academic literature. The results show that, free market systems have decreased access to care, good quality of care, and are economically inefficient resulting in 2.7 years of life expectancy lost and wasted expenditures (expenditures that do not increase life expectancy) of $3474 per capita ($1.12 trillion per year in the U.S.). Socialized systems are the most economically efficient systems but have decreased access to care compared to universal systems, increased access to care compared to free market systems and have the lowest quality of care of all three systems resulting in 3 months of life expectancy lost per capita and a saving of $335 per capita. Universal systems perform better than either of the other 2 systems based on quality and access to care. The models show that health insurance is a Giffen Good; a good that defies the law of demand. This study is the first fully demonstrated case of a Giffen good. This investigation shows how the theoretically informed integrative model behaves as predicted and influences health outcomes contingent upon the system type. To test and substantiate this integrative model, regression analysis, Time-Series-Cross-Section analysis, and structural equation modeling were performed using longitudinal data provided and standardized by the Organization for Economic Cooperation and Development (OECD). The results demonstrate that universal health care systems are superior to the other two systems.

Opioid abuse has become a global epidemic and is now a huge public health concern here in the US. Non-medicinal use of opioid prescription drugs is at the forefront of the epidemic and considered the "gateway" drug to other illicit opioid use. As opioid prescribing has increased over the last decade in the US, so has opioid-related deaths, surpassing car accidents and suicide as the leading cause of injury-related deaths. Medication assisted treatment (MAT) is fundamental in decreasing opioid abuse overdose and mortality. Therefore, the research study aims to determine if counseling adherence, opioid abstinence, and retention in MATs are influenced by personal characteristics, socio-economic factors, readiness to change, social support, and integrated care. Guided by social cognitive theory, transtheoretical model, and theory of reasoned action, the study will employ a retrospective cohort design utilizing opioid dependent patients from a MAT Program in West Florida. Analysis of three cox regression models indicated for personal factors: an increase in age was associated with patients being more likely to adhere to counseling (p=.001) and retention (p=.034), full-time employment (p=.043) was positively associated with opioid abstinence, whereas part-time employment (p=.037) was positively associated with retention, having insurance (public: p=.000) was positively associated with counseling adherence, opioid abstinence (public: p=.000, private: p=.035) and retention (public: p=.000, private: p=.000). With regards to environmental influences, social support was positively associated with opioid abstinence (p=.022) and integrated care was positively associated with opioid abstinence (p=.027) and retention (p=.000). Examining these factors are necessary to improve treatment adherence and expand MAT programs. Additionally, providing funding is crucial for practitioners to continually create educational intervention strategies to engage patients in treatment, thereby reducing the opioid overdose epidemic. This study extends the literature contributing to understanding personal factors and environmental influences in MATs.

Registered nurses (RNs) are essential to providing care in the healthcare system. To date, research on the relationship between healthcare provider supply and population health has focused on physician supply. This study explored the effect of RN supply on population health outcomes in the U.S. This is a retrospective, cross-sectional study of U.S. counties and county equivalents using national data. Seven population health outcomes (total and disease specific mortalities and low infant birth weight rate) were the response variables. The predictor variable, RN supply, and some control variables were anticipated to have an asynchronous effect on the seven outcome variables in the hypothesized relationship. Therefore, these variables were examined using three different models: contemporaneous; a three-year lagged; and a distributed lag (both contemporaneous and lagged variables). Quadratic terms for RN and physician supply variables were included. Because the Area Health Resource File (AHRF) outcome variables were skewed toward zero and left censored, Tobit regression analyses were used. Data were obtained from 19 states using historical RN Supply data for 1,472 counties, representing 47% of the total target population of 3,108 U.S. counties and county equivalents. Regions with rural populations—the Midwest and Southeast—were overrepresented. Higher RN supply is positively related to higher mortality rates from ischemic heart disease, other cardiovascular disease, and chronic lower respiratory disease in the distributed lag models. Higher RN supply is not significantly related to rates of low infant birth weight, infant mortality, or mortality from cerebrovascular disease in any model. Higher RN supply is positively related to total deaths in the contemporaneous and lagged model. The results suggest a counter-intuitive, but non-linear relationship between RN supply and health outcomes. More research is needed to understand these relationships and policies must be devised to reduce the current and growing future RN shortage.