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Master of Public Health - MPH / Urban health policy has remained a neglected area in India. The homeless remain the most deprived, neglected and stigmatized group amongst the urban poor. While they suffer from a large burden of disease, there are a variety of reasons that prevent them from accessing the available health care services – particularly in the public health sector. Some interventions by concerned non-governmental organisations have attempted to circumvent the barriers to health care access faced by the homeless but these have not been well documented or assessed. This study seeks to establish both the barriers and facilitating factors for access to health care and health care seeking amongst adult street dwellers in an area of New Delhi which is known for a high concentration of homeless persons. Using a qualitative approach 18 adult street dwellers (both male and female) were individually interviewed – along with 6 key informants working in the public and non-governmental health sector. This was accompanied by a process of participant-observation. The results were analyzed by identifying recurrent themes associated with barriers and facilitating factors for access to health care by the homeless, following which a set of recommendations related to the homeless, have been developed so as to inform those working in the public health sector. In terms of ethics, informed consent was taken from each interviewee and they were explicitly given the option not to participate without adverse consequences to themselves. If any participant was found with acute health problems immediate assistance was facilitated. The study reveals a number of barriers faced by the homeless in attempting to access health care services. While minor ailments are taken care of by local private practitioners, they need to access public health care services for major problems. There they encounter many barriers due to the lack of money, delays and being shunted from place to place. Moreover, they are not able to get admission for reasons such as lack of address and the lack of an attendant. Facilitating factors include assistance for transportation, facilitation of admissions, arranging money for out of pocket expenditures on drugs and consumables, arranging blood and providing after-care. The role of social contacts in enabling access is also demonstrated through this study. The recommendations that emerge from the study are intended to assist in policy advocacy towards a comprehensive health care system for them, as well as assist health care providers to provide a better service for homeless people.

One of the major obstacles to dealing with homelessness has been the difficulty in defining the term. In the mid-1980s, the United Nations proposed a definition of homelessness which acknowledges a range of housing related needs. However, in practice the public sector generally uses a narrower meaning of the term, considering only those who are dependent on emergency shelters and those absolutely without shelter, to be “homeless”. No common definition of homelessness has gained wide acceptance in Canada. Conceptual gaps are created, as the problem of homelessness is defined differently by various sectors and levels of government. The absence of formal recognition of this complex social problem has not served to diminish its impact. An alternative concept of homelessness relates to the continuum of shelter uncertainty among the poverty population. Certain markings of vulnerability to homelessness have been identified to determine which groups are “at risk” of experiencing homelessness. This thesis contends that the broader concept of homeless may be utilized at the municipal level, to better characterise the local nature of the problem and inform responses to local housing need. A case study is presented to explore how the term “homelessness” is operationalized by the City of Vancouver. The opportunities and constraints of municipal housing planning and policy in addressing homelessness are analyzed. Service providers and government representatives were surveyed to evaluate the effectiveness of the City of Vancouver’s responses to the homeless. While the limitations on municipal action were acknowledged, respondents generally support an expanded role for the City as a more proactive facilitator and advocate. The study finds that the range and diversity of acute housing need in the Vancouver case, supports the rationale for broadening the meaning of homelessness and including at risk groups in local planning for the homeless. / Applied Science, Faculty of / Community and Regional Planning (SCARP), School of / Graduate

As pessoas em situação de rua (PSR) apresentam riscos aumentados de desenvolver ou agravar doenças e enfrentam muitas barreiras no cuidado à saúde, inclusive no âmbito da saúde bucal. Porém, existem poucos estudos, principalmente no Brasil, que investigam a saúde bucal dessa população. A presente dissertação teve como objetivo avaliar, sob diferentes ângulos, a condição de saúde bucal de adultos em situação de rua e a sua relação com os serviços odontológicos na cidade de Porto Alegre-RS. Foram produzidos dois artigos que se complementam para ampliar o olhar sobre a temática. O primeiro trata-se de um estudo transversal descritivo que foi realizado com os profissionais de saúde bucal da Atenção Primária à Saúde (APS) de Porto Alegre, com o uso de questionários autoaplicáveis. O instrumento inclui questões socioeconômicas, sobre a formação e atuação profissional, além de questões sobre conhecimentos, experiências e opiniões dos profissionais com relação à população em situação de rua. Foi realizada a descrição das variáveis por meio de frequência absoluta e relativa. Participaram desse estudo 200 profissionais, correspondendo a um percentual de respostas de 62,5%. Viu-se que há pouca experiência das Equipes de Saúde Bucal (ESB) com esse grupo, além de fraca equidade e baixa presença da PSR nos serviços de saúde bucal. Porém, os profissionais demonstraram interesse na temática e conhecem a legislação relacionada. O segundo artigo trata-se de um estudo transversal que foi realizado com adultos em situação de rua que acessam 5 serviços de assistência social da Prefeitura de Porto Alegre (1 albergue, 2 abrigos e 2 centro de atendimento-dia). Foram aplicados questionários contendo variáveis socioeconômicas, questões de saúde, uso de tabaco/álcool/drogas e dor dentária. Uma pesquisadora treinada e calibrada fez exame bucal, avaliando o índice CPOD. A análise estatística foi realizada por meio do teste qui-quadrado, teste-t e teste de Mann Whitney. Participaram do estudo 214 adultos em situação de rua, sendo a maior parte do sexo masculino, não branco, solteiro, com pouca escolaridade e baixa renda. Verificou-se que essa população apresenta muitas perdas dentárias e teve muitas experiências de dor dentária durante a vida, com impacto na realização das tarefas habituais. Mesmo com episódios de dor intensa, a maioria não procurou o dentista e preferiu fazer o auto manejo da dor, incluindo o uso de álcool ou drogas. Viu-se associação entre o tempo na rua com a frequência de dor dentária e com o modo de alívio da dor. Em ambas as metodologias a análise dos dados foi realizada por meio do software SPSS v.21.0 e esta pesquisa foi aprovada pelo Comitê de Ética em Pesquisa da Universidade Federal do Rio Grande do Sul e pelo Comitê de Ética em Pesquisa da Secretaria Municipal de Saúde de Porto Alegre. Antes de serem convidados, os participantes leram e assinaram os respectivos Termos de Consentimento Livre e Esclarecido. Por ser o primeiro estudo no Brasil a pesquisar atitudes de ESB da APS com esse grupo e por descrever as condições bucais e de dor dentária, os dados dessa dissertação tem potencial para romper a invisibilidade da PSR, discutir a sensibilização dos profissionais para o cuidado qualificado em saúde bucal, e embasar o planejamento dos serviços. / Homeless people present increased risks of developing or aggravating diseases and face many barriers to health care, including in the field of oral health. However, there are few studies, mainly in Brazil, that investigate the oral health of this population. The aim of this dissertation was to evaluate, from different angles, the oral health condition of homeless adults and their relationship with dental services in the city of Porto Alegre, RS. Two articles were produced that complement each other to broaden the view on the theme. The first is a cross-sectional descriptive study that was carried out with oral health professionals from Primary Health Care (PHC) in Porto Alegre, using self-administered questionnaires. The instrument includes socioeconomic questions, about training and professional exercise, as well as questions about professionals' knowledge, experiences and opinions regarding the street population. The variables were described by absolute and relative frequency. 200 professionals participated in this study, corresponding to a percentage of responses of 62.5%. It has been seen that there is little experience of Oral Health Teams (OHT) with this group, in addition to poor equity and low homeless people presence in oral health services. However, the professionals showed interest in the subject and know the related legislation. The second article deals with a cross-sectional study carried out with homeless adults accessing 5 services of Porto Alegre City Hall (1 shelter, 2 transitional housing and 2 day care centers). Questionnaires containing socioeconomic variables, health issues, tobacco / alcohol / drug use and dental pain were applied. A trained and calibrated researcher underwent oral examination evaluating the CPOD index. Statistical analysis was performed using the chi-square test, t-test and Mann Whitney test. A total of 214 homeless adults participated in the study, most of them male, not white, single, with little schooling and low income. It was verified that this population presents many dental losses and had many experiences of dental pain during the life, with impact in the accomplishment of the habitual tasks. Even with episodes of intense pain, most did not seek the dentist and preferred to self-manage pain, including the use of alcohol or drugs. There was an association between the time on the street with the frequency of dental pain and the mode of pain relief. In both methodologies the data analysis was performed using the SPSS v.21.0 software and this research was approved by the Research Ethics Committee of the Federal University of Rio Grande do Sul and by the Research Ethics Committee of the Municipal Health Department of Porto Alegre. Before being invited, the participants read and signed the respective Terms of Free and Informed Consent. Because it is the first study in Brazil to research the OHT of PHC attitudes with this group and to describe oral conditions and dental pain, the data of this dissertation has the potential to break the homeless people invisibility, to discuss the sensitization of professionals to qualified care in oral health, and to base the planning of services.

Tuberculosis (TB) is one of the most deadly diseases worldwide. In the United States, TB disproportionately affects foreign-born individuals, individuals living in congregate settings, people with human immunodeficiency virus, and people who use illicit drugs. In 2005, a large homeless shelter outbreak in San Joaquin County resulted in 67 individuals diagnosed with TB with links to a homeless shelter. It is hypothesized that by using bed analysis to identify contacts that have been exposed to TB during this outbreak will allow for better identification of exposed high-risk individuals than screening alone. Demographics, exposure, screening, and QuantiFERON-Tuberculosis results were analyzed using bed assignments from the homeless shelter database and data from a homeless shelter screening (HSS) program. Individuals diagnosed with active TB disease were on average more likely to be identified through bed analysis than HSS, 95.08% versus 59.02%. Utilizing both bed analysis and HSS allows for improvement of identification and continuous testing of individuals exposed to TB.

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Submitted by Filipe dos Santos (fsantos@pucsp.br) on 2018-07-27T13:30:46Z No. of bitstreams: 1 Diego Borges Cordeiro.pdf: 2931254 bytes, checksum: f45774729fbd18fca8eb3204b0fcd386 (MD5) / Made available in DSpace on 2018-07-27T13:30:46Z (GMT). No. of bitstreams: 1 Diego Borges Cordeiro.pdf: 2931254 bytes, checksum: f45774729fbd18fca8eb3204b0fcd386 (MD5) Previous issue date: 2018-06-06 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / Pontifícia Universidade Católica de São Paulo - PUCSP / The present dissertation presents results of a "case study", whose analysis is developed from the attendance of a service of public social assistance network of the city of São Paulo and its users-beneficiaries. The research flourishes with the hypothesis that such services do not precisely meet the demands (needs, expectations and aspirations) of its users and that many of these services have been implemented "top-down", that is, services are decided by the political sphere and implementation is merely an administrative effort to find means for the purpose set. Thus, we chose the Espaço de Convivência known as "Tenda Bela Vista", a facility located in the central region of the city and intended for the specific service of the adult homeless population. Through the Tenda we verify if the Public Policy of Social Assistance "lives" or not in conflict with the demands of its public. One of the methodological procedures in this dissertation is to have "attention" to the conflict, justifying the importance of the phenomenon to analyze the confrontations and contradictions in the field of social assistance public policies in the city of São Paulo, believing that it is through conflict that a more accurate reflection is achieved in the face of the public policy implemented. In this way, the methodology used in the field research comprises: participant observation and ethnography, structured interviews through application of forms, analysis of quantitative data, besides the bibliography(ies) of theorists who debate about public policies, of the homeless population and of social assistance policies in Brazil. In the presentation of the results of this research it is pointed out that the public policy of social assistance is exhausted by the demands (which are constantly redefined) of its public-beneficiary and that the conflicts of social assistance interventions are expressed as a phenomenon for their transformations / A presente dissertação expõe resultados de um “estudo de caso”, cuja análise se desenvolve a partir do atendimento de um serviço da rede pública socioassistencial da cidade de São Paulo e seus usuários-beneficiários. A pesquisa floresce com a hipótese de que tais serviços não atendem precisamente as demandas (necessidades, expectativas e aspirações) de seus usuários e que muitos desses serviços vêm sendo implementados “de cima para baixo”, isto é, os serviços são decididos pela esfera política e a implementação é mero esforço administrativo de achar meios para os fins estabelecidos. Assim, escolhemos o Espaço de Convivência conhecido como “Tenda Bela Vista”, equipamento localizado na região central da cidade e que se destina ao atendimento especificamente da população adulta em situação de rua. Através da Tenda verificamos se a Política Pública de Assistência Social “vive” ou não em conflito com as demandas de seu público. Um dos procedimentos metodológicos nesta dissertação é ter “atenção” com o conflito, justificando a importância do fenômeno para se analisar os enfrentamentos e contradições no campo das políticas públicas de assistência social na cidade de São Paulo, acreditando-se que é por meio do conflito que se atinge uma reflexão mais apurada diante da política pública executada. Desta forma, a metodologia utilizada na pesquisa de campo compreende: observação-participante e etnografia, entrevista estruturada por meio de aplicação de formulários, análise de dados quantitativos, além da(s) bibliografia(s) de teóricos que debatem acerca das políticas públicas, da população em situação de rua e das políticas de assistência social no Brasil. Na exposição dos resultados desta pesquisa aponta-se que a política pública de assistência social esgota-se diante das demandas (que se redefinem a cada momento) de seu público-beneficiário e que os conflitos dos atendimentos socioassistenciais se expressam como um fenômeno para suas transformações

The purpose of this study was to interview the social workers that work with the homeless population within the Inland Empire. Explored were the social workers perceptions of and attitudes about the homeless population as well as hoping to understand the lack of housing for the homeless and to find out what can be done to provide housing for them.

Many researchers argue the increasing reliance on sit/lie ordinances to regulate homeless people's use of public space is one in a suite of neoliberal policies that shape the geographies of public space in cities to serve the needs of global capital. However, these policies are developed at the local, not global, level as specific actors make claims in the public sphere that communicatively shape policy formation. Through comparative case study, this research asks, how do different actors, situated in specific local and global contexts, influence the adoption of sit/lie ordinances? I examine two cases of policymaking in Portland and San Francisco. I use discourse analytic strategies and thematic coding of newspapers, archival documents, and key informant interviews to look at policy-making processes as they occur in their political, social, and economic contexts. I focus especially on the role of language in policy-making, policy-making arenas, and actions of grassroots actors, drawing from three interdisciplinary literatures to develop an explanatory theory of policy-making. I find the four interrelated explanatory factors in policy-making were: the actors (neoliberal and right-to-the-city); the tactics they use; the policy talk they use; and the policy arenas. First, political processes provide windows of opportunity and determine arenas for political activities. The different policy arenas (citizen election, committee, council led, litigation, etc.) influence the audience that the actors care about, and thus the policy talk. Additionally, elected officials have a determining effect on which arenas they use, which in turns structures the opportunities for policy talk. Second, the arena influences the depth to which resisters can discuss the issues with the wider public and decision-makers. This may explain why the right-to-the-city frame may not have been used as much as the academic literature might suggest. Resisters find it much harder to use this framing with the general public or elected officials because it takes too much time to explain to those unfamiliar. Instead, they rely more on concepts that may be more familiar like the dependent poor and unequal impact of the law on minority groups. Third, I find local actors have different positions in the global economy, however on the local level their different avenues and strategies of involvement are due to local conditions rather than global ones. The location in the global political economy seems to be less important than local political decision making contexts and the actions of individuals who are locally powerful due to their economic status and political connections. This suggests room for resisters to use local politics to resist these ordinances, without having to take on the entire global economy. Finally, actors use different narratives to influence decision makers and each other, responding and shifting to competing frames over time. The change over time is important, as it shows how policy debates change based on influences from different actors. My findings suggest the framing of the original necessity for the policy can influence the policy trajectory, but actors can and do respond and successfully shift policy talks over time. The dissertation concludes with additional implications for grassroots practice based on these theoretical findings.