Le problème de la responsabilité médicale se pose avec acuité dans le monde. S'agissant de nos Etats comme le Sénégal nous observons une timide évolution de la responsabilité. Cette dernière est induite par le type d'offre de soins. Cette interdépendance s'exprime au niveau de la nature de la responsabilité et de son régime juridique. Dans le cadre d'une offre publique de soins, la responsabilité est administrative et relève de la compétence du juge administratif. Dans le cadre de l'offre privée de soins, la responsabilité est civile et est de la compétence du juge judiciaire. A travers cette étude, nous avons observé que l'offre de soins est diversifiée du fait des nombreux acteurs et déséquilibrée du fait de l'absence de couverture de santé généralisée. Nous avons également constaté que les mécanismes traditionnels d'engagement de la responsabilité sont surannés dans certains cas, ayant pour conséquence la difficulté d'indemnisation des victimes. Une amélioration de la réglementation des pratiques médicales, y compris de la médecine traditionnelle, et une meilleure prise en charge des dépenses de santé de la population sénégalaise seraient souhaitables. Au vu de ces constats, nous préconisons donc l'accélération de l'adoption du Code de la santé publique du Sénégal et la création d'une Commission Régionale d'Indemnisation des accidents médicaux et des infections nosocomiales dans l'espace de l'Union Economique Monétaire Ouest Africaine, comme il en existe une en France. / The problem of the medical liability arises with acuteness in the world. In Senegal, we observe a shy evolution of the liability. This last one is inferred by the type of healthcare services. This interdependence expresses at the level of the nature of the liability and its legal regime. Within the framework of public healthcare services, the liability is administrative and recovers from the competence of the administrative judge. Within the framework of the private healthcare services, the liability is civil and is the competence of the judicial judge. Through this study, we observed that the healthcare services are diversified because of the numerous actors and unbalanced because of the absence of cover of generalized health. We also noticed that the traditional mechanisms of commitment of the liability are outmoded in certain cases, having for consequence the difficulty of compensation of the victims. An improvement of the regulations of the medical practices, including the traditional medicine, and a better coverage of the expenses of health of the Senegalese population would be desirable. In view of these reports, we thus recommend the acceleration of the adoption of the Public health code of Senegal and the creation of a Regional committee for Compensation of the medical accidents and the hospital-borne infections in the space of the Monetary Economic union the West African, as there is there one in France.

No description available.

A intensificação do debate sobre a epidemia de DST/aids na população negra, trazida por entidades da sociedade civil na última década, aparece na esteira da recente sistematização de políticas voltadas para a saúde desta população. O objetivo do presente estudo foi conhecer a avaliação que o movimento social negro do ABC paulista tem sobre as condições de vulnerabilidade em relação às DST/aids vividas pelos cidadãos negros da região. Trata-se de estudo qualitativo, construído com base em entrevistas individuais em profundidade com lideranças diversas deste movimento. A representatividade dos entrevistados foi ancorada no conceito de Luta por Reconhecimento e a estrutura das entrevistas foi organizada a partir do conceito teórico orientador de todo o trabalho que é o conceito de Vulnerabilidade. A construção e interpretação das entrevistas foram apoiadas em uma concepção de linguagem entendida como desveladora de processos de interação a partir do cotejo de duas tradições filosóficas principais: o materialismo histórico dialético e a hermenêutica. As avaliações dos entrevistados sobre as três dimensões de vulnerabilidades vivenciadas pelos negros em relação às DST/aids, produziram um quadro no qual diversas situações cotidianas são relatadas e discutidas. No plano institucional, três grupos centrais de problemas foram levantados: as condições de atendimento nos serviços de saúde; a atuação do Estado sobre as condições de iniquidade e a relação do Estado com o movimento social. Em relação às vulnerabilidades sociais, foram destacadas as desigualdades sócio-econômicas entre negros e não-negros e suas consequências, que incluem a persistência de baixa escolaridade, precarização das moradias, fixação da população negra para a periferia das áreas urbanas, barreiras à ascensão social, desigualdades sociais em saúde e a persistência da discriminação racial nas relações sociais. Em relação às vulnerabilidades individuais, os entrevistados relataram algumas de suas vivências pessoais e familiares em que sobressaem os sentimentos de insegurança e desrespeito trazidos pela tensão da discriminação racial, o que tem implicações não apenas morais, mas manifesta-se também no modo como os sujeitos vivenciam, apreendem e lidam com os aspectos dos demais planos de vulnerabilidade, acima citados. Os entrevistados apontaram, ainda, alternativas de reconstrução prática com potencial de redução do impacto da vulnerabilidade para a aids entre os brasileiros negros / The intensified discussion about the STD/AIDS epidemic among black population, brought about by civil society organizations in the last decade, appears in the wake of recent policies aimed at health of this population. The objective of this study was to explore the assessment that the black social movement in the ABC region (State of SP) make about vulnerability conditions regarding STD/AIDS experienced by black citizens from the region. This is a qualitative study, built on individual in-depth interviews with several leaders of this movement. Representativeness of respondents was based on the concept of \"Struggle for Recognition\", and the structure of the interviews on the theoretical concept of Vulnerability that guided the whole work. The structure and interpretation of interviews were backed by designing a language understood as unfolding processes of interaction based on confrontation of two major philosophical traditions: historical dialectical materialism and hermeneutics. The evaluations of the respondents about the three dimensions of vulnerability experienced by brazilian blacks in relation to STD/AIDS, resulted in a framework in which many daily situations are reported and discussed. At institutional level, three core groups of issues were raised: the conditions of care in health services, State action concerning inequity conditions and the relation between the State and social movements. As to social vulnerabilities, socioeconomic inequalities and their consequences were highlighted between blacks and non-blacks, including persistence of low schooling, precarious housing, setting the black population in the periphery of urban areas, barriers to social mobility, health inequalities and persistence of racial discrimination in social relations. In relation to individual vulnerabilities, respondents reported some of their personal and family experiences that stress feelings of lack of confidence and disrespect due to tension resulting from racial discrimination, which has moral implications and also manifests in how the subjects experience, perceive and deal with vulnerability aspects at other levels, as mentioned above. Yet, the interviewees pointed out practical reconstruction alternatives with potential to reduce the impact of vulnerability to AIDS among black Brazilians

Darbo tikslas – įvertinti šeimos gydytojo pasirinkimą ir keitimą lemiančius veiksnius priklausomai nuo įstaigos tipo. Uždaviniai :1. Nustatyti ir įvertinti PSP paslaugų teikėjo pasirinkimą lemiančius veiksnius priklausomai nuo įstaigos tipo. 2. Įvertinti ir palyginti šeimos gydytojo keitimą įtakojančius motyvus priklausomai nuo įstaigos tipo. 3. Įvertinti ir palyginti pacientų elgseną ir pasitenkinimą paslaugomis priklausomai nuo įstaigos tipo. Tyrimo metodika. Tyrimas atliktas 2013m. sausio- kovo mėn. Naudota anoniminė anketinė viešosiose: Prienų rajono PSPC ir Birštono PSPC bei privačiose PSP įstaigose besilankančių pacientų apklausa( n═247). Atsakas dažnumas 81,5 proc. Tyrimo rezultatų statistinė analizė atlikta naudojant SPSS 17.0 ( Statistical Package of Social Scienles ) for Windows statistinių duomenų paketą. Ryšiai tarp požymių vertinti pagal Chi kvadrato ( x2 ) kriterijų. Rodiklių skirtumas laikytas statistiškai reikšmingu, kai p< 0,05. Rezultatai. Pacientų tyrimo rezultatų analizė atskleidė, jog (48 proc.) privačių PSPC ir (46 proc.) viešųjų PSP įstaigų pacientų yra patenkinti šeimos gydytojo teikiamomis paslaugomis. Tyrimo metu nustatyta, kad statistiškai šeimos gydytojo paslaugų vertinimas neturi sąsajų su išsilavinimu, socialiniu statusu ir mokėjimu už paslaugas. Privačiose gydymo įstaigose (40 proc.) respondentų nepasirenka šeimos gydytojo dėl nepatenkinamų paslaugų kokybės, o (75 proc.) viešųjų PSP centrų respondentų - dėl netinkamo šeimos gydytojo... [toliau žr. visą tekstą] / The aim of the study is to assess factors that determine the choice and change of family doctor depending on the type of institution. Objectives: 1. To identify and assess factors that determine the choice of a primary healthcare service provider depending on the type of institution. 2. To assess and compare motives that influence the change of a family doctor depending on the type of institution. 3. To assess and compare patientes behaviour and satisfaction depending on the type of institution. Methods of the research. The research was conducted in between January and March, 2013. An anonymous survey was performed on patients who visit public institutions of Prienai district primary health care and Birštonas primary health care and also private primary health care institutions (n=247). The response in public primary health care institutions was 81.5%. The statistical analysis of the research results was performed using SPSS 17.0 (Statistical Package for Social Sciences). The relationships between the features were assessed using x2 criterion. Results. The analysis of patient research results showed that 48% of patients of private primary healthcare and 46% of public healthcare institutions are satisfied with the services provided by family doctors. During the research it was found that statistically the assessment of family doctor service quality does not have connection with education, social status or payment for services, 40% of respondents do not choose family doctor... [to full text]

Στην παρούσα διατριβή προτείνονται Μηχανισμοί Ασφάλειας για την ανάπτυξη ασφαλών και αξιόπιστων διάχυτων υπηρεσιών υγείας πάνω σε Δίκτυα Επόμενης Γενιάς (Next Generation Networks – NGN). Οι προτεινόμενοι Μηχανισμοί Ασφάλειας έχουν ως στόχο να λειτουργήσουν προσθετικά στο επίπεδο ασφάλειας που προσφέρουν οι υπάρχοντες μηχανισμοί ασφάλειας που υποστηρίζονται από το NGN. Αυτό είναι αναγκαίο καθώς οι διάχυτες υπηρεσίες υγείας εμπεριέχουν ιδιαιτέρως ευαίσθητη πληροφορία. Επιπρόσθετα, στην παρούσα διατριβή προτείνεται ένα γενικό πλαίσιο εφαρμογής, το οποίο υποστηρίζει τους προτεινόμενους Μηχανισμούς Ασφάλειας, προκειμένου να επιτυγχάνεται γρήγορη και αποτελεσματική ανάπτυξη ασφαλών και αξιόπιστων διάχυτων υπηρεσιών υγείας πάνω σε NGN. Πιο συγκεκριμένα, το προτεινόμενο πλαίσιο βασίζεται στην αρχιτεκτονική του προτύπου ETSI/Parlay και επεκτείνει το σύνολο των Διεπαφών των Χαρακτηριστικών Ικανότητας Υπηρεσίας (Service Capability Features Interfaces – SCFs Interfaces) και το σύνολο των μηχανισμών που υποστηρίζει το Πλαίσιο ETSI/Parlay. Το προτεινόμενο πλαίσιο επεκτείνει το σύνολο των Διεπαφών των Χαρακτηριστικών Ικανότητας Υπηρεσίας προκειμένου αυτό να περιλαμβάνει όχι μόνο τις διεπαφές που σχετίζονται με τις υπηρεσίες του υποκείμενου δικτύου (NGN), αλλά και επιπλέον διεπαφές που δίνουν τη δυνατότητα σε διάχυτες υπηρεσίες υγείας να έχουν πρόσβαση σε ικανότητες επαίσθησης (sensing capabilities) δικτύων αισθητήρων που είναι υπεύθυνα για τη συλλογή πληροφορίας περιβάλλοντος καθώς και βιοπληροφορίας. Επίσης, το προτεινόμενο πλαίσιο επεκτείνει το σύνολο των μηχανισμών που υποστηρίζει το Πλαίσιο ETSI/Parlay προκειμένου να είναι δυνατή η παροχή σε διάχυτες υπηρεσίες υγείας όχι μόνο των βασικών μηχανισμών, που υποστηρίζονται από το προτυποποιημένο Πλαίσιο ETSI/Parlay, αλλά και των Μηχανισμών Δικτύων Αισθητήρων καθώς και των Μηχανισμών Ασφάλειας, οι οποίοι προτείνονται στην παρούσα διατριβή. Οι Μηχανισμοί Ασφάλειας, οι οποίοι προτείνονται, στοχεύουν στην παροχή ασφάλειας στα δεδομένα των τελικών χρηστών καθώς και στην ασφαλή πρόσβαση στις διάχυτες υπηρεσίες υγείας και στην ασφαλή χρήση τους. Πιο συγκεκριμένα, οι προτεινόμενοι Μηχανισμοί Ασφάλειας επικεντρώνονται στη διασφάλιση της εμπιστευτικότητας των δεδομένων, της ακεραιότητας των δεδομένων, της πιστοποίησης αυθεντικότητας καθώς και του ελέγχου πρόσβασης των οντοτήτων που συμμετέχουν σε διάχυτες υπηρεσίες υγείας. Για τη διασφάλιση της εμπιστευτικότητας των δεδομένων προτείνεται ένα γενικό σχήμα κρυπτογράφησης. Αυτό το σχήμα επιτρέπει το σχεδιασμό και την υλοποίηση ασφαλών εξατομικευμένων κρυπτογραφικών αλγορίθμων τμήματος για την κρυπτογράφηση δεδομένων διάχυτων υπηρεσιών υγείας, όπως οι ιατρικοί φάκελοι των ασθενών. Επίσης, προτείνεται ένας μηχανισμός για διασφάλιση της ακεραιότητας των δεδομένων για σύστημα ιατρικής τηλε-παρακολούθησης. Αυτό το σύστημα τηλε-παρακολούθησης λειτουργεί σε περιβάλλον έξυπνου σπιτιού και υποστηρίζει τη μεταφορά βιοσημάτων του ασθενή από τον ασθενή στη Μονάδα Παροχής Υπηρεσιών Υγείας. Επιπρόσθετα, προτείνονται δύο μηχανισμοί για διασφάλιση της πιστοποίησης αυθεντικότητας. Ο πρώτος μηχανισμός είναι ένας ευφυής μηχανισμός πιστοποίησης αυθεντικότητας για εφαρμογές e-Hospital πάνω σε WLAN μέσα σε νοσοκομείο. Ο δεύτερος μηχανισμός είναι ένας μηχανισμός συμφωνίας κλειδιού ομάδας και ανάκτησης σε ad hoc δίκτυα, που χρησιμοποιούνται κατά τη διαχείριση ιατρικών συμβάντων έκτακτης ανάγκης σε περιοχές στις οποίες δεν υπάρχει σταθερή τηλεπικοινωνιακή υποδομή. Τέλος, προτείνεται μία υποδομή PKI σε ένα ιατρικό δίκτυο μεγάλης κλίμακας που συνδέει ένα ευρύ φάσμα από Μονάδες Παροχής Υπηρεσιών Υγείας. Η προτεινόμενη υποδομή PKI εστιάζεται στη διασφάλιση της πιστοποίησης αυθεντικότητας και του ελέγχου πρόσβασης των επαγγελματιών του χώρου της υγείας που επιθυμούν να αποκτήσουν πρόσβαση σε υπηρεσίες που σχετίζονται με αυτούς καθώς και σε υπηρεσίες υγείας που σχετίζονται με τον ασθενή. / In this dissertation, Security Mechanisms are proposed for the development of secure and reliable pervasive healthcare services over Next Generation Networks (NGN). The proposed Security Mechanisms aim at increasing the security level provided by the existing security mechanisms supported by NGN. It is essential since pervasive healthcare services include extremely sensitive information. Furthermore, in this dissertation, a generic application framework is proposed supporting the proposed Security Mechanisms in order the rapid and efficient development of secure and reliable pervasive healthcare services over NGN to be achieved. In particular, the proposed framework is based on the ETSI/Parlay architecture and extends the set of the Service Capability Features Interfaces (SCFs Interfaces) as well as the set of mechanisms supported by the ETSI/Parlay Framework. The proposed framework extends the set of the SCFs Interfaces in order to integrate not only the interfaces related to the services of the underlying network (NGN), but also additional interfaces enabling pervasive healthcare services to access sensing capabilities of sensor networks which are responsible for gathering context and bio information. Moreover, the proposed framework extends the set of mechanisms supported by the ETSI/Parlay Framework to provide pervasive healthcare services not only with the basic mechanisms supported by the standardized ETSI/Parlay Framework, but also with the Sensor Networks Mechanisms and the Security Mechanisms proposed in this dissertation. The proposed Security Mechanisms aim at securing the end-user data as well as the access to the pervasive healthcare services and the use of them. In particular, the proposed Security Mechanisms focus on ensuring data confidentiality, data integrity, authentication and access control of entities participating in pervasive healthcare services. To ensure data confidentiality, a generic encryption schema is proposed. This schema enables the design and implementation of secure personalized block ciphers for encryption of data included in pervasive healthcare services such as patients’ medical records. Moreover, a data integrity mechanism for a tele-monitoring system is proposed. This tele-monitoring system operates in a smart home environment and supports transmission of patient’s biosignals from the patient to the Healthcare Center. Additionally, two authentication mechanisms are proposed. The first mechanism is an intelligent authentication mechanism for e-Hospital applications over WLAN in a hospital. The second mechanism is a group key agreement and recovery mechanism in ad hoc networks used for handling emergency medical incidents in areas without fixed telecommunications infrastructure. Finally, a PKI infrastructure in a large-scale healthcare network connecting a wide spectrum of Healthcare Centers is proposed. The proposed PKI infrastructure focuses on ensuring authentication and access control of healthcare professionals willing to access services related to them as well as healthcare services related to patient.

Orientador: João Luiz Carvalho Pinto e Silva / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-04T17:18:23Z (GMT). No. of bitstreams: 1 EspejoCarvacho_IngriddeLourdes_D.pdf: 310301 bytes, checksum: ecf2c9b4bc1df26da82cdcdcd868f818 (MD5) Previous issue date: 2005 / Resumo: Para o Brasil, assim como para outros países, o índice crescente de gravidez na adolescência representa um problema social e de saúde pública devido às repercussões orgânicas, psicológicas e sociais que a gravidez acarreta nesta faixa etária. São vários e complexos os fatores etiológicos envolvidos no fenômeno. Entre eles, a literatura aponta a desinformação das adolescentes sobre o funcionamento do corpo e a falta de acesso aos serviços de saúde, onde as adolescentes são alvo de ações educativas e preventivas apropriadas. Este estudo de corte transversal teve como objetivos verificar o uso de métodos anticoncepcionais e a intenção reprodutiva, avaliar o conhecimento sobre o aparelho genital feminino e alguns aspectos da fisiologia da reprodução, bem como o acesso aos serviços de saúde entre adolescentes gestantes atendidas em uma unidade básica de saúde do Município de Indaiatuba, através de metodologia quantitativa. Foram entrevistadas individualmente 200 adolescentes primigestas no momento de sua primeira consulta de pré-natal, aplicando-se um questionário (pré-testado) com perguntas abertas e fechadas relativas às características sociodemográficas das adolescentes, intenção reprodutiva, uso de métodos anticoncepcionais na primeira relação sexual e antes de engravidar, identificação, localização e função dos órgãos genitais femininos, barreiras de acessos geográfico, econômico, administrativo, psicossocial e à informação, ao serviço de saúde. Na análise descritiva univariada dos dados foram utilizados a distribuição de freqüência absoluta e índices percentuais; na análise bivariada foi aplicado teste qui-quadrado de Pearson ou exato de Fisher, e, na multivariada, regressão logística para analisar a associação entre as características sociodemográficas e reprodutivas e o conhecimento e acesso a serviços de saúde. O conhecimento das adolescentes foi avaliado através da elaboração de três indicadores: anatomia, fisiologia dos órgãos genitais e fisiologia da reprodução, e o acesso ao serviço de saúde através de cinco indicadores de acessos: geográfico, econômico, administrativo, psicossocial e à informação. Concluiu-se que o uso de métodos anticoncepcionais é descontínuo e que a gravidez não foi programada na maioria dos casos. O conhecimento sobre os órgãos genitais femininos foi insatisfatório, principalmente os conceitos fisiológicos da reprodução. A idade e escolaridade das adolescentes, a religião, idade dos parceiros, a diferença de idade do casal e o vínculo com o parceiro após a gravidez associaram-se aos indicadores de conhecimento. Entre as barreiras de acesso ao serviço de saúde foram consideradas significativas apenas as barreiras de natureza psicossocial. A escolaridade, o trabalho, a idade dos parceiros e o vínculo com o parceiro associaram-se com o acesso ao serviço de saúde em suas diversas dimensões. Há a necessidade de novas estratégias para facilitar o acesso ao serviço de saúde pelas adolescentes e que minimizem as barreiras de gênero, respeitem a autonomia das adolescentes e considerem as características e o vínculo com seus parceiros / Abstract: In Brazil, as in other countries, high adolescent pregnancy rates represent a significant social and public health problem due to the organic, psychological and social repercussions of pregnancy in this age group. Several complex etiological factors are involved in this phenomenon. Of these, previous studies have reported misinformation regarding the functioning of the adolescent¿s own body and difficult access to health services where appropriate educational information is provided and preventive actions are implemented. The objective of this cross-sectional study was to assess the prior use of contraceptive methods, reproductive intentions, and the knowledge among pregnant adolescents seeking healthcare at a basic health center in the municipality of Indaiatuba with respect to the female genital organs, some aspects of reproductive physiology and the adolescents¿ perception of healthcare access. Quantitative methodology was used in the data analysis. Two hundred primigravidae were interviewed individually at the time of their first prenatal consultation. A pre-tested questionnaire was applied, containing both open and closed questions regarding the sociodemographic characteristics of the adolescents, their reproductive intentions, use of contraceptive methods during first sexual intercourse and prior to becoming pregnant, identification, localization and function of the female genital organs, geographical, economical, administrative and psychosocial barriers, as well as information barriers to health services. Absolute frequency distribution and percent index were used in the univariate descriptive data analysis. Pearson¿s chi-squared test or Fisher¿s exact test were used in the bivariate descriptive analysis, and logistic regression was used in the multivariate analysis to analyze the association between sociodemographic and reproductive characteristics and knowledge and access to health services. The adolescents¿ knowledge was evaluated by elaborating three indicators: anatomy, physiology of the genital organs and reproductive physiology. Access to health services was evaluated in 5 categories: geographic, economic, administrative, information and psychosocial. Our results show that use of contraceptive methods is sporadic and in most cases the pregnancy was not planned. Knowledge regarding the female genital organs is insufficient, principally with respect to concepts of reproductive physiology. The age and education level of the adolescents, religion, age of partners, age difference within the couple, and the bond with partner after the pregnancy were associated with indicators of knowledge. The only barriers to access to health services that were considered significant were those of a psychosocial nature. Education level, age of partner, bond with partner and employment were, in their individual dimensions, associated with access to health services. There is a need for new strategies to make access to health services easier for adolescents, minimizing gender barriers, respecting the autonomy of the adolescents and taking the characteristics of their partners and the relationship between the adolescents and their partners into consideration / Doutorado / Ciencias Biomedicas / Doutor em Tocoginecologia

A intensificação do debate sobre a epidemia de DST/aids na população negra, trazida por entidades da sociedade civil na última década, aparece na esteira da recente sistematização de políticas voltadas para a saúde desta população. O objetivo do presente estudo foi conhecer a avaliação que o movimento social negro do ABC paulista tem sobre as condições de vulnerabilidade em relação às DST/aids vividas pelos cidadãos negros da região. Trata-se de estudo qualitativo, construído com base em entrevistas individuais em profundidade com lideranças diversas deste movimento. A representatividade dos entrevistados foi ancorada no conceito de Luta por Reconhecimento e a estrutura das entrevistas foi organizada a partir do conceito teórico orientador de todo o trabalho que é o conceito de Vulnerabilidade. A construção e interpretação das entrevistas foram apoiadas em uma concepção de linguagem entendida como desveladora de processos de interação a partir do cotejo de duas tradições filosóficas principais: o materialismo histórico dialético e a hermenêutica. As avaliações dos entrevistados sobre as três dimensões de vulnerabilidades vivenciadas pelos negros em relação às DST/aids, produziram um quadro no qual diversas situações cotidianas são relatadas e discutidas. No plano institucional, três grupos centrais de problemas foram levantados: as condições de atendimento nos serviços de saúde; a atuação do Estado sobre as condições de iniquidade e a relação do Estado com o movimento social. Em relação às vulnerabilidades sociais, foram destacadas as desigualdades sócio-econômicas entre negros e não-negros e suas consequências, que incluem a persistência de baixa escolaridade, precarização das moradias, fixação da população negra para a periferia das áreas urbanas, barreiras à ascensão social, desigualdades sociais em saúde e a persistência da discriminação racial nas relações sociais. Em relação às vulnerabilidades individuais, os entrevistados relataram algumas de suas vivências pessoais e familiares em que sobressaem os sentimentos de insegurança e desrespeito trazidos pela tensão da discriminação racial, o que tem implicações não apenas morais, mas manifesta-se também no modo como os sujeitos vivenciam, apreendem e lidam com os aspectos dos demais planos de vulnerabilidade, acima citados. Os entrevistados apontaram, ainda, alternativas de reconstrução prática com potencial de redução do impacto da vulnerabilidade para a aids entre os brasileiros negros / The intensified discussion about the STD/AIDS epidemic among black population, brought about by civil society organizations in the last decade, appears in the wake of recent policies aimed at health of this population. The objective of this study was to explore the assessment that the black social movement in the ABC region (State of SP) make about vulnerability conditions regarding STD/AIDS experienced by black citizens from the region. This is a qualitative study, built on individual in-depth interviews with several leaders of this movement. Representativeness of respondents was based on the concept of \"Struggle for Recognition\", and the structure of the interviews on the theoretical concept of Vulnerability that guided the whole work. The structure and interpretation of interviews were backed by designing a language understood as unfolding processes of interaction based on confrontation of two major philosophical traditions: historical dialectical materialism and hermeneutics. The evaluations of the respondents about the three dimensions of vulnerability experienced by brazilian blacks in relation to STD/AIDS, resulted in a framework in which many daily situations are reported and discussed. At institutional level, three core groups of issues were raised: the conditions of care in health services, State action concerning inequity conditions and the relation between the State and social movements. As to social vulnerabilities, socioeconomic inequalities and their consequences were highlighted between blacks and non-blacks, including persistence of low schooling, precarious housing, setting the black population in the periphery of urban areas, barriers to social mobility, health inequalities and persistence of racial discrimination in social relations. In relation to individual vulnerabilities, respondents reported some of their personal and family experiences that stress feelings of lack of confidence and disrespect due to tension resulting from racial discrimination, which has moral implications and also manifests in how the subjects experience, perceive and deal with vulnerability aspects at other levels, as mentioned above. Yet, the interviewees pointed out practical reconstruction alternatives with potential to reduce the impact of vulnerability to AIDS among black Brazilians

Les acteurs de la santé publique ont aujourd'hui de nombreux défis à relever relatifs à des besoins nouveaux liés, entre autres, au vieillissement de la population et à l’augmentation du nombre de maladies chroniques. Ces besoins et leurs coûts obligent à repenser la prise en charge des patients et à rationaliser leurs parcours de soins afin de les rendre plus efficients.Nos travaux de thèse ont permis les résultats principaux suivants.Dans un premier temps et après avoir présenté le système de santé en général, nous avons analysé les évolutions du système de santé, ses grands principes et ses challenges. Nous avons ensuite donné un aperçu des tendances et innovations organisationnelles en réponse à ces challenges.Dans un deuxième temps et sur une base bibliographique, nous avons présenté nos définitions du parcours (de soin, de santé, de vie), leur positionnement relatif et l’influence des challenges préalablement définis sur ces derniers.Puis, afin de modéliser les parcours, nous avons analysé les concepts introduits par les définitions précédentes et nous les avons structurés dans le cadre d'un méta-modèle. Nous avons ensuite utilisé celui-ci pour enrichir un langage de modélisation d'entreprise existant (GRAI Extended Actigram) et obtenir ainsi un langage totalement adapté à nos besoins. Ensuite, et à titre d’exemple, nous avons utilisé ce langage enrichi pour représenter les processus de soins de deux maladies (la grippe A(H1N1) et la BPCO) tout en soulignant plusieurs aspects méthodologiques : sources d'information, traduction, pour n’en citer que quelques-uns. Enfin et sur la base d'un état de l'art des services proposés par des plateformes informatiques existantes, nous avons proposé une méthodologie de définition de services à forte valeur ajoutée qui offrent une meilleure accessibilité à l'information et donc qui améliorent la dynamique et l'efficience des soins sur la base des parcours de soins modélisés. / Today, the actors of public health face many challenges related to the ever-changing needs of an aging population and the increasing number of chronic diseases.These needs and the related cost, lead to rethink the care management and rationalize the patient healthcare pathways to make them more efficient.Our thesis work has the following main results.First a general introduction of the health system is presented, followed by an analysis of the evolution of the health system, its principles and its challenges. Next, we provided an overview of trends and organizational innovations in response to these challenges.Secondly, based on a bibliographic, we presented our definitions of pathways (healthcare, health, and life), their relative positioning and their influence on the challenges mentioned above.To model the pathways, we analyzed the concepts mentioned in the preceding definitions and we structured them into a meta-model. Then we used it to enrich an existing enterprise modeling language (GRAI Extended Actigram) and thus obtain a language totally suited to our needs.The latter was used to represent the heathcare processes of two examples of diseases, influenza A (H1N1) and COPD. In the frame of this presentation, methodological aspects were discussed (information resources, translation, etc.).Finally, on the basis of a state-of-the-art of the offered services by current computer platforms, we proposed a methodology for defining value-added services providing an improved access to information and improving the dynamics and efficiency of healthcare based on the modeled healthcare processes.

Les cancers primitifs du péritoine ont une incidence qui varie de 1 à 2 cas/an/1 000 000 d'habitants selon les types. Leur diagnostic et leur prise en charge sont complexes et exigent des spécificités de moyens et de compétences. Dans le cadre du plan cancer, le réseau national de prise en charge des tumeurs rares du péritoine (RENAPE) s'est structuré autour de centres experts et de missions transversales pour garantir à chaque patient, l'accès à l'expertise médicale et diagnostique. Après une revue de la littérature sur l'épidémiologie de ces cancers et leurs caractéristiques de prise en charge, l'objectif de ce travail est d'évaluer l'impact de l'organisation du réseau RENAPE, et de ses actions mises en œuvre, pour améliorer le parcours de soins des patients et favoriser l'évolution des pratiques dans la prise en charge de ces cancers. Une première étude, menée sur une cohorte de mésothéliomes péritonéaux, démontre l'apport de l'organisation RENAPE sur la diminution des délais de prise en charge thérapeutique. Une seconde étude rapporte les actions mises en œuvre par le réseau pour standardiser et homogénéiser les procédures chirurgicales et approches thérapeutiques. Une troisième étude présente les caractéristiques épidémiologiques de la population issue de l'observatoire mis en place au sein du réseau. Enfin, une quatrième étude analyse la distribution spatiale des patients pris en charge au sein du réseau et évalue l'impact de facteurs socio-économiques sur l'incidence des mésothéliomes péritonéaux. En s'appuyant sur une dynamique de réseau, l'organisation RENAPE a permis de structurer une filière de référence qui intègre une approche multidisciplinaire / Rare peritoneal malignancies (RPM) are extremely rare with annual incidence of 1 to 2 case/1,000,000 of the population per year depending types. Diagnostic and therapeutic management are complex and need specialized clinical skills associated to specific technical platforms. As part of the French cancer plan the national network for the treatment of rare peritoneal malignancies (RENAPE) has been organized including expert centres and cross-disciplinary healthcare issues to allow the patients to access to clinical expertise. After literature review of epidemiological data, the aim of this work is to evaluate the impact of the RENAPE healthcare organization on the clinical pathways of patients and to support the development of clinical practices in the management of RPM. A first study demonstrated the benefit of the RENAPE network to reduce the therapeutic management delays in cohort of peritoneal mesothelioma (PM). Then a second work reports the RENAPE initiative to standardize and homogenize the surgical procedures and therapeutic approach. A next study describes the epidemiological characteristic of the population from the RENAPE registry. Finally a fourth study analyzes the geographical distribution of RENAPE cohort and to evaluate the impact of the socioeconomic factors on the PM incidence. Based on the network approach, the RENAPE organization succeeded to structure a healthcare system with multidisciplinary integrated approach

It is estimated that 10% of the global population is impaired to a significant degree by a decrease in hearing sensitivity. With the greatest proportion of these persons residing in developing countries where communities are grossly underserved, it is incumbent on hearing healthcare professionals to seek means of offering equitable hearing health care services to these communities. The delivery of conventional diagnostic hearing services to these population groups is challenged by limitations in human resources, financial constraints and by the dearth of audiometric testing facilities that are compliant with permissible ambient noise levels for reliable testing. Valid diagnostic hearing assessment without an audiometric test booth will allow greater mobility of services and could extend hearing healthcare service delivery in underserved areas. The purpose of this study was to investigate the validity of diagnostic pure tone audiometry in a natural environment, outside a sound treated room, using a computer-operated audiometer with insert earphones covered by circumaural earcups incorporating real-time monitoring of environmental noise. A within-subject repeated measures research design was employed to assess elderly adults with diagnostic air (250 to 8000 Hz) and bone (250 to 4000 Hz) conduction pure tone audiometry. The study was of a quantitative nature and the required data was collected by testing subjects initially in a natural environment and subsequently in a sound booth environment to compare the threshold measurements. One experienced audiologist used audiometric KUDUwave test equipment to evaluate subjects in both environments. A total of 147 adults with an average age of 76 (± 5.7) years were tested. Ears had pure tone averages (500, 1000, 2000 and 4000 Hz) of ≥ 25 dB in 59%, >40 dB in 23% and ˃ 55 dB in 6% of cases. Analysis of collected data showed air conduction thresholds (n = 2259) corresponding within 0 to 5 dB in 95% of all comparisons between testing in the natural and sound booth environments. Bone conduction thresholds (n = 1669) corresponded within 0 to 5 dB in 86% of comparisons and within 10 dB or less in 97% of cases. Average threshold differences (–0.6 to 1.1) and standard deviations (3.3 to 5.9) were within typical test-retest reliability limits. Recorded thresholds showed no statistically significant differences with a paired samples t-test (p ˃ 0.01) except at 8000 Hz in the left ear. Overall the correlation between the air-conduction thresholds recorded in the sound booth environment and the natural environment was very high (˃ 0.92) across all frequencies while for bone conduction threshold correlation for the two environments fell between 0.63 and 0.97. This study demonstrates that valid diagnostic pure tone audiometry in an elderly population can be performed in a natural environment using an audiometer employing insert earphones covered by circumaural earcups with real-time monitoring of ambient noise levels. Mobile diagnostic audiometry performed outside of an audiometric sound booth may extend current hearing healthcare services to remote underserved communities where booths are scarce or inaccessible. In combination with Telehealth applications this technology could offer a powerful and viable alternate diagnostic service to persons unable to attend conventional testing facilities for whatever reasons. / Dissertation (MCommunication Pathology)--University of Pretoria, 2013. / gm2014 / Speech-Language Pathology and Audiology / Unrestricted