- / This article makes critical observations about the popular examination of dying and its care, identifies the key challenges to modern dying, and argues for a public health approach to end-of life care. Only by adopting a global and non-clinical perspective on the human experience of dying can we address people’s concerns where these arise—in their own homes and workplaces—and to offer alternatives to the more radical choices offered by modern medicine.

Thesis (Ph. D.)--University of Wisconsin--Madison, 2001. / Includes bibliographical references (p. 517-547). Also available on the Internet.

Thesis (Ph. D.)--University of Wisconsin--Madison, 2001. / Includes bibliographical references (p. 517-547).

The objective of this thesis is to examine which socio-economic, structural and cultural factors may influence Indian women’s propensity to contract HIV and later their ability to access the relevant healthcare services for their condition. The research draws on two theoretical frameworks, the first being Barnett and Whiteside’s (2002) concept of social structural factors of disease transmission. Second, Anderson and Aday’s (1981) model of access examines how a variety of structural and resource-based factors, e.g. area of residence, can influence usage of healthcare facilities. Two stages of data analysis were undertaken, the first being secondary statistical analysis of the National Family Health Survey III. The survey provided state level estimates on the HIV sero-status of the general population in India and data on demographic and socio-economic determinants for family planning, nutrition, utilization of healthcare and emerging health issues. The second stage of analysis consisted of a set of qualitative interviews conducted in Andhra Pradesh, India. Thirty-three interviews were conducted with female sero-positive patients and ten with HIV-infected women who were providing social services to others with the same condition. Statistical results on social structural determinants of HIV transmission illustrated that Indian women who were formerly married (OR=5.27, CI=3.07-9.04), lived in higher prevalence states (OR=3.48, CI=2.19-5.54), had a low level of education (OR=2.27, CI=1.40-3.68) and were employed (OR=1.45, CI=0.96-2.18) had significantly (<.05) higher odds of being HIV-positive in comparison to those who were not. Findings in the qualitative phase of analysis were similar but participants’ narratives illustrated that their risk of contracting HIV begun before they even had the opportunity to seek a match as they seemed to live in communities with a high level of HIV prevalence. Many of the participants commented that there were factors outside of their sphere of control, e.g. lack of education, which resulted in them having a narrow choice of potential partners. Additionally, statistical results on female participants’ access to healthcare services indicated the vast majority of HIV-positive respondents were almost certainly not aware of their sero-status as they had not undertaken an HIV test prior to the survey. As the sample of female HIV infected respondents was relatively small, it was difficult to ascertain which social factors had an impact on these participants utilisation of HIV testing services. On the other hand, respondents’ narratives from the qualitative stage of research highlighted on social structural factors which could potentially influence WLHA’s continual utilisation of HIV-related healthcare services. It was found that participants experienced the most barriers to accessing healthcare facilities in the initial phases of their treatment. These barriers were mediated by the structure of healthcare services, culturally sanctioned medical practices (e.g. physicians refusal to inform the patient of their sero-status) and quality of services.

The collapse of the communist regimes in Central and Eastern Europe in 1989-1990 heralded the beginning of an economic transition from central planning to market economies. The subsequent period was marked by malfunctioning of these countries’ social sectors, including their health care systems, raising serious issues of equity. This thesis examines the impact of the transition period and the introduction of social insurance on equity in health care provision in Bulgaria. Equity in health care is investigated with respect to function - i.e. financing (according to ability to pay) and delivery (according to need) - and outcomes - i.e. health status, income inequality and poverty. Differences in health, health care financing and delivery are explored by income, education, ethnic, employment, marital status, age and sex groups. Furthermore, the thesis outlines the impact of health care provision, in particular social insurance, on poverty and health inequalities. The thesis employs empirical analysis based on household data. Its methodology includes concentration and decomposition analysis, and provides new ways of modelling health care financing and delivery, as well as the link between health and health care delivery. The thesis concludes that social insurance does not provide a uniform means of improving equity and that the root cause of the problem lies in the large proportion of out-of-pocket payments and the rather limited size of the health insurance sector. Inequity in health care provision leads to poverty and untreated illness. The data suggests that there are differences between socio-economic groups as regards their likelihood to seek treatment for their ill health, which result in differences in their health status. The social factors that have impacted the most on health are low education and low income.

<b>Background:</b> Defined by their mechanisms, social and psychological interventions are those interventions that work through mental processes and social phenomena. They are often complex and challenging to evaluate, so understanding randomised controlled trials (RCTs) of these interventions requires detailed reports of the interventions tested and the methods used to assess them. However, reports of these RCTs often omit important information. Poor reporting hinders critical appraisal and synthesis of RCTs in systematic reviews, thereby impeding the effective transfer of research evidence to policy and practice. The Consolidated Standards for Reporting Trials (CONSORT) Statement is a reporting guideline that has contributed to improvements in the quality of RCT manuscripts in journals publishing medical research. However, studies have shown persistent deficiencies in the reporting quality of social and psychological intervention trials. A new CONSORT extension for these interventions may be needed given their distinct and complex features. This DPhil thesis reports on a project to develop and disseminate an official CONSORT Extension for Social and Psychological Interventions: CONSORT-SPI. <b>Structure:</b> Following a preface, this DPhil thesis includes eight chapters. Chapter 1 provides an overview of the conceptual rationale that prompted the CONSORT-SPI project. Chapter 2 details the project protocol, which consists of a five-phase methodology that follows current best practices for reporting guideline development and dissemination. Chapter 3 discusses systematic literature reviews to assess reporting guidelines for and the reporting quality of publications of social and psychological intervention RCTs. Chapter 4 discusses an online, international Delphi process to generate a prioritised list of possible items to include in the CONSORT-SPI extension. Chapter 5 discusses a formal consensus meeting to select reporting items to add to or modify for the CONSORT-SPI Extension checklist. Chapter 6 involves drafts of the CONSORT-SPI checklist as well as a template for the Explanation and Elaboration (E&E) document providing detailed advice and examples of good reporting for each checklist item. These drafts have not yet been circulated to co-authors or other members of the project team; their purpose in this thesis is to give an indication of how previous project phases have led into initial prototypes of the checklist and E&E, which will undergo further development and revision by the project team before publication. Chapter 7 proposes a coordinated dissemination and implementation strategy informed by theoretical frameworks and tools used to guide the implementation of clinical guidelines and empirically-supported interventions. The final chapter summarises the information gained from the CONSORT-SPI project to date, assesses strengths and limitations of the project methodology, and discusses implications for future research. <b>Conclusion:</b> A CONSORT-SPI Extension could improve the reporting quality of social and psychological intervention RCTs. This extension could also facilitate better critical appraisal of this body of research and its use in evidence-based decision-making. With successful dissemination and implementation, the guideline will hopefully contribute to the improvement of intervention evaluations—as well as the methodology underpinning these studies—within the social and behavioural sciences.

Made available in DSpace on 2016-12-23T14:36:49Z (GMT). No. of bitstreams: 1 dissertacao marlon bertolani.pdf: 1217798 bytes, checksum: 8ad34118a49d79e31016c94a1d50fa35 (MD5) Previous issue date: 2008-09-25 / O movimento indígena, a partir da década de 80 do século passado, inscreveu definitivamente na agenda nacional o direito a um atendimento específico, capaz de concatenar a melhoria na saúde com o respeito à diversidade cultural. Alicerçado na Teoria das Representações Sociais, este estudo tem por objetivo principal identificar e analisar as relações entre dois diferentes sistemas de saúde a biomedicina e o sistema de saúde indígena , no contexto das ações direcionadas aos Guarani aldeados no município de Aracruz (ES). Busca compreender como as representações sociais que os indígenas e profissionais de saúde constroem acerca de diversos aspectos dessa questão, relativos a si mesmos e aos outros , num cenário marcado por relações interétnicas, impactam ações desenvolvidas em tal área. A complexidade de implementação da referida proposição, aliada à intenção de compreender as representações dos atores em suas conexões com a vida cotidiana, demandou uma abordagem envolvendo diferentes métodos de coleta e análise de dados, quais sejam: pesquisa documental, observação participante, entrevistas na modalidade semi-estruturada e análise de conteúdo. Os resultados apontaram para a existência de relações de poder e disputas pela hegemonia entre os sujeitos ligados aos sistemas de saúde ora analisados. As representações da saúde e da biomedicina expressas pelos Guarani encontram-se em sintonia com as demandas do grupo no campo da saúde e orientam suas reivindicações, dentre as quais assume destaque aquela pelo direito à diferença. Destarte, os especialistas e as lideranças indígenas mobilizam o capital simbólico de que dispõem em estratégias para preservar a hegemonia do sistema de saúde Guarani no interior do próprio grupo, galgando maior controle da agência ocidental, bem como mais espaço na relação com a biomedicina. Por sua vez, nas representações expressas pelos profissionais de saúde, o sistema indígena de saúde aparece como subalterno e portador de eficácia mais simbólica do que propriamente empírica. Essa postura é corroborada pelas ações da Fundação Nacional de Saúde, que ignoram as demandas do grupo. Ademais, as representações existentes entre os profissionais de saúde acerca da cultura do grupo e do comportamento dos indígenas em assuntos relacionados à saúde e/ou aos serviços a eles prestados revelaram a perpetuação de uma postura quinhentista, manifesta na sociedade envolvente e calcada na compreensão do indígena pelo paradigma da falta. Perde-se, assim, a possibilidade de compreendê-lo em sua positividade concreta, ou como o outro é, realmente. Constata-se, portanto, no tocante aos Guarani enfocados neste estudo, que o reconhecimento da eficácia da medicina indígena e do direito desses povos à sua cultura, embora ratificado de um ponto de vista formal pelo Estado brasileiro, mantém-se, na prática, como parte de um enorme alfabeto de letras mortas . / The Brazilian indigenous movement, from the 1980s on, has definitively set in the national agenda the indigenous right to specific service, which should be able to join health improvement and the respect to cultural diversity. Based on the Theory of Social Representations, the main objective of this research is to identify and to analyze the relationships between two different healthcare systems biomedicne and the Indigenous healthcare system , in the context of actions towards the Guarani indians living in settlements in the outskirts of Aracruz (Espírito Santo, Brazil). It tries to understand how much impact on the actions developed in this área was caused by the social representations that indigenous and health professionals have created regarding the various aspects of this issue, concerning themselves and others , in a scenary marked by inter-ethnical relationships. Because of the complexity of implementing this proposition, which intends to understand actors representations in connection with daily life, an approach envolving a pool of different methodologies for collecting and analysing data has been required: document research, participant observation, semi-structured interview and content analysis. The results have shown the existence of power relationship and fight for hegemony between the subjects linked to the two healthcare systems hereby been analysed. The Guarani representations of health and biomedicine are in accordance with the group s health demands and lead their claims, among which the right to difference is of great importance. Thus, the indigenous experts and leaders have mobilized their available symbolical capital in strategies that aim at preserving the Guarani healthcare system within their own group, gaining this way more control over Occidental agency, as well as more space regarding biomedicine. On the other hand, in the representations expressed by health professionals, the indigenous healthcare system is shown as subordinated and as having a more symbolical than really empirical effectiveness. This attitude is reinforced by the actions put into effect by the Fundação Nacional de Saúde (Health National Foundation), which has ignored the indigenous demands. Besides that, the manner in which health professionals represent the indigenous culture and behavior regarding health and/or the provided services has revealed the perpetuation of an ancient position which is expressed by the envolving society and based on the undestanding of the indigenous by the lack paradigm. This way, the possibilty of understanding them in their concrete positiveness or of perceiving how the other really is get lost. So, what can be said about the Guarani focused in this research is that the recognition of the indian medicine and of theese people s right to their culture, although ratified by the Brazilian State under a formal point of view, has in fact been kept as part of an enormous alphabet of dead letters