Rwanda has made significant progress in decreasing the number of maternal deaths and increasing the number of antenatal care visits and childbirths at health facilities. This thesis seeks to illuminate potential barriers for Rwanda’s goal for maternal survival. The studies explore the bottom-up perspective of policies and practices in regards to maternal care in Kigali. Semi-structured interviews were conducted between 2013 and 2016 with women who nearly died (‘near-miss’) during pregnancy, their partners, and with other recent fathers and community members, as well as healthcare providers who work within abortion care. The framework of naturalistic inquiry guided the study design and data collection. Analysis was conducted using framework analysis, thematic analysis and naturalistic inquiry. The findings identify paradoxical outcomes in the implementation of maternal care policies. Despite recent amendments of the abortion law, safe abortion was identified as being non-accessible. Abortion-related symptoms continue to carry a criminalized and stigmatized label, which encourages risk-taking and clandestine solutions to unwanted pregnancies, and causes care-seeking delays for women with obstetric complications in early pregnancy. Healthcare providers had limited awareness of the current abortion law, and described tensions in exercising their profession due to fear of litigation. The first antenatal care visit appeared to require the accompaniment of a male partner, which underpinned women’s reliance on men in their care-seeking. Men expressed interest in taking part in maternal care, but faced resistance for further engagement from healthcare providers. Giving birth at a health facility was identified as mandatory, yet care was experienced as suboptimal. Disrespect during counseling and care was identified, leading to repeated care-seeking and may underpin the uptake of traditional medicine. An enhanced implementation of the current abortion law is recommended. Reconsideration of policy is recommended to ensure equitable and complete access to antenatal care: women should be able to seek care accompanied by their person of choice. These findings further recommend action for improved policy to better address men’s preferred inclusion in maternal health matters. The findings of this thesis promote continued attention to implementing changes to strengthen quality, and trust, in public maternal care.

Background: Little is known about the experience and psychological outcomes for women who experience emergency peripartum hysterectomy (EPH). The objective of this study was to explore women's experiences of EPH and to determine if women who experience EPH were more likely to experience mental health sequelae. Methods: This mixed method design involved a quantitative and a qualitative phase. The quantitative phase used a retrospective cohort design. Women were sampled through on-line communities, including an EPH support group, and a larger website for mothers. Women completed on-line surveys covering sociodemographic, obstetric/gynecological/ and psychiatric information, including screens for depression and Post-Traumatic Stress Disorder (PTSD). Logistic regression was used to calculate the independent risk that exposure to EPH has on screening positive for PTSD. Participants from the EPH support group who completed the on-line interview were then selected to participate in the second phase. In-depth telephone interviews were conducted and analyzed using Constant Comparative Analysis. Results: 74 exposed women and 355 non-exposed women completed the survey. In the adjusted logistic regression model, women who experienced EPH were over 6 times more likely to screen positive for current PTSD compared to women who did not experience EPH (adjusted Relative Risk (aRR): 6.76; 95% CI: 4.24, 8.88). When women recalled their psychological state at 6 months postpartum, exposed women were 11 times more likely to screen positive for current PTSD (aRR: 11.35; 95% CI: 8.43, 12.95). In the qualitative phase, 15 women participated and 7 major themes were identified: fear, pain, death and dying, numbness or delay in emotional reaction, bonding with baby, communication and the need for information. A major finding is the need for additional follow-up visits to address the emotional after-effects and to fill in gaps in women's understanding and memory of what had occurred. Conclusion: Understanding women's experiences and sequelae can help providers address not only women's initial complications but provide needed long-term support.

Orientador: Adriano Dias / Resumo: Análise da incidência, identificação dos casos e distribuição dos critérios para a morbidade materna grave, no Distrito Federal. Utilizou-se para a identificação dos casos os critérios da OMS (2010). Inicialmente, delineou-se um estudo transversal, desenvolvido em nove hospitais públicos do Distrito Federal que são referência para a assistência a gestação e ao parto de risco habitual e alto risco, no período entre 01 de julho de 2013 e 29 de dezembro de 2015, a fim de verificar a incidência e identificar os casos de condições potencialmente ameaçadoras da vida (CPAV) e near miss (NM) por meio de busca ativa dos casos e entrevista direta com a paciente. Identificou-se 174 casos de morbidade materna grave em 62.706 nascidos-vivos, gerando uma incidência de 2,77 casos por mil nascidos-vivos. Dos 174 casos entrevistados, 26 foram classificados como CPAV e 148 como NM correspondendo a incidências de 0,4/1.000 e 2,36/1.000, respectivamente. As condições hemorrágicas foram as condicionantes primárias mais significantes (p<0,001) nos casos de maior gravidade (NM). Concomitantemente, desenvolveu-se um estudo caso-controle para estimar a associação entre os fatores de risco para a ocorrência de morbidade materna grave (MMG) utilizando-se o modelo de regressão logística múltipla hierarquizada. Verificou-se a associação entre cada variável preditora e a variável desfecho por meio do teste do Quiquadrado, em sequência, a análise multivariada foi realizada seguindo a entrada hierarquizada ... (Resumo completo, clicar acesso eletrônico abaixo) / Doutor

Submitted by DANIELA MENDES DOS SANTOS MAGALHÃES null (danymendes@yahoo.com.br) on 2017-07-26T04:54:14Z No. of bitstreams: 1 Tese Daniela Magalhaes.pdf: 1427419 bytes, checksum: a1e1e559a3794b7205af5fb16ebc0ddd (MD5) / Approved for entry into archive by Luiz Galeffi (luizgaleffi@gmail.com) on 2017-07-26T19:00:45Z (GMT) No. of bitstreams: 1 magalhaes_dms_dr_bot.pdf: 1427419 bytes, checksum: a1e1e559a3794b7205af5fb16ebc0ddd (MD5) / Made available in DSpace on 2017-07-26T19:00:45Z (GMT). No. of bitstreams: 1 magalhaes_dms_dr_bot.pdf: 1427419 bytes, checksum: a1e1e559a3794b7205af5fb16ebc0ddd (MD5) Previous issue date: 2017-05-26 / Outra / Análise da incidência, identificação dos casos e distribuição dos critérios para a morbidade materna grave, no Distrito Federal. Utilizou-se para a identificação dos casos os critérios da OMS (2010). Inicialmente, delineou-se um estudo transversal, desenvolvido em nove hospitais públicos do Distrito Federal que são referência para a assistência a gestação e ao parto de risco habitual e alto risco, no período entre 01 de julho de 2013 e 29 de dezembro de 2015, a fim de verificar a incidência e identificar os casos de condições potencialmente ameaçadoras da vida (CPAV) e near miss (NM) por meio de busca ativa dos casos e entrevista direta com a paciente. Identificou-se 174 casos de morbidade materna grave em 62.706 nascidos-vivos, gerando uma incidência de 2,77 casos por mil nascidos-vivos. Dos 174 casos entrevistados, 26 foram classificados como CPAV e 148 como NM correspondendo a incidências de 0,4/1.000 e 2,36/1.000, respectivamente. As condições hemorrágicas foram as condicionantes primárias mais significantes (p<0,001) nos casos de maior gravidade (NM). Concomitantemente, desenvolveu-se um estudo caso-controle para estimar a associação entre os fatores de risco para a ocorrência de morbidade materna grave (MMG) utilizando-se o modelo de regressão logística múltipla hierarquizada. Verificou-se a associação entre cada variável preditora e a variável desfecho por meio do teste do Quiquadrado, em sequência, a análise multivariada foi realizada seguindo a entrada hierarquizada das variáveis definidas à priori e que produziram estimativas de odds ratio (OR) com valores de p≤0,25 no modelo univariado. O nível mais distal foi constituído de fatores sociodemográficos, o nível mais proximal por cuidados obstétricos e o intermediário os antecedentes clínicos. Neste estudo foram considerados fatores de risco para morbidade materna grave a cor da pele declarada não branca, renda familiar de até dois salários mínimos, não tem companheiro, realizar menos que seis consultas de pré-natal, não estar vinculada a maternidade de referência e a ausência de trabalho de parto na admissão. Neste estudo, a presença de indicadores socioeconômicos precários e o cuidado obstétrico desqualificado apresentaram relação significativa com o risco para morbidade materna grave. / Incidence analysis, case identification and distribution of criteria for severe maternal morbidity in the Federal District. The WHO criteria (2010) were used to identify the cases. Initially, a cross-sectional study was developed in 09 public hospitals of the Federal District there are a reference for the assistance of gestation and delivery at usual risk and high risk, between July 1, 2013 and December 29, 2015, In order to verify the incidence and identify the cases of potentially life threatening conditions (PLTC) and near miss (NM) by means of active case search and direct interview with the patient. We identified 174 cases of severe maternal morbidity in 62,706 live births, generating an incidence of 2.77 cases per thousand live births. Of the 174 interviewed cases, 26 were classified as PLTC and 148 as NM corresponding to incidence of 0.4 / 1,000 and 2.36 / 1,000, respectively. Hemorrhagic conditions were the most significant primary conditioners (p <0.001) in cases of greater severity (NM). Concurrently, a case-control study was developed to estimate the association between risk factors for the occurrence of severe maternal morbidity (SMM) using the hierarchical multiple logistic regression model. The association between each predictor variable and the outcome variable was verified by means of the Qui-square test, in sequence, the multivariate analysis was performed following the hierarchical input of the variables defined a priori and that produced estimates of odds ratio (OR) with values of P≤0,25 in the univariate model. The most distal level was composed of sociodemographic factors, the most proximal level for obstetric care and the intermediate clinical history. In this study, the risk factors for severe maternal morbidity were declared non-white skin, family income of up to two minimum wages, no partner, less than six prenatal consultations, no reference maternity, and Absence of labor on admission. In this study, the presence of precarious socioeconomic indicators and disqualified obstetric care had a significant relation with the risk for severe maternal morbidity.

The neonatal period is almost half of all deaths in children under five years. Neonatal near miss (NMN) is defined as the newborn had a serious complication but survived during the first seven days of life. Although the assessment of NMN identify factors that cause the high number of deaths in the first week of life, few studies have explored this important issue. Objective: To analyze the risk factors for NMN in High Risk Maternity, Sergipe / Brazil. Methods: A case-control study was conducted in which were classified cases of NMN and their respective controls, after evaluation of all records of live births of hospitalized pregnant women for delivery in March-September 2015. After this identification the collection was performed information through interviews with mothers of newborns and verification of records and cards of pregnant women. For data analysis was used descriptive statistics through absolute and relative frequencies, measures of central tendency and variability. Associations were evaluated using the chi-square test and the Student t test, with α = 0.05 significance level. Next was performed logistic regression analysis considering the variables with p <0.20. Multivariate analysis was performed with pre-selected variables in the previous step, according to the hierarchy shown in the conceptual model. The criterion established in this analysis stage to the variables remained in the model was p <0.05. Results: We classified as NMN 125 newborns (cases) and 250 controls selected. It was observed similarity between the average age of the cases (mean = 25.9 + 7) and controls (mean = 25.6 + 6.9). In this study, 97% of mothers interviewed (344/356) attended school. Conducting prenatal care showed protection against the onset of NMN (OR = 0.04; 95% CI: 0,00 to 0.29). The risk of NMN was higher for RNs of pregnant women who had complications during the pregnancy (OR = 13.37; 95% CI: 7.22-24.76). Conclusion: Conducting prenatal care was an important protective factor for NMN. / O período neonatal representa quase a metade das mortes em crianças menores de cinco anos. Near miss neonatal (NMN) é definido como o recém-nascido que teve uma complicação grave, mas sobreviveu durante os primeiros sete dias de vida. Embora a avaliação de NMN identifique fatores que ocasionam o número elevado de mortes na primeira semana de vida, poucos estudos têm explorado esta importante temática. Nesse estudo, objetivou-se analisar os fatores de risco para NMN na maternidade de alto risco, Sergipe/Brasil. Para tanto, foi realizado um estudo caso-controle em que foram classificados os casos de NMN e seus respectivos controles, após avaliação de todos os prontuários dos nascidos vivos das grávidas internadas para parto, de março a setembro de 2015. Após essa identificação, foi realizada a coleta de informações por meio de entrevistas com as mães dos neonatos e verificação dos prontuários e cartões das gestantes. Para a análise dos dados, foi utilizada a estatística descritiva, por meio de frequências absolutas e relativas, medidas de tendência central e variabilidade. As associações foram avaliadas por meio do teste do Qui-Quadrado e o teste t de Student, com nível de significância α = 0,05. Em seguida, foi realizada análise de regressão logística, contemplando as variáveis, com o p <0,20. A análise multivariada foi feita com as variáveis pré-selecionadas na etapa anterior, de acordo com a hierarquização apresentada no modelo conceitual. O critério estabelecido nesta etapa de análise para que as variáveis permanecessem no modelo foi de p < 0,05. Assim, foram classificados como NMN 125 recém-nascidos (casos) e selecionados 250 controles. Foi observada semelhança entre as médias de idades dos casos (média=25.9+ 7) e dos controles (média=25.6+ 6.9). Neste estudo, 97% das mães entrevistadas (344/356) frequentou a escola. A realização de pré-natal apresentou proteção para o surgimento de NMN (OR = 0.04; IC95%: 0.00-0.29). O risco de NMN foi maior para os RNs de grávidas que tiveram intercorrência na gestação atual (OR= 13.37; IC95%:7.22-24.76). Por fim, observou-se que a realização de pré-natal representou um importante fator protetor para o NMN.

Orientador: Jose Guilherme Cecatti / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-14T20:54:38Z (GMT). No. of bitstreams: 1 Haddad_SamiraElMaerrawiTebecherane_M.pdf: 6986091 bytes, checksum: 426357180584abd261e39ad98c68b5ff (MD5) Previous issue date: 2009 / Resumo: Introdução: A saúde materna é um dos focos das Metas de Desenvolvimento do Milênio das Nações Unidas para 2015. A manutenção dos altos índices de mortalidade decorre principalmente das dificuldades de acesso aos serviços de saúde e inadequação do manejo das complicações obstétricas em locais pouco desenvolvidos. Por outro lado, a ocorrência da morte materna em locais desenvolvidos é um evento relativamente raro em comparação com o número de casos mórbidos. Neste sentido, o estudo da morbidade materna ganhou relevância. Estudos mostraram que a falta de padronização de critérios definidores de morbidade materna grave, a dificuldade de identificação e relato dessas condições nos registros oficiais e pelas próprias mulheres e a condução de investigações retrospectivas, podem distorcer o número real de casos de morbidade. Sistemas de vigilância eletrônica podem trazer melhorias à investigação, por facilitar o relato e completude das informações e diminuir o tempo de coleta e análise das mesmas. Recentemente, foram divulgados pela Organização Mundial da Saúde o novo conceito de near miss materno e critérios de condições definidoras de gravidade. Com este avanço, o seguimento da vigilância e a elaboração de estratégias de redução do problema mundial da morte materna podem ter sua condução embasada em fonte teórica unificada, dando solidez à investigação e norteando o foco da atenção. Objetivos: Criar uma rede nacional de vigilância de morbidade materna grave no Brasil, com abrangência em todas as regiões geográficas do país, elaborar o planejamento teórico de caracterização da rede de vigilância e descrever os métodos e procedimentos adotados para sua implementação. Métodos: O projeto desenvolvido foi de um estudo transversal multicêntrico para implantação em unidades obstétricas de referência em diversas regiões geográficas do Brasil. Durante um período de doze meses, deve ser realizada a vigilância prospectiva e coleta de dados para a identificação dos casos de near miss materno e de condições potencialmente ameaçadoras da vida, segundo os novos critérios da OMS. A partir da elaboração teórica do projeto, foi realizada a seleção dos centros da rede, revisão dos critérios de morbidade materna grave e formulários de coleta de dados, seleção do sistema eletrônico para inclusão de casos, desenvolvimento das ferramentas específicas do software e hardware, desenvolvimento do material de pesquisa, iniciado processo de implementação e análise de processo. Conclusão: A formação teórica da Rede Nacional de Vigilância de Morbidade Materna Grave foi uma conseqüência da experiência adquirida em diversos estudos na área nos últimos anos. A estrutura teórica é parte de um conceito abrangente de cuidado à saúde materna e perinatal, e a sua implementação é a primeira etapa da execução desse planejamento. A arquitetura do sistema de informação da Rede poderá ser utilizada para novos estudos em saúde reprodutiva e perinatal. / Abstract: Introduction: Maternal health is one of the United Nations Millenium Development Goals for 2015. The maintenance of high levels of mortality is due mostly to difficulties to access health care services and inadequacy on the management of obstetrical complications in least developed regions. Furthermore, the occurence of maternal death in developed regions is a relatively rare event compared to the number of morbid cases. Therefore, the study of maternal morbidity became more relevant. Studies showed that the lack of standardization of severe maternal morbidity criteria, difficulties in identifying and reporting these conditions in the official records and the women themselves and retrospective investigations, can distort the actual number of cases of morbidity. Electronic surveillance systems can bring improvements to research, facilitate reporting and completeness of the information and reduce the time of collection and examination. Recently the concept of maternal near miss and defining criteria of severity have been released by the World Health Organization. With this advance, tracking and surveillance strategies to reduce the global problem of maternal mortality may have their management based on a unified theoretical source, giving strength to the research and guiding the focus of attention. Objectives: To create a national surveillance network of severe maternal morbidity in Brazil covering all geographic regions of the country, to develop the theoretical planning of characterization of the network and to describe the methods and procedures adopted for its implementation. Methods: It was developed a cross sectional multicentric study in reference obstetric units in various geographical regions of Brazil. During a period of twelve months, it should be carried out prospective surveillance and data collection for the identification of cases of maternal near miss and potentially life-threatening conditions, according to the new WHO criteria. After the theoretical development of the project, the network centers were selected, the severe maternal morbidity criteria and data collection forms were reviewed, selection of the software for case inclusion, development of specific tools of the software and hardware, development of the research material, initiated the process of implementation and process analysis. Conclusion: The theoretical development of the Brazilian Network for Surveillance of Severe Maternal Morbidity was a result of experience learned in several studies in this area in recent years. The theoretical framework is part of a comprehensive concept of maternal and perinatal health care, and its implementation is the first step in executing this plan. The system architecture of the network information system may be used for further studies in reproductive and perinatal health. / Mestrado / Tocoginecologia / Mestre em Tocoginecologia

Im Schwerpunkt der Dissertation stand die Untersuchung des Zusammenhangs zwischen psychischer Fehlbeanspruchung und Arbeitssicherheit. Psychische Fehlbeanspruchung – mit den Schwerpunkten Über- und Unterforderung – wurde dabei zum einen auf der habituellen Ebene erfasst (mittels Fragebogen). Zum Anderen interessierten die selten oder einmalig auftretenden Fehlbeanspruchungen, die üblicherweise keine Berücksichtigung im Fragebogen finden. Diese wurden mithilfe eines Arbeitstagebuchs erfasst. Die Argumentation für diese differentielle Betrachtungsweise ergibt sich aus der Überlegung, dass während in der Entstehungsgeschichte einer Erkrankung erst eine langfristige Fehlbeanspruchung eine Rolle spielt, kann ein Arbeitsunfall bereits durch eine einmalige oder nur kurzfristig auftretende Fehlbeanspruchung beeinflusst werden. Im Zusammenhang mit der verwendeten Methodik wurde – in einer zusätzlichen Fragestellung - ein sensibilisierender und damit unfallpräventiver Effekt der Tagebuchführung auf die Gefahrenwahrnehmung angenommen und mit einer Pilot-Befragung verifiziert. An der Studie haben vier sächsische Unternehmen der metallverarbeitenden Industrie teilgenommen. Insgesamt 212 männliche Produktionsarbeiter haben einen Fragebogen ausgefüllt (Rücklaufquote: 60%), und 63 von ihnen haben ebenfalls ein vollständig über 15 Arbeitstage geführtes Tagebuch abgegeben. Beide Datenquellen erfassten parallel (als Prädiktoren) die wahrgenommenen Belastungsfaktoren am Arbeitsplatz bzw. die psychische Fehlbeanspruchung (qualitative und quantitative Über- bzw. Unterforderung sowie soziale Belastung) sowie deren negative Folgen (Merkmale von Stress, psychischer Ermüdung und Monotonie). Ebenfalls auf zweierlei Art wurden die Kriterienvariablen erhoben (meldepflichtige Arbeitsunfälle, Verletzungen und Beinahe-Unfälle; im Fragebogen zusätzlich noch ein Index sicheren Verhaltens). Die Ergebnisse der Regressionsanalysen haben die Annahme bestätigt, dass sowohl Überforderung als auch Unterforderung die individuelle Arbeitssicherheit beeinträchtigen. Sicheres Verhalten am Arbeitsplatz wird von Merkmalen der Arbeitsgestaltung, insbesondere durch Unterbrechungen und quantitative Überforderung, negativ beeinflusst. Beeinträchtigend auf die Einhaltung der Arbeitsschutzregeln wirkt sich auch belastendes Verhalten des Vorgesetzten aus. Relevant für die Regeleinhaltung sind ebenfalls die erlebten Folgen einer Über- und Unterforderung: Merkmale psychischer Ermüdung einerseits, Langeweile und Unzufriedenheit mit der Aufgabe andererseits. Interessant sind die Ergebnisse bezüglich der individuellen Variabilität der täglich erlebten Fehlbeanspruchungsfolgen. Mit steigenden Schwankungen von Langeweile und Erschöpfung werden die Arbeitsschutzregeln seltener eingehalten und Beinahe-Unfälle kommen häufiger vor. Erlebte meldepflichtige Unfälle und Verletzungen (im Fragebogen erfasst) stehen lediglich mit zwei tagebuchbasierten Prädiktoren in einem signifikanten Zusammenhang: mit Häufigkeit der sozialen Konflikte und mit der kumulierten Erschöpfung. Diese Faktoren weisen in ihrem Zusammenhang mit individueller Arbeitssicherheit somit eine besonders hohe Validität und Generalisierbarkeit auf. Die Methode der Tagebuchführung stieß, selbst bei einer relativ langen Untersuchungsdauer, auf eine hohe Akzeptanz der Teilnehmer. Die angenommene, auf Gefahren und für Arbeitssicherheit sensibilisierende Wirkung der Tagebuchführung konnte anhand der Selbsteinschätzungen bestätigt werden. Als innovatives und mitarbeiterorientiertes Instrument betrieblicher Unfallprävention hat die Tagebuchführung das Potenzial, einen wichtigen Beitrag zur Umsetzung der Ziele der Gemeinsamen Deutschen Arbeitsschutzstrategie für den Zeitraum 2008 - 2012 zu leisten.

The practice of reporting workplace incident events is adopted as best practice by organizations and complies with Occupational Safety and Health Administration (OSHA) mandates. Reporting the near miss incident type in which no injury or damage to equipment or the environment occurs is buttressed by the assumption that both the worker and the organization ascribe to the same goal to identify workplace hazards and prevent incident recurrence. The goal of incident reporting is not apparent, and the path to achieving the goal is obstructed by internal and external hazards that act to oppose the reporting process, such that the goals are obscured by competing priorities. The general qualitative method was applied to a nonrandom snowball sampling technique to recruit eight participants. Over 176 years of combined experience across aircraft maintenance and petrochemical operations are represented. Participants were removed from either industry within the last five years. Each participant experienced multiple near miss incident events in the past. At the time an incident occurs, the compelling individual need that exists is explained in terms of Abraham Maslow’s (1943) theory of motivation. The Process- Practice-Purpose principle is developed and used to demonstrate the association between activities (the “what”) that occur within workspaces and customary practices (the “how”) that develop in the course of realizing the incident reporting goal. Three recurring themes support the findings: (a) The motivation to report, (b) Beliefs about reporting, and (c) The purpose of 7 reporting over time. Together, the themes form the three-legged stool of the incident reporting perception. Any leg missing renders the stool out of balance. Hazards are identified in terms of personal safety. The near miss definition is expressed in terms of individual perspective and is guided by experience, personality, knowledge, and personal agency to take action. The goal of reporting is explained in terms of benefit to people, the process, and practice. Alignment with the OHSA goal is evaluated by examining the motivation to report, beliefs about reporting, and the purpose of reporting over time. The Principle of Understanding partnership model is developed to engage the worker and the organization in active learning from near miss incidents through awareness and knowledge about the cumulative utility of near miss data, perceptions of incident severity, and optimizing communication.

Im Schwerpunkt der Dissertation stand die Untersuchung des Zusammenhangs zwischen psychischer Fehlbeanspruchung und Arbeitssicherheit. Psychische Fehlbeanspruchung – mit den Schwerpunkten Über- und Unterforderung – wurde dabei zum einen auf der habituellen Ebene erfasst (mittels Fragebogen). Zum Anderen interessierten die selten oder einmalig auftretenden Fehlbeanspruchungen, die üblicherweise keine Berücksichtigung im Fragebogen finden. Diese wurden mithilfe eines Arbeitstagebuchs erfasst. Die Argumentation für diese differentielle Betrachtungsweise ergibt sich aus der Überlegung, dass während in der Entstehungsgeschichte einer Erkrankung erst eine langfristige Fehlbeanspruchung eine Rolle spielt, kann ein Arbeitsunfall bereits durch eine einmalige oder nur kurzfristig auftretende Fehlbeanspruchung beeinflusst werden. Im Zusammenhang mit der verwendeten Methodik wurde – in einer zusätzlichen Fragestellung - ein sensibilisierender und damit unfallpräventiver Effekt der Tagebuchführung auf die Gefahrenwahrnehmung angenommen und mit einer Pilot-Befragung verifiziert. An der Studie haben vier sächsische Unternehmen der metallverarbeitenden Industrie teilgenommen. Insgesamt 212 männliche Produktionsarbeiter haben einen Fragebogen ausgefüllt (Rücklaufquote: 60%), und 63 von ihnen haben ebenfalls ein vollständig über 15 Arbeitstage geführtes Tagebuch abgegeben. Beide Datenquellen erfassten parallel (als Prädiktoren) die wahrgenommenen Belastungsfaktoren am Arbeitsplatz bzw. die psychische Fehlbeanspruchung (qualitative und quantitative Über- bzw. Unterforderung sowie soziale Belastung) sowie deren negative Folgen (Merkmale von Stress, psychischer Ermüdung und Monotonie). Ebenfalls auf zweierlei Art wurden die Kriterienvariablen erhoben (meldepflichtige Arbeitsunfälle, Verletzungen und Beinahe-Unfälle; im Fragebogen zusätzlich noch ein Index sicheren Verhaltens). Die Ergebnisse der Regressionsanalysen haben die Annahme bestätigt, dass sowohl Überforderung als auch Unterforderung die individuelle Arbeitssicherheit beeinträchtigen. Sicheres Verhalten am Arbeitsplatz wird von Merkmalen der Arbeitsgestaltung, insbesondere durch Unterbrechungen und quantitative Überforderung, negativ beeinflusst. Beeinträchtigend auf die Einhaltung der Arbeitsschutzregeln wirkt sich auch belastendes Verhalten des Vorgesetzten aus. Relevant für die Regeleinhaltung sind ebenfalls die erlebten Folgen einer Über- und Unterforderung: Merkmale psychischer Ermüdung einerseits, Langeweile und Unzufriedenheit mit der Aufgabe andererseits. Interessant sind die Ergebnisse bezüglich der individuellen Variabilität der täglich erlebten Fehlbeanspruchungsfolgen. Mit steigenden Schwankungen von Langeweile und Erschöpfung werden die Arbeitsschutzregeln seltener eingehalten und Beinahe-Unfälle kommen häufiger vor. Erlebte meldepflichtige Unfälle und Verletzungen (im Fragebogen erfasst) stehen lediglich mit zwei tagebuchbasierten Prädiktoren in einem signifikanten Zusammenhang: mit Häufigkeit der sozialen Konflikte und mit der kumulierten Erschöpfung. Diese Faktoren weisen in ihrem Zusammenhang mit individueller Arbeitssicherheit somit eine besonders hohe Validität und Generalisierbarkeit auf. Die Methode der Tagebuchführung stieß, selbst bei einer relativ langen Untersuchungsdauer, auf eine hohe Akzeptanz der Teilnehmer. Die angenommene, auf Gefahren und für Arbeitssicherheit sensibilisierende Wirkung der Tagebuchführung konnte anhand der Selbsteinschätzungen bestätigt werden. Als innovatives und mitarbeiterorientiertes Instrument betrieblicher Unfallprävention hat die Tagebuchführung das Potenzial, einen wichtigen Beitrag zur Umsetzung der Ziele der Gemeinsamen Deutschen Arbeitsschutzstrategie für den Zeitraum 2008 - 2012 zu leisten.

Healthcare systems require continuous monitoring of risk to prevent adverse events. Risk analysis is a time consuming activity that depends on the background of analysts and available data. Patient safety data is often incomplete and biased. This research proposes systematic approaches to monitor risk in healthcare using available patient safety data. The methodologies combine traditional healthcare risk analysis methods with safety theory concepts, in an innovative manner, to allocate available evidence to potential risk sources throughout the system. We propose the use of data mining to analyze near-miss reports and guide the identification of risk sources. In addition, we propose a Maximum-Entropy based approach to monitor risk sources and prioritize investigation efforts accordingly. The products of this research are intended to facilitate risk analysis and allow for timely identification of risks to prevent harm to patients.