The aim of this diploma thesis is to practically analyse the application of a value added tax in healthcare services. The thesis focuses on a correct identification of the output tax in healthcare services. Since an accountant or a tax adviser can carry out this identification only in a cooperation with a doctor, the text is accompanied by summary tables for healthcare workers. The first chapter focuses on basic aspects of economy in a healthcare sector. The second chapter analyses related Czech and European legislations. The third chapter explains the correct identification of VAT in selected healthcare services. The last chapter analyses VAT in questionable healthcare services - medical reports based on german tax office interpretations.

Bakgrund: I Sverige drabbas ca 13 000 personer varje år av hjärtstopp, där HjärtLungRäddning (HLR) är primär åtgärd för chans till överlevnad. Ställningstagande att inte utföra HLR på sjukhus benämns ”beslut om utebliven HLR”. Befogenhet till beslut angår legitimerade läkare, men sjuksköterskor är en viktig resurs. I samskapande omvårdnad utformas vård i samråd mellan patienter och yrkesutövare, vilket tydliggör patienters ställning i vårdsituationen. Sjuksköterskor behöver säkerhet i beslut gällande utebliven HLR för att undvika att orsaka omotiverat lidande hos patienter. Syfte: Att beskriva sjuksköterskors erfarenheter av att vårda patienter vid beslut om utebliven HLR på somatisk vårdavdelning. Metod: Litteraturöversikten baserades på 13 vetenskapliga artiklar med kvalitativ metod. Litteratursökning utfördes i databaserna Cinahl samt Medline. Dataataanalys utfördes genom Fribergs analys i fem steg och inspirerades av Graneheim & Lundmans standardiserade modell.   Resultat: Resultatet presenterades i tre huvudteman med tillhörande sub-teman. Huvudteman var Etik, Informationsutbyte samt Beslutsprocessen. Resultatet beskrev sjuksköterskors önskan att inte orsaka lidande samt att bevara patienters värdighet. En välinformerad patient ansågs förmögen för eget ställningstagande till beslut om utebliven HLR. Trots sjuksköterskors begränsade roll i beslutsfattandet beskrevs sjuksköterskors roll i uppmärksammande av förändringar i patienters status. Vidare beskrevs vikt av tydlig dokumentation, direktiv och riktlinjer. Slutsats: Trots nuvarande riktlinjer beskrivs sjuksköterskors osäkerhet vid beslut och vård av patienter med beslut om utebliven HLR. Vidare forskning, utveckling av PM och riktlinjer är nödvändigt för sjuksköterskors trygghet i sin yrkesutövning samt för främjande av patienters autonomi. / Background: In Sweden, approximately 13 000 people suffer cardiac arrest each year, where CardioPulmonaryResuscitation (CPR) is the primary measure for a chance of survival. A decision to not perform CPR in hospitals is referred to as a “Decision to not perform cardiopulmonary resuscitation”. The authority to make decisions about treatment restrictions concerns the authorized physician but nurses are important resources in the decision process. In the co-production of healthcare services, care is designed as a consultation between patients and professionals, which makes the patients ‘position clear. Nurses need certainty in their decisions to not perform CPR, to avoid causing unjustified suffering to patients.  Aim: To describe nurses’ experiences of caring for patients in the event of a decision of non-CPR in somatic care units.  Method: The literature review was based on 13 scientific original articles with qualitative methods. A literature search was performed in the databases Cinahl and Medline. Data analysis was performed with Friberg´s analysis in five steps and inspired by Graneheim & Lundman´s standardized model. Results: The results were presented in three main themes with associated sub-themes. The main themes were Ethics, Information exchange and Decision Process. The result described nurses ‘desire to not cause suffering and to preserve patients ‘dignity. A well-informed patient was considered capable of making their own decision about CPR. Despite nurses´ limited role in decision-making, nurses ‘role in noticing changes in patient´s status was described. Furthermore, the importance of clear documentation, directives and guidelines was described.   Conclusion: Despite current guidelines, nurses ‘uncertainty in the decision process and in the care of patients with decisions are described. Further research and development of PMs and guidelines are necessary for nurses ‘security in their work and for the promotion of patient autonomy.

Introduction The differential accessibility of healthcare services in the Nordic region can be drawn along socioeconomic and sociodemographic lines. Previous literature has established the association between the processes of marginalisation and inequitable healthcare access outcomes. This study contributes to existing knowledge by exploring the association with regard to primary healthcare service accessibility.     Methods Logistic regression assessed the association between perceived marginalisation and medical consultation barriers. A multinomial regression further analysed the specific type of systemic primary healthcare barriers marginalised respondents were more likely to encounter in comparison to non-marginalised respondents. This analysis used data from 5,689 respondents residing in the Nordic region from the 7th round of the European Social Survey.   Results After adjusting for health problems, socioeconomic, sociodemographic, and sociocultural factors, respondents who reported perceived marginalisation were more likely to face healthcare access barriers (OR = 2.87, 95 % CI = 2.28 – 3.64, p < 0.001). Additionally, marginalised respondents were more likely to report facing systemic access barriers pertaining to long wait times in comparison to non-marginalised respondents (RRR = 3.69, 95% CI = 2.52– 5.40, p < 0.001).    Conclusion This thesis observes that individuals who see themselves as marginalised invariably encounter amplified systemic obstacles when seeking primary healthcare services. Public health policies in the Nordics aimed at increasing accessibility have not conclusively resulted in an improved accessibility among marginalised communities. Thus, a re-evaluation of policies aimed at improving primary healthcare access is necessary.

No description available.

Cette étude de cas vise à comparer le modèle de soins implanté sur le territoire d’un centre de santé et des services sociaux (CSSS) de la région de Montréal aux modèles de soins en étapes et à examiner l’influence de facteurs contextuels sur l’implantation de ce modèle. Au total, 13 cliniciens et gestionnaires travaillant à l’interface entre la première et la deuxième ligne ont participé à une entrevue semi-structurée. Les résultats montrent que le modèle de soins hiérarchisés implanté se compare en plusieurs points aux modèles de soins en étapes. Cependant, certains éléments de ces derniers sont à intégrer afin d’améliorer l’efficience et la qualité des soins, notamment l’introduction de critères d’évaluation objectifs et la spécification des interventions démontrées efficaces à privilégier. Aussi, plusieurs facteurs influençant l’implantation d’un modèle de soins hiérarchisés sont dégagés. Parmi ceux-ci, la présence de concertation et de lieux d’apprentissage représente un élément clé. Néanmoins, certains éléments sont à considérer pour favoriser sa réussite dont l’uniformisation des critères et des mécanismes de référence, la clarification des rôles du guichet d’accès en santé mentale et l’adhésion des omnipraticiens au modèle de soins hiérarchisés. En somme, l’utilisation des cadres de référence et d’analyse peut guider les gestionnaires sur les enjeux à considérer pour favoriser l’implantation d’un modèle de soins basé sur les données probantes, ce qui, à long terme, devrait améliorer l’efficience des services offerts et leur adéquation avec les besoins populationnels. / The purpose of the present study was to compare the care model of one Montreal local territory to the stepped-care model and to investigate factors influencing the implementation of this model. A qualitative case-study approach was employed involving 13 semi-structured interviews with services providers and managers from primary and specialist mental healthcare. Results showed that the hierarchical care model in place in this territory is compared in several points with the stepped-care model. However, some elements of these models have to be integrated to improve efficiency and quality of care, including the introduction of objective evaluation criteria and the specification of evidence-based interventions. Furthermore, some factors influenced the implementation of this hierarchical care model. Thus, the presence of collaborative working and learning strategies were identified to be a key condition. However, some elements must be considered to facilitate its success like the standardization of the referral criteria and process, the clarification of the mental health guichet d’accès (centralized access point) roles and the general practitioners' adherence to the care model. In conclusion, the use of the reference and analysis frames of this study may guide managers on issues to be considered to support the implementation of an evidence-based care model which may facilitate mental healthcare efficiency and its adequacy with the population needs.

Depuis les années 1990, les indicateurs de la santé sexuelle des jeunes de 18 à 25 ans démontrent que ce groupe d’âge est sexuellement vulnérable, ce qui est observable en raison de la hausse du taux d’infections transmises sexuellement, ainsi que des lacunes de connaissances en matière de santé sexuelle. Ce mémoire propose un regard nouveau sur la santé sexuelle des jeunes à partir d’un faisceau de perspectives sociologiques axées sur les déterminants sociaux de la santé pour mieux comprendre la vulnérabilité sexuelle chez les jeunes. Nous faisons appel à trois pistes analytiques en particulier : la perspective matérialiste, la perspective bio-psycho-sociale et la perspective des parcours de vie. Notre démarche de recherche s’inscrit dans une approche issue de la théorisation ancrée, employée au sein d’une clinique jeunesse de Montréal. Nos outils d’investigation consistent en entretiens semi-dirigés réalisés avec des intervenantes de la clinique et des jeunes patients âgés de 18 à 25 ans, ainsi qu’en observations non participantes dans divers lieux de la clinique. Les résultats de cette recherche font ressortir quatre déterminants sociaux : la question des connaissances en matière de santé sexuelle, les scripts sexuels genrés, la période de la jeunesse lors du parcours sexuel et les caractéristiques du quartier du centre-ville de Montréal. En tenant compte des perspectives croisées de ceux qui voient (les intervenantes) et de ceux qui vivent (les jeunes) la vulnérabilité sexuelle, nous pouvons mieux définir ces déterminants, leurs sources et leurs effets. Nous faisons également état de nos résultats au prisme des trois cadres analytiques des déterminants sociaux de la santé. Nous espérons que ces résultats inciteront la poursuite de recherches dans le domaine des déterminants sociaux de la vulnérabilité sexuelle et qu’ils seront utiles dans la formulation des recommandations pratiques pour les interventions en santé sexuelle auprès des jeunes. / Since the 1990s, public health indicators have continuously highlighted negative sexual health outcomes for youth aged 18 to 25, ranging from increases in rates of sexually transmitted infections, to major sexual health knowledge gaps. These indicators suggest that youth are increasingly sexually vulnerable. The objective of this study was to shed new light on the domain of youth sexual health from the vantage point of sociological perspectives on health. Our research interrogations are theoretically grounded in a social determinants of health perspective, in which three analytical perspectives were explored: materialist, bio-psycho-social and life course perspectives. Our research methodology is inspired by a grounded theory approach, which was adopted to examine a youth sexual health clinic based in Montreal. In this milieu, it was possible for us to meet healthcare workers and youth aged 18 to 25 with the objective of better understanding the social determinants of youth sexual vulnerability. Our methods included semi-structured interviews and non-obtrusive observations in various locations of the clinic. The results from this study underscore four social determinants of youth sexual vulnerability: youth sexual health knowledge, gendered sexual scripts, the period of youth during their sexual lives and characteristics of the downtown neighborhood of Montreal. An approach taking into account the perspectives of those who witness (the healthcare professionals) and those who experience (the youth) sexual vulnerabilities enabled us to better understand these determinants, their sources and effects. We analyze these determinants using the three social determinants of health perspectives. We hope that the results of this study will encourage further research in the field of youth sexual health within a sociological approach, as well as encourage and improve interventions for youth and their sexual health.

La présente thèse explore, à travers quatre papiers, la possibilité d’étendre le régime d’assurance maladie sociale (SHI) vers la couverture santé universelle (CSU) et ce en présence d’obstacles structurels économiques.Les effets moyens de deux traitements, les deux assurances MHI et MAS, sur l’utilisation des soins de santé (consultations externes et hospitalisations) sont estimés. L’actuel régime d’assurance sociale en Tunisie (SHI), malgré l’amélioration de l’utilisation des soins de santé procurée aux groupes couverts, reste incapable d’atteindre une couverture effective de tous les membres de la population vis-à-vis des services de soins dont ils ont besoin. L’atteinte de cet objectif requière une stratégie qui cible les ‘‘arbres’’ et non la ‘‘forêt’’.Le chapitre deux contourne les principaux obstacles à l’extension de la couverture par l’assurance maladie et propose une approche originale permettant de cibler les travailleurs informels et les individus en chômage. Une étude transversale d’évaluation contingente (CV) a été menée en Tunisie se proposant d’estimer les volontés d’adhésion et les consentements à payer (WTP) pour deux régimes obligatoires présentés hypothétiquement à l’adhésion. Les résultats confirment l’hypothèse selon laquelle la proposition d’une affiliation volontaire à un régime d’assurance obligatoire serait acceptée par la majorité des non couverts et que les WTP révélés pour cette affiliation seraient substantiels. Enfin, dans le chapitre trois, on insiste sur l'’importance de prendre en compte les attitudes protestataires en évaluant la progression vers la CSU. / This thesis explores, in a four paper format, the possibility of extending social health insurance (SHI) schemes towards Universal Health Coverage (UHC) in presence of structural economic obstacles.The average treatment effects of two insurance schemes, MHI and MAS, on the utilization of outpatient and inpatient healthcare are estimated. The current Tunisian SHI schemes, despite improving utilization of healthcare services, are nevertheless incapable of achieving effective coverage of the whole population for needed services. Attaining the latter goal requires a strategy that targets the “trees” not the “forest”.Chapter two gets around major challenges to extending health insurance coverage and proposes an original approach by targeting informal workers and unemployed. A cross-sectional Contingent valuation (CV) study was carried out in Tunisia dealing with willingness-to-join and pay for two mandatory health and pension insurance schemes.Results support the hypotheses that the proposition of a voluntary affiliation to mandatory insurance schemes can be accepted by the majority of non-covered and that the WTP stated are substantial.Finally in chapter three we focus on methodological aspects that influence the value of the WTP. Our empirical results show that the voluntary affiliation to the formal health insurance scheme could be a step towards achieving UHC in Tunisia. Overall, we highlight the importance of taking into account protest positions for the evaluation of progress towards UHC.

Cette étude de cas vise à comparer le modèle de soins implanté sur le territoire d’un centre de santé et des services sociaux (CSSS) de la région de Montréal aux modèles de soins en étapes et à examiner l’influence de facteurs contextuels sur l’implantation de ce modèle. Au total, 13 cliniciens et gestionnaires travaillant à l’interface entre la première et la deuxième ligne ont participé à une entrevue semi-structurée. Les résultats montrent que le modèle de soins hiérarchisés implanté se compare en plusieurs points aux modèles de soins en étapes. Cependant, certains éléments de ces derniers sont à intégrer afin d’améliorer l’efficience et la qualité des soins, notamment l’introduction de critères d’évaluation objectifs et la spécification des interventions démontrées efficaces à privilégier. Aussi, plusieurs facteurs influençant l’implantation d’un modèle de soins hiérarchisés sont dégagés. Parmi ceux-ci, la présence de concertation et de lieux d’apprentissage représente un élément clé. Néanmoins, certains éléments sont à considérer pour favoriser sa réussite dont l’uniformisation des critères et des mécanismes de référence, la clarification des rôles du guichet d’accès en santé mentale et l’adhésion des omnipraticiens au modèle de soins hiérarchisés. En somme, l’utilisation des cadres de référence et d’analyse peut guider les gestionnaires sur les enjeux à considérer pour favoriser l’implantation d’un modèle de soins basé sur les données probantes, ce qui, à long terme, devrait améliorer l’efficience des services offerts et leur adéquation avec les besoins populationnels. / The purpose of the present study was to compare the care model of one Montreal local territory to the stepped-care model and to investigate factors influencing the implementation of this model. A qualitative case-study approach was employed involving 13 semi-structured interviews with services providers and managers from primary and specialist mental healthcare. Results showed that the hierarchical care model in place in this territory is compared in several points with the stepped-care model. However, some elements of these models have to be integrated to improve efficiency and quality of care, including the introduction of objective evaluation criteria and the specification of evidence-based interventions. Furthermore, some factors influenced the implementation of this hierarchical care model. Thus, the presence of collaborative working and learning strategies were identified to be a key condition. However, some elements must be considered to facilitate its success like the standardization of the referral criteria and process, the clarification of the mental health guichet d’accès (centralized access point) roles and the general practitioners' adherence to the care model. In conclusion, the use of the reference and analysis frames of this study may guide managers on issues to be considered to support the implementation of an evidence-based care model which may facilitate mental healthcare efficiency and its adequacy with the population needs.

Antecedentes: Varios estudios han demostrado como las políticas de control del tabaquismo favorecen el abandono del consumo del tabaco entre los fumadores, incrementan la aceptabilidad y el cumplimiento de los espacios sin humo. Sin embargo, se desconoce el impacto que las diferentes medidas de control del tabaquismo tienen en los hospitales catalanes. Hipótesis: 1) La política de espacios sin humo en los hospitales reduce la prevalencia de consumo de tabaco entre los trabajadores, favoreciendo cambios en la actitud y el comportamiento en el cumplimiento de las normativas. 2) La Ley 28/2005 ha contribuido a la progresión y el avance de las políticas de control de tabaquismo en los hospitales y 3) ha fomentado cambios en la disminución del humo ambiental del tabaco (HAT) en los hospitales de Cataluña. 4) Los hospitales de 7 países europeos que han desarrollado el modelo de hospital sin humo de la Red Europea sin Humo (ENSH) presentan niveles bajos de HAT en distintas áreas de hospitalización. 5) El programa de cesación tabáquica dirigido a trabajadores fumadores de los hospitales miembros de la Red Catalana de Hospitales sin Humo (XCHsF) consigue una alta tasa de abstinencia. Objetivos: 1) Describir los efectos en el consumo de tabaco tras la implantación progresiva de las políticas de control de tabaquismo en un centro hospitalario: el Instituto Catalán de Oncología (ICO). 2) Valorar la progresión de las políticas de control de tabaquismo en los hospitales miembros de la XCHsF antes y después de la implantación de la Ley de medidas de control del tabaco 28/2005. 3) Evaluar el impacto de la Ley de control de tabaquismo 28/2005 en la exposición al HAT en los hospitales públicos catalanes, antes (2005) y después (2006) de su implantación. 4) Describir los niveles de HAT mediante la determinación de partículas PM2.5, en una muestra de hospitales europeos en el año 2007. 5) Evaluar la efectividad de un programa de cesación tabáquica dirigido a los trabajadores hospitalarios. Metodología: Para conseguir los objetivos marcados se han realizado cinco estudios que incluyen: una serie de encuestas transversales, un estudio pre-post de evaluación de las medidas de control del tabaco, dos estudios de determinación del HAT - uno realizado en Cataluña, y el otro en 7 países europeos- y un estudio de evaluación de la efectividad de un programa de cesación tabáquica coordinado por la XCHsF en 33 hospitales. Resultados: La prevalencia de consumo de tabaco en el ICO disminuyó del 34,5% en 2001 al 30,6% en el 2006. Entre los médicos la prevalencia descendió del 20,0% al 15,2%, entre las enfermeras del 34,0% al 32,6%, y entre los administrativos del 56,0% al 37,0%. Se produjeron cambios en el patrón de consumo como la reducción del número de cigarrillos y del número de fumadores diarios. La puntuación media de la implementación de las políticas de control del tabaco en los hospitales fue del 52,4 (IC 95%: 45,4-59,5) en 2005 y 71,6 (IC 95%: 67,0-76,2) en 2007 (aumento del 36,7%). Los hospitales con mayor incremento fueron los hospitales generales (48%), hospitales con >300 camas (41,1%), hospitales cuyos trabajadores fuman entre un 35-39% (72,2%), hospitales con un implantación reciente de políticas de control del tabaco (74,2%). En los hospitales de Cataluña la concentración media de nicotina disminuyó de 0,23 μg/m3 (rango intercuartil: 0,13-0,63) antes de la Ley 28/2005, a 0,10 μg/m3 (rango intercuartil: 0,02-0,19) después de la Ley (disminución del 56,5%). Tras la Ley se observaron reducciones significativas en la concentración mediana de nicotina en todas las localizaciones, aunque se continuaron detectando valores de HAT en las entradas de los hospitales, sala de urgencias, escaleras de incendios y cafeterías. La mediana de las concentraciones de PM2.5 en una muestra de 30 hospitales europeos fue de 3,0 μg/m3. La mitad de las medidas presentaron valores entre 2,0 a 7,0 μg/m3. Los niveles de PM2.5 fueron similares entre los diferentes países. Once medidas (5,5%) estaban por encima de 25,0 μg/m3, límite recomendado por la OMS para los espacios exteriores. Los trabajadores de una muestra de hospitales catalanes que entraron en el programa de cesación tabáquica coordinado por la XCHsF presentaron una probabilidad de abstinencia global a los 6 meses de 0,504 (IC 95%: 0,431- 0,570). Los hombres obtuvieron mejor abstinencia 0,526 (IC 95%: 0,398-0,651) que las mujeres (0,495 IC 95%: 0,410-0,581). Por grupos profesionales, los médicos obtuvieron una abstinencia más alta (0,659, IC 95%: 0,506-0,811) que las enfermeras (0,463, IC 95%: 0,349-0,576). Los trabajadores con mayor dependencia a la nicotina tuvieron una menor probabilidad de abstinencia (0,376, IC 95%: 0,256-0,495) que los trabajadores con baja dependencia (0,529, IC 95%: 0,458-0,599). Se observa una alta probabilidad de abstinencia en trabajadores que siguieron un tratamiento farmacológico combinado (bupropion y sustitutivos de la nicotina) (0,761, IC 95%: 0,588-0,933). Conclusiones: La introducción progresiva de políticas de control del tabaquismo en los hospitales se asocia con una ligera disminución del consumo de tabaco y la modificación del patrón de consumo entre los trabajadores fumadores. La política de espacios sin humo en los hospitales disminuye la percepción de la exposición al HAT e incrementa el cumplimiento auto reportado de la normativa entre los trabajadores. Los niveles de HAT disminuyen en los hospitales tras la entrada en vigor de la Ley 28/2005. La valoración de las concentraciones de nicotina en fase vapor ofrece un sistema de monitorización objetivo y fiable que refuerza el cumplimiento de los espacios sin humo. La presencia de HAT en los hospitales europeos monitorizada mediante PM2.5 es baja, a excepción de la hallada en lugares en los que se permite fumar cuya concentración es elevada. Los hospitales miembros de la XCHsF presentan un mayor control de tabaquismo (medidas mediante el cuestionario europeo selfaudit) tras dos años de implantación de la Ley 28/2005 (2007) que los obtenidos antes de la Ley (2005). El programa de cesación tabáquica coordinado por la XCHsF dirigido a los trabajadores hospitalarios fumadores obtiene una alta probabilidad de abstinencia a los seis meses. Los trabajadores tratados con dependencia baja o media, los fumadores de 10-19 cigarrillos al día y los tratados con terapia combinada obtuvieron mejores tasas de abstinencia / "Implementation and Evaluation of Tobacco control Policies in Hospitals" Background: Several studies have shown that tobacco control policies favour the cessation of tobacco use, increase population support and improve compliance with smoke free policies. However, the impact of tobacco control measures in Catalan hospitals is unknown. Hypothesis: 1) The smoke free policy in hospitals reduces the prevalence of tobacco consumption among workers and increases compliance with smoke free regulations; 2) Law 28/2005 has increased tobacco control policies in hospitals; 3) has decreased second-hand smoke (SHS) levels among Catalan hospitals; 4) European hospitals which have developed the European smoke free model (ENSH) have low levels of SHS in different areas; 5) the smoking cessation program addressed to hospital employees achieves a high rate of abstinence. Aims: 1) To describe the effects on tobacco consumption after the gradual implementation of tobacco control policies in a hospital; 2) to evaluate the progression of tobacco control policies in hospitals members of the XCHsF before and after the implementation of Law 28/2005, 3) To assess the impact of tobacco control Law 28/2005 on exposure to SHS in public hospitals in Catalonia, before (2005) and after (2006) its implementation. 4) To describe the levels of SHS by the assessment of PM2.5 particles in a sample of European hospitals in 2007; 5) to evaluate the effectiveness of a smoking cessation program addressed to hospital workers. Methodology: Five studies have been conducted, which were: a series of cross-sectional surveys, a pre-post evaluation of tobacco control measures, two studies for the assessment of SHS- one in Catalonia, and another in 7 European countries- and a study evaluating the effectiveness of a smoking cessation program. Results: The tobacco consumption at one hospital dropped from 34.5% in 2001 to 30.6% in 2006. Smokers changed their consumption patterns with the reduction of the number of cigarettes smoked per day and the decrease of daily smokers. The average score of the implementation of tobacco control policies in hospitals was 52.4 (95% CI 45.4 to 59.5) in 2005 and 71.6 (95% CI 67.0 to 76.2) in 2007 (up 36.7%). The average median concentration of nicotine decreased 56.5% after the implementation of Law 28/2005. However, nicotine was found in hospitals halls, emergency rooms, fire escapes and cafeterias. The median concentrations of PM2.5 in a sample of 30 European hospitals were low (3.0 ug/m3). The abstinence probability of the XCHsF tobacco cessation program at 6 months was 0.504 (95% CI 0.431 to 0.570). Workers with higher nicotine dependence showed a lower likelihood of abstinence (0.376, 95% CI: .256 to .495) than the low-dependence (0.529, 95% CI 0.458 to 0.599). There is a high probability of abstinence among workers treated with combined drug therapy (bupropion and nicotine replacement) (0.761, 95% CI 0.588 to 0.933). Conclusions: Tobacco control policies in hospitals are associated with a slight decline in smoking consumption, reduction of levels of SHS, and high probability of abstinence at 6 months.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / In community pharmacies, at the time the pharmacist incorporates clinical practice into their routine, several barriers and facilitators influencing the implementation of patient care services. Objectives: To learn and understand the perception of a group of pharmacists on the process of implementation of Clinical Pharmacy Services in community pharmacies; Understand through a Scoping Review of literature, pharmacist perception about Clinical Pharmacy Services in community pharmacy. Methods: The study was structured in two stages. The first step corresponded to Scoping Review held in the Lilacs, PubMed, Scopus, Scielo and Web of Knowledge database. Studies should be of the pharmacist perception, and the pharmaceutical services should be patient-focused. The second stage corresponded to a qualitative study in which three focus groups were conducted with a group of 11 pharmacists. Data analysis was done using the technique of content analysis. Results: Step 1 - The literature search resulted in 29 articles that met the inclusion criteria. The studies were performed in eight different countries, had qualitative methods (focus groups, interviews, diaries and questionnaires) and quantitative (questionnaires) and 12 different classifications of pharmaceutical services were found. In most studies, pharmacists believed that their role in community pharmacies was positive for patients, barriers and facilitators for service were reported. Step 2 - The audio recording of the focus groups were fully transcribed and analyzed. The perception of pharmacists brought issues such as access to medication, barriers and facilitators to service, expectations, changes generated during the implementation of services, results achieved and consolidation of services. Conclusion: The Scoping Review made recommendations for implementation of Clinical Services Pharmacists in community pharmacies, making it easier to service delivery and enhancing practices in community pharmacies. The dissemination of positive experiences in implementations of services through perception studies have shown that it is possible to develop a model of clinical services in community pharmacies. / Em farmácias comunitárias, no momento em que o farmacêutico incorpora a prática clínica em sua rotina, várias barreiras e facilitadores influenciam a implantação de serviços de cuidado aos pacientes. Objetivos: Conhecer e compreender a percepção de um grupo de farmacêuticos sobre o processo de implementação dos Serviços Clínicos Farmacêuticos em farmácias comunitárias; Conhecer e compreender por meio de uma Revisão de Escopo da literatura, a percepção farmacêutico na provisão de Serviços Clínicos Farmacêuticos em farmácia comunitária. Metodologia: O estudo foi estruturado em duas etapas. A primeira etapa correspondeu a Revisão de Escopo realizada nas bases de dados Lilacs, PubMed, Scopus, Scielo e Web of Knowledge. Os estudos deveriam ser e se declarar de percepção de farmacêutico e os Serviços Farmacêuticos deveriam ser centrados no paciente. A segunda etapa correspondeu a um estudo qualitativo, no qual foram realizados três Grupos Focais com um grupo de 11 farmacêuticos. A análise dos dados foi feita por meio da técnica de análise de conteúdo. Resultados: Etapa 1 - A pesquisa bibliográfica resultou em 29 artigos que cumpriram os critérios de inclusão. Os estudos foram realizados em oito países diferentes, possuíam metodologias qualitativas (grupos focais, entrevistas, diários e questionários) e quantitativas (questionários), e foram encontradas 12 diferentes classificações de serviços farmacêuticos. Na maioria dos estudos, os farmacêuticos acreditavam que seu papel em farmácias comunitárias era positivo para os pacientes, barreiras e facilitadores para os serviços foram relatados. Etapa 2 - A gravação dos áudios dos grupos focais foi integralmente transcrita e analisada. A percepção dos farmacêuticos trouxe temas como acesso ao medicamento, barreiras e facilitadores para o serviço, expectativas, mudanças geradas ao longo da implementação dos serviços, resultados atingidos e a consolidação dos serviços. Conclusão: A Revisão de escopo apresentou recomendações para a implementação de serviços clínicos farmacêuticos em farmácias comunitárias, tornando mais fácil a provisão de serviços e valorizando as práticas em farmácias comunitárias. A divulgação de experiências positivas em implementações de serviços por meio de estudos de percepção têm mostrado que é possível desenvolver um modelo de serviços clínicos em farmácias comunitárias.