La mortalité maternelle et périnatale est un problème majeur de santé publique dans les pays en développement. Elle illustre l’écart important entre les pays développés et les pays en développement. Les interventions techniques pour améliorer la santé maternelle et périnatale sont connues dans les pays en développement, mais ce sont la faiblesse des systèmes de santé et les défis liés aux ressources qui freinent leur généralisation. L’objectif principal de ce travail était de mieux comprendre le rôle des ressources humaines en particulier ceux de la première ligne dans la performance d’un système de référence maternelle. Au Mali, la mise en place d’un système de référence maternelle, système de référence-évacuation « SRE », fait partie des mesures nationales de lutte contre la mortalité maternelle et périnatale. Les trois composantes du SRE, soit les caisses de solidarité, le transport et la communication et la mise à niveau des soins obstétricaux, permettent une action simultanée du côté de la demande et de l’offre de soins maternels et périnatals. Néanmoins, la pénurie de personnel qualifié a conduit à des compromis sur la qualification du personnel dans l’implantation de ce système. La région de Kayes, première région administrative du Mali, est une région de forte émigration. Elle dispose d’une offre de soins plus diversifiée qu’ailleurs au Mali, grâce à l’appui des Maliens de l’extérieur. Son SRE offre ainsi un terrain d’études adéquat pour l’analyse du rôle des professionnels de première ligne. De façon plus spécifique, ce travail avait pour objectifs 1) d’identifier les caractéristiques des équipes de soins de première ligne qui sont associées à une meilleure performance du SRE en termes de survie simultanée de la mère et du nouveau-né et 2) d’approfondir la compréhension des pratiques de gestion des ressources humaines, susceptibles d’expliquer les variations de la performance du SRE de Kayes. Pour atteindre ces objectifs, nous avons, à partir du cadre de référence de Michie et West modélisé les facteurs liés aux ressources humaines qui ont une influence potentielle sur la performance du SRE de Kayes. L’exploration des variations du processus motivationnel a été faite à partir de la théorie de l’attente de Vroom. Nous avons ensuite combiné une revue de la littérature et un devis de recherche mixte (quantitative et qualitative). Les données pour les analyses quantitatives proviennent d’un système d’enregistrement continu de toutes les urgences obstétricales (GESYRE : Gestion du Système de Référence Évacuation mis en place depuis 2004 dans le cadre du suivi et de l’évaluation du SRE de Kayes) et des enquêtes à passages répétés sur les données administratives et du personnel des centres de santé. Un modèle de régression biprobit a permis d’évaluer les effets du niveau d’entrée dans le SRE et des équipes de soins sur la survie jointe de la mère et du nouveau-né. A l’aide d’entrevues semi-structurées et d’observations, nous avons exploré les pratiques de gestion des personnes dans des centres de santé communautaires « CScom » sélectionnés par un échantillonnage raisonné. Les résultats de ce travail ont confirmé que la main d’œuvre humaine demeure cruciale pour la performance du SRE. Les professionnels de première ligne ont influencé la survie des femmes et des nouveau-nés, à morbidités égales, et lorsque la distance parcourue est prise en compte. La meilleure survie de la mère et du nouveau-né est retrouvée dans les cas d’accès direct à l’hôpital régional. Les femmes qui sont évacuées des centres de première ligne où il y a plus de professionnels ou un personnel plus qualifié avaient un meilleur pronostic materno-fœtal que celles qui ont consulté dans des centres qui disposent de personnel peu qualifié. Dans les centres de première ligne dirigés par un médecin, des variations favorables à la performance comme une implication directe des médecins dans les soins, un environnement de soins concurrentiel ont été retrouvés. Concernant les pratiques de gestion dans les centres de première ligne, les chefs de poste ont mis en place des incitatifs pour motiver le personnel à plus de performance. Le processus motivationnel demeure toutefois très complexe et variable. La désirabilité de bons résultats des soins (valence) est élevée pour tous les professionnels ; cependant les motifs étaient différents entre les catégories de personnel. Par ailleurs, le faible niveau d’équipements et la multiplicité des acteurs ont empêché l’établissement d’un lien entre l’effort fourni par les professionnels et les résultats de soins. Cette compréhension du rôle des professionnels de première ligne pourra aider le personnel administratif à mieux cibler le monitorage de la performance du SRE. Le personnel de soins pourra s’en servir pour reconnaitre et appliquer les pratiques associées à une bonne performance. Dans le domaine de la recherche, les défis de recherche ultérieurs sur les facteurs humains de la performance du SRE seront mieux identifiés. / Although proven effective interventions have been transferred from the developed world, developing countries still face high maternal and perinatal deaths. Weak health systems and human resources crisis hinder the scaling up of those interventions. This study is aimed at improving the understanding of the role of human resources, especially the first line staff in a maternal referral system, the evacuation and referral system (ERS) of Kayes (Mali). The implantation of the ERS as part of major strategies for fighting maternal and perinatal deaths has been generalised in Mali’s eight administrative regions. The ERS main components are: upgrading of emergency obstetric care (EmOC); funding by a solidarity fund; and improving transport and communication by ambulance. These components allows for joint action regarding the supply and the use of maternal and perinatal services. Yet, due to the shortages in skilled birth attendants, the extension of the coverage in emergency obstetric services has been made with less qualified staff. Kayes is Mali’s first administrative region and a cradle of emigration. It therefore offers, with the support of its immigrants, a more diversified primary care provision than elsewhere in Mali. This gives an opportunity of studying the role of primary care staff in the ERS performance. More precisely, the objectives of this research were to: 1 identify characteristics of primary care teams that influenced the ERS performance assessed by the joint mother-child survival and 2) improve the understanding of human resources practices associated with ERS performance. We combined a systematic literature review with a mixed quantitative and qualitative research design. Kayes ERS performance was modelised using Michie and West conceptual framework and the motivational process was explored with Vroom’s expectancy theory. Data for the quantitative analyses derived from an ongoing system of registering all obstetric emergencies implemented since 2004 (GESYRE: Gestion du Système de Référence Évacuation / Management of the Evacuation Referral System) and periodic surveys. A biprobit regression model has been fitted to estimate the effects of the point of entry in the ERS and the primary care team composition on the joint mother-newborn survival. We also conducted semi structured interviews and non participant observations in order to explore human resources practices in purposely selected community health centers. This research confirmed the importance of human resources in ERS performance. When women’ individual risk factors are controlled for, there is a combined effect of distance traveled and the point of entry in the ERS on one side and the community health centers staff on the other hand, on the mother-child joint survival. The best prognosis of care was found in women who directly accessed care at the regional hospital. Having been transferred from a community health center where there is a physician or more than three professionals increased the mother-child survival probability. Physicians in community health centers develop strategies for a better performance of the health centers they managed: direct implication in care and a competitive care environment. Primary care managers set up incentives to motivate staff. The motivation process remains however a variable and complex one. The desirability of good results was common for all staff though its motivations varied according to the type of staff. Besides, due to insufficiency of material and multiples intermediate factors, perception of a linkage between effort and result was low. This increased understanding of the role of primary care human resources in the ERS performance would focus the management of ERS performance on targeted but effective interventions. The workforce could benefit from the study conclusions in identifying and applying best practices. Further research challenges would also be more precisely identified.

The purpose of the present study was to investigate the influence of pain causal attributions on patient pain-related functioning, treatment engagement, and clinical outcomes. Additionally, the impact of discordant pain causal attributions between patients and their providers as well as between interdisciplinary providers was examined. Patients rated their pain functioning and causal pain attributions during a regular clinic visit. Following the patient’s visit both the behavioral medicine provider and internal medicine resident provided ratings of similar pain-related functioning domains and causal attributions. Follow-up data were collected from the electronic medical record three months following that clinic visit. Overall, results revealed that patients’ chronic pain attributions did influence pain-related functioning, however the impact was relatively small. There was insufficient evidence to conclude that chronic pain attributions influence a patient’s readiness to adopt self-management coping strategies and their subsequent treatment engagement. Additionally, results confirmed that different health care disciplines attribute the cause of patients’ chronic pain in distinct ways and these unique perspectives can lead to discrepant pain-related functioning assessments between providers. Discordant ratings between providers were shown to influence referring patterns for interdisciplinary services and the patient’s overall opioid dose. Similarly, discrepancies between patients and their providers influenced subsequent referral for behavioral health services, the patient’s attendance at those visits, and their overall morphine equivalent doses. Together the results indicate the important role pain attributions can play in chronic pain management and highlight the central role of the patient-provider and provider-provider relationship.

Abstrakt Bakgrund: Flertalet av patienterna vilka söker akuten är inte i behov av akutsjukvård. Sjuksköterskor på akutmottagningarna kan idag hänvisa patienter till annan vårdnivå så som primärvård eller till hemmet med egenvårdsråd.   Syfte: Syftet var att belysa triagesjuksköterskans erfarenhet av hänvisning till annan vårdnivå än akutmottagning.   Metod: Studien var en kvalitativ intervjustudie genomförd med semistrukturerade intervjuer. I studien ingick intervjuer med 12 sjuksköterskor, både med och utan specialistutbildning, vilka arbetar på akutmottagning samt har erfarenhet av hänvisning av patienter till annan vårdnivå. Kvalitativ innehållsanalys har använts för att bearbeta insamlad data.   Resultat: Triagesjuksköterskans erfarenhet av att hänvisa patienter till annan vårdnivå tolkades utifrån följande teman för att belysa olika faktorer som påverkar sjuksköterskans handling på en akutmottagning; faktorer som påverkar hänvisning, professionella stöd och handläggningsstrategier vid hänvisning. Resultatet visade att respondenterna upplever hänvisning som komplext och stundtals svårt där sjuksköterskan känner sig osäker, samtliga respondenter uppgav att de hade erfarenhet av patienter som uppträder agiterat samt hotfullt vid hänvisning, flertalet uttryckte därför att de kände sig otrygga på sin arbetsplats, de uttryckte även att erfarenhet samt klinisk blick var av stor betydelse vid hänvisning av patienter.   Slutsats: Författarnas kliniska slutsats är att respondenterna anser att möjligheten till att kunna hänvisa patienterna till en annan vårdnivå är av stor patientnytta. Detta då patienten får adekvat och rätt vård från början relaterat till deras sjukdomstillstånd vilket även kan leda till att väntetiden på akutmottagningen minskar. Mer utbildning liksom beslutstöd behövs för att göra sjuk sjuksköterskor tryggare med sin hänvisning. Författarna anser även att studien ger viktiga infallsvinklar inom problemområdet som kan vara användbara i en kommande yrkesroll. / Abstract Background: The majority of patients who seek emergency care, are not in need of it. Nurses at emergency departments can refer patients to other type of care, such as primary care or to the home with self-care advices. Referral are often carried out independent and therefore the nurses requires a high level of expertise as well as good communication skills.   Purpose: The aim of the study is to highlight the triage nurse's experience of referral of patients from the emergency department to other care givers such as primary healthcare and self-care.   Method: The study was a qualitative interview study, conducted with semi-structured interviews. The study included interviews with 12 nurses, both with and without specialisteducation, who works in the emergency department and has experience of referring patients to other level of care. Content analysis has been used to process the collected data   Result: The triagenurse experience of referring patients to other care was interpreted based on the following themes to highlight the various factors affecting the nurse's action in an emergency; factors affecting reference, professional support and management strategies by reference. The results showed that respondents perceive reference as complex and sometimes difficult where the nurse feels insecure, all respondents stated that they had the experience of patients who appear agitated and threatening at time of referral, the majority of the respondents therefore expressed they felt insecure in their workplace, they also expressed that the experience and clinical gaze was of great importance in referring patients.   Conclusion: The authors' clinical conclusion is that the respondents believe that the ability to be able to refer patients to other level of care is of significant patient benefit. This resulting in the patient receiving adequate care from the start related to their disease severity which also can lead to that the waiting time at the emergency room is reduced. More education and decision support is needed to make nurses more secure whilst performing referrals. The authors also believe that the study provides important insights in the problem area that may be useful in a future profession.

Submitted by SBI Biblioteca Digital (sbi.bibliotecadigital@puc-campinas.edu.br) on 2018-04-11T12:44:28Z No. of bitstreams: 1 MARINA AUTUORI.pdf: 1422722 bytes, checksum: c8da9e0caa1128cd23ab88f7c58a03ca (MD5) / Made available in DSpace on 2018-04-11T12:44:28Z (GMT). No. of bitstreams: 1 MARINA AUTUORI.pdf: 1422722 bytes, checksum: c8da9e0caa1128cd23ab88f7c58a03ca (MD5) Previous issue date: 2018-02-27 / Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior - CAPES / The growing demand for child psychological care results in increased referral of children to mental health services. However, a rate of 50% to 60% abandonment of child psychotherapy is estimated. Since the beginning of child psychological care is the most delicate and decisive phase for the success or failure of psychotherapy, we must investigate the purposes of children's psychological referrals to understand the meanings attributed to this process. To do so, using a psychoanalytically oriented qualitative methodology, we interviewed four children, their parents, psychologists and other professionals involved in the referral to a Public Health Unit for Children and Adolescents. We adopted as a procedure the framework of individual open interviews and the investigative resource of Interactive Narratives to facilitate access to the experience undergone by the participants. We have established five thematic axes that contemplate the meanings found, both in the scientific literature and in the participants' reports, as follows: Reasons for child referral; Sources of child referral; Profile of children's clientele; Parents and the psychological care of their children; and Adherence and abandonment of psychotherapy. Such axes guide the discussion about the theme of the psychological referral of children in the light of the scientific literature as well as the work of Donald Woods Winnicott. Parents appear as the main part involved, although usually excluded from decision making, whose participation in all stages of the referral process is decisive to the success or failure of the referral itself. In addition, the inclusion of the child's perspective has enabled us not only to reveal the meanings that it attributes to the efforts of understanding by professionals, to parental care and to their own suffering, but to doubt the effectiveness of any intervention that disregards the child's view and excludes a deep partnership with parents. / La creciente demanda por la atenci?n psicol?gica infantil resulta en el aumento de la derivaci?n de ni?os a los servicios de salud mental. Sin embargo, se estima una tasa de 50% a 60% de abandono de la psicoterapia infantil. Siendo el inicio de la atenci?n psicol?gica infantil la fase m?s delicada y decisiva para el ?xito o fracaso de la psicoterapia, cabe investigar los sentidos de las derivaciones psicol?gicas infantiles, a fin de comprender los significados atribuidos a este proceso. Para ello, utilizando el m?todo cualitativo de orientaci?n psicoanal?tica entrevistamos cuatro ni?os, sus padres, psic?logos y otros profesionales involucrados en las derivaciones a una Unidad P?blica de Salud Mental Infanto-Juvenil. Adoptamos como procedimiento el encuadre de entrevistas abiertas individuales y el recurso investigativo de las Narrativas Interactivas, con la intenci?n de facilitar el acceso a la experiencia vivida por los participantes. Establecimos cinco ejes tem?ticos que contemplan los sentidos encontrados, tanto en la literatura cient?fica como en los relatos de los participantes, que son: Motivos para la derivaci?n infantil; Fuentes de derivaci?n infantil; Perfil de la clientela infantil; Los padres y la atenci?n psicol?gica de los hijos; y Adhesi?n y abandono de la psicoterapia. Tales ejes gu?an la discusi?n sobre el tema de derivaci?n infantil a la luz de la literatura cient?fica, as? como la obra de Donald Woods Winnicott. Los padres aparecen como los principales involucrados, aunque usualmente excluidos de la toma de decisiones, siendo su participaci?n en todas las etapas de proceso de derivaci?n decisiva para el ?xito o fracaso de la derivaci?n psicol?gica infantil. Adem?s de eso, la inclusi?n de la perspectiva del ni?o nos permiti? no solo revelar los sentidos que ?l atribuye a los esfuerzos de comprensi?n por parte de los profesionales, al cuidado parental y a su propio sufrimiento, sino dudar de la eficacia de cualquier intervenci?n que no tenga en cuenta la visi?n infantil y excluya una profunda cooperaci?n con los padres. / A crescente demanda pelo atendimento psicol?gico infantil resulta no aumento do encaminhamento de crian?as para os servi?os de sa?de mental. Entretanto, estima-se uma taxa de 50% a 60% de abandono da psicoterapia infantil. Sendo o in?cio do atendimento psicol?gico infantil a fase mais delicada e decisiva para o sucesso ou fracasso da psicoterapia, cabe investigarmos os sentidos do encaminhamento psicol?gico infantil, a fim de compreendermos os significados atribu?dos a esse processo. Para tanto, utilizando metodologia qualitativa de orienta??o psicanal?tica entrevistamos quatro crian?as e seus pais, al?m de psic?logos e outros profissionais envolvidos com os encaminhamentos para uma Unidade P?blica de Sa?de Mental Infanto-Juvenil. Adotamos como procedimento o enquadre de entrevistas abertas individuais e o recurso investigativo das Narrativas Interativas, no intuito de facilitar o acesso ? experi?ncia vivida pelos participantes. Estabelecemos cinco eixos tem?ticos que contemplam os sentidos encontrados, tanto na literatura cient?fica quanto nos relatos dos participantes, a saber: Motivos para o encaminhamento infantil; Fontes de encaminhamento infantil; Perfil da clientela infantil; Os pais e o atendimento psicol?gico dos filhos; e Ades?o e abandono da psicoterapia. Tais eixos norteiam a discuss?o sobre o tema do encaminhamento psicol?gico infantil ? luz da literatura cient?fica e da obra de Donald Woods Winnicott. Os pais figuram como os principais envolvidos, embora usualmente exclu?dos da tomada de decis?o, cuja participa??o em todas as etapas do processo de encaminhamento psicol?gico ? decisiva para o sucesso ou fracasso do pr?prio encaminhamento. Al?m disso, a inclus?o da perspectiva da crian?a nos permitiu n?o s? revelar os sentidos que esta atribui aos esfor?os de compreens?o dos profissionais, ao cuidado parental e ao seu pr?prio sofrimento, mas duvidar da efic?cia de qualquer interven??o que desconsidere a vis?o infantil e exclua uma profunda parceria com os pais.

Made available in DSpace on 2016-04-29T14:17:56Z (GMT). No. of bitstreams: 1 Solange Silva dos Santos Fidelis.pdf: 19440012 bytes, checksum: 96f027392e08f7ae6a632ddb2ad28e57 (MD5) Previous issue date: 2009-10-09 / Conselho Nacional de Desenvolvimento Científico e Tecnológico / This research aimed to understand how it has developed the process of implementation and deployment of CRAS in western Parana, considering the political administrative division of the State, the SETP by the Regional Office of Cascavel. First constructed a table with the profile of the municipalities that make up the coverage area of the ER in Cascavel, and from the data listed was established methodological procedures with clipping by intentional sampling by setting 7 of a total of 34 municipalities. It involved 10 professionals working in CRAS, 4 professionals in the management of municipal social care policy and 1 professional as the representative of the State Authorities in the region. In the data collection technique was used semi-structured interview in order to enable the construction of the profile of CRAS: conditions of physical infrastructure and human; the actions taken and the conditions that have been carried; conception of persons involved directly with the public social care as the SUAS and the CRAS; the relationship of CRAS and social care network in this context, considering also the conditions for the development of social care policy. It was then possible to view the progress made after initiating the deployment of SUAS, the limitations in that process and the challenges to the achievement of the advocates that the National Policy for Social Care/SUAS. It was possible from direct contact with the subjects, systematize and is currently regarded as the SUAS towns in the region, considering the different realities set in PNAS/SUAS at the rate of population municipalities, large and small porte I, and level of full and basic management. Considering the variety of realities and different degrees of development of social care policy, the research presented common issues, among which stands out: the lack of full team of human resources, physical structure and equipment inadequate; the vulnerable identity of CRAS, an issue exacerbated as installed in the same structure as previously established services, absence of social diagnosis to support interventions; wide emergency demand assuming seconded volume of actions taken hindering the advancement of social-educational work, and allocations of CRAS finally settled, especially as regards the relationship with the social care network in the territory. Finally, this work contributes to trigger the debate about the actual conditions for the deployment of CRAS as an innovative and essential proposal to the success of SUAS, which represents a breakthrough for social care policy / Essa pesquisa teve como objetivo conhecer de que forma tem se desenvolvido o processo de implementação e implantação dos CRAS na região oeste do Paraná, considerando a delimitação político administrativa do Estado, pela SETP através do Escritório Regional de Cascavel. Inicialmente construiu-se um quadro com o perfil dos municípios que compõem a área de abrangência do ER de Cascavel, e a partir dos dados elencados estabeleceu-se os procedimentos metodológicos com recorte por amostragem intencional, definindo 7 de um total de 34 municípios. Foram entrevistados 10 profissionais que atuam nos CRAS, 4 profissionais da área de gestão da política de assistência municipal e 1 profissional da SETP enquanto representante do órgão gestor do Estado na região. Na coleta de dados foi utilizada a técnica de entrevista semi-estruturada, de forma a possibilitar a construção do perfil dos CRAS; as condições de estrutura física e humana; as ações desenvolvidas e as condições em que têm sido realizadas; a concepção dos sujeitos envolvidos diretamente com a assistência social pública quanto ao SUAS e ao CRAS; a relação entre CRAS e a rede socioassistencial; nesse contexto, considerando também as condições de desenvolvimento da política de assistência social. A partir daí foi possível visualizar os avanços alcançados depois de iniciada a implantação do SUAS, as limitações encontradas nesse processo e os desafios a fim de que se alcance o que preconiza a Política Nacional de Assistência Social/SUAS. Foi possível a partir do contato direto com os sujeitos da pesquisa, sistematizar como está se constituindo o SUAS nos municípios da região, considerando as distintas realidades estabelecidas na PNAS/SUAS, pelo índice populacional dos municípios, em grande porte e pequeno porte I, e os níveis de gestão plena e básica. Diante da variedade de realidades locais e de graus distintos de desenvolvimento da política de assistência social, a pesquisa permitiu identificar alguns problemas comuns, entre os quais, destacam-se: a falta de equipe completa de recursos humanos; a inadequada estrutura física e de equipamentos inadequadas; a fragilizada ou por se constituir - identidade do CRAS, questão agravada quando instalado na mesma estrutura que serviços anteriormente estabelecidos; ausência de diagnóstico social para dar suporte às intervenções; ampla demanda emergencial assumindo destacado volume das ações realizadas e dificultando o avanço do trabalho socioeducativo; as atribuições do CRAS por se estabelecerem, principalmente no que se refere à relação com a rede socioassistencial no território. Por fim, essa dissertação vem contribuir para desencadear o debate acerca das condições concretas de implantação dos CRAS, enquanto proposta inovadora e essencial para o sucesso do SUAS, que representa um grande avanço para a política de assistência social

<p><strong>Sammanfattning</strong></p><p>Syfte: Syftet med denna studie var att undersöka samband mellan några utvalda faktorer av betydelse vid förskrivning av fysisk aktivitet på recept (FaR) på hälso- och vårdcentraler i Sverige.</p><p>Metod: En enkätundersökning genomfördes på 37 icke-privata hälso- och vårdcentraler i Malmö, Stockholm och Umeå. Totalt 241 enkäter besvarades av legitimerad personal med förskrivningsrätt av FaR. Studerade faktorer, uttryckta som enkätfrågor, var: förskrivarens<em> kön, ålder, befattning, landstingstillhörighet, användning av FaR/FYSS, egen motion, FaR-utbildning, tidsbrist, riktlinjer, uppföljning, samarbete med friskvårdsaktör, FaR-ansvarig, hänvisning av FaR-patienter, kunskap i att motivera till fysisk aktivitet </em>samt<em> kunskap om vilka sjukdomstillstånd som kan behandlas med fysisk aktivitet</em>. En webb-baserad enkät distri-buerades och samlades in via e-post och en pappersenkät användes på ett par hälso- och vårdcentraler. Resultatet från enkätundersökningen analyserades med chitvåtest och binär logistisk regression. </p><p>Resultat: Sannolikheten att förskriva FaR var signifikant sju gånger högre hos personal som visste vart de kunde <em>hänvisa patienter med FaR-ordination</em> i jämförelse med dem som inte visste vart hänvisning kunde ske. Vidare var sannolikheten att förskriva FaR signifikant fyra gånger högre hos personal med specifik <em>utbildning om FaR</em> i jämförelse med dem som inte hade någon FaR-utbildning. I undersökningen framkom även att förskrivning av FaR samvarierade signifikant med faktorerna <em>befattning, landstingstillhörighet, samarbete med friskvårdsaktör/-er, riktlinjer från arbetsgivaren, kunskap om vilka sjukdomstillstånd som kan behandlas med fysisk aktivitet</em> samt <em>kunskap i att motivera patienter till fysisk aktivitet</em>. Ingen signifikant samvariation sågs mellan förskrivning av FaR och följande faktorer: förskrivarens <em>kön</em>, <em>ålder</em>, <em>användning av FaR/FYSS</em>, <em>egen motion</em>, <em>FaR-ansvarig</em>, <em>uppföljning</em> samt <em>om personalen avstår från att förskriva FaR pga att det förlänger patientbesöken</em>.</p><p>Slutsats: Vid arbete med FaR är det viktigt att skapa tydliga <em>riktlinjer</em>, <em>samarbeta med frisk-vårdsaktör/-er</em>, <em>att personalen har kunskap om vilka sjukdomstillstånd som kan behandlas med fysisk aktivitet</em> samt om<em> motivation till fysisk aktivitet</em>. Vi vill poängtera att det framförallt är viktigt att personalen är <em>utbildad om FaR</em> samt att de vet vart de kan <em>hänvisa patienter med FaR-ordination</em> i syfte att effektivisera FaR som arbetsmetod på hälso- och vårdcentraler i Sverige.</p> / <p><strong>Abstract</strong></p><p>Aim: The aim of this study was to examine relations between selected factors significant to the prescription of Physical Activity Referral Scheme (PAR, Swedish: Fysisk aktivitet på recept, FaR) at health centers in Sweden.</p><p>Method: A questionnaire study was carried out within 37 non-private health centers in Malmö, Stockholm and Umeå. A total of 241 questionnaires were answered by personnel authorized to prescribe FaR. Studied factors, expressed as questions in the questionnaire, were: prescriptors<em> sex, age, profession, county council, the use of FaR/FYSS, personal exer-cise, FaR-education, lack of time, guidelines, follow-up, cooperation with preventive health care centers, FaR-coordinator, reference of FaR-patients, knowledge about how to inspire people to physical activity </em>and<em> knowledge about which conditions/diseases that can be treated with physical activity</em>. A web-based questionnaire was distributed and collected through e-mail and a questionnaire in paperform was used at a couple of health centers. Results from the questionnaire were analysed with chi-square test and binary logistic regression.</p><p>Results:  The probability to prescribe FaR was significantly seven times higher for personnel who knew where to <em>refer FaR-patients</em> compared to those who did not know where reference could be given. Further the probability to prescribe FaR was significantly four times higher for personnel with specific<em> FaR-education</em> compared to those who lacked FaR-education. The study also showed that FaR-prescription had significant covariation with the factors <em>profession, county council, cooperation with preventive health care centers, guidelines from the employer, knowledge about what conditions/diseases that can be treated with physical activity</em> and <em>knowledge about how to motivate patients to physical activity</em>. No significant covariation were found between FaR-prescription and the following factors: prescriptors <em>sex</em>, <em>age</em>, <em>use of FaR/FYSS</em>, <em>personal exercise</em>, <em>FaR-coordinator</em>, <em>follow-up</em> or <em>if personnel refrain from prescribing FaR because it extends patient visiting-hours.</em></p><p>Conclusion: When working with FaR it is important to create clear <em>guidelines</em>, <em>cooperate with preventive health care centers</em>, that the personnel has<em> knowledge about conditions/diseases which can be treated with physical activity</em> and <em>motivation to physical activity.</em> Above all we want to point out that it is important that the personnel is educated about FaR and that they know where to refer patients with FaR-prescription in order to make the working method more effective at health centers in Sweden.</p>

Sammanfattning Syfte: Syftet med denna studie var att undersöka samband mellan några utvalda faktorer av betydelse vid förskrivning av fysisk aktivitet på recept (FaR) på hälso- och vårdcentraler i Sverige. Metod: En enkätundersökning genomfördes på 37 icke-privata hälso- och vårdcentraler i Malmö, Stockholm och Umeå. Totalt 241 enkäter besvarades av legitimerad personal med förskrivningsrätt av FaR. Studerade faktorer, uttryckta som enkätfrågor, var: förskrivarens kön, ålder, befattning, landstingstillhörighet, användning av FaR/FYSS, egen motion, FaR-utbildning, tidsbrist, riktlinjer, uppföljning, samarbete med friskvårdsaktör, FaR-ansvarig, hänvisning av FaR-patienter, kunskap i att motivera till fysisk aktivitet samt kunskap om vilka sjukdomstillstånd som kan behandlas med fysisk aktivitet. En webb-baserad enkät distri-buerades och samlades in via e-post och en pappersenkät användes på ett par hälso- och vårdcentraler. Resultatet från enkätundersökningen analyserades med chitvåtest och binär logistisk regression.  Resultat: Sannolikheten att förskriva FaR var signifikant sju gånger högre hos personal som visste vart de kunde hänvisa patienter med FaR-ordination i jämförelse med dem som inte visste vart hänvisning kunde ske. Vidare var sannolikheten att förskriva FaR signifikant fyra gånger högre hos personal med specifik utbildning om FaR i jämförelse med dem som inte hade någon FaR-utbildning. I undersökningen framkom även att förskrivning av FaR samvarierade signifikant med faktorerna befattning, landstingstillhörighet, samarbete med friskvårdsaktör/-er, riktlinjer från arbetsgivaren, kunskap om vilka sjukdomstillstånd som kan behandlas med fysisk aktivitet samt kunskap i att motivera patienter till fysisk aktivitet. Ingen signifikant samvariation sågs mellan förskrivning av FaR och följande faktorer: förskrivarens kön, ålder, användning av FaR/FYSS, egen motion, FaR-ansvarig, uppföljning samt om personalen avstår från att förskriva FaR pga att det förlänger patientbesöken. Slutsats: Vid arbete med FaR är det viktigt att skapa tydliga riktlinjer, samarbeta med frisk-vårdsaktör/-er, att personalen har kunskap om vilka sjukdomstillstånd som kan behandlas med fysisk aktivitet samt om motivation till fysisk aktivitet. Vi vill poängtera att det framförallt är viktigt att personalen är utbildad om FaR samt att de vet vart de kan hänvisa patienter med FaR-ordination i syfte att effektivisera FaR som arbetsmetod på hälso- och vårdcentraler i Sverige. / Abstract Aim: The aim of this study was to examine relations between selected factors significant to the prescription of Physical Activity Referral Scheme (PAR, Swedish: Fysisk aktivitet på recept, FaR) at health centers in Sweden. Method: A questionnaire study was carried out within 37 non-private health centers in Malmö, Stockholm and Umeå. A total of 241 questionnaires were answered by personnel authorized to prescribe FaR. Studied factors, expressed as questions in the questionnaire, were: prescriptors sex, age, profession, county council, the use of FaR/FYSS, personal exer-cise, FaR-education, lack of time, guidelines, follow-up, cooperation with preventive health care centers, FaR-coordinator, reference of FaR-patients, knowledge about how to inspire people to physical activity and knowledge about which conditions/diseases that can be treated with physical activity. A web-based questionnaire was distributed and collected through e-mail and a questionnaire in paperform was used at a couple of health centers. Results from the questionnaire were analysed with chi-square test and binary logistic regression. Results:  The probability to prescribe FaR was significantly seven times higher for personnel who knew where to refer FaR-patients compared to those who did not know where reference could be given. Further the probability to prescribe FaR was significantly four times higher for personnel with specific FaR-education compared to those who lacked FaR-education. The study also showed that FaR-prescription had significant covariation with the factors profession, county council, cooperation with preventive health care centers, guidelines from the employer, knowledge about what conditions/diseases that can be treated with physical activity and knowledge about how to motivate patients to physical activity. No significant covariation were found between FaR-prescription and the following factors: prescriptors sex, age, use of FaR/FYSS, personal exercise, FaR-coordinator, follow-up or if personnel refrain from prescribing FaR because it extends patient visiting-hours. Conclusion: When working with FaR it is important to create clear guidelines, cooperate with preventive health care centers, that the personnel has knowledge about conditions/diseases which can be treated with physical activity and motivation to physical activity. Above all we want to point out that it is important that the personnel is educated about FaR and that they know where to refer patients with FaR-prescription in order to make the working method more effective at health centers in Sweden.

African American women, in particular those who are economically marginalized, are disproportionately subject to surveillance by social service and criminal justice agencies (James et al., 2003) and are vulnerable to race- and gender-biased policy implementation (Chibnall et al., 2003; Zerai, 2002). They also experience population-specific personal (Ehrmin, 2001, 2002), social (Riehman, Iguchi, Zeller, & Morral, 2003; MacMaster, 2005), and economic barriers (Tighe & Saxe, 2006) to accessing and entering substance abuse treatment services. These factors contribute to lower rates of treatment entry follow-through (Siqueland et al., 2002) and higher drop-out rates (Scott-Lennox, Rose, Bohlig, & Lennox, 2000) than women from other racial and ethnic groups. This qualitative study explored African American women’s perceptions of mandated referral to substance abuse treatment and the impact of those perceptions on their treatment entry. The sample included 17 women age 18 years and over who were currently enrolled at three gender-specific treatment programs (one intensive outpatient and two residential) in a major southeastern urban area. This naturalistic inquiry (Lincoln and Guba, 1987) was informed by Black feminist epistemology (Collins, 2000) in accordance with recommendations for culturally sensitive research with women of color (Landrine, Klonoff, & Brown-Collins, 1995). Participants completed one-time, in-depth (one to two hour) interviews in which they were invited to explore their experiences with mandated substance abuse treatment referrals from state agencies (child protective services and the criminal justice system). Results indicate that participants generally perceived the treatment mandate as helpful. However, they also indicated that their willingness and ability to follow-through with treatment entry were influenced by multidimensional (Marlowe, Merikle, Kirby, Festinger, & McLellan, 2001) and interacting factors. Participants identified influence factors that included intra- and interpersonal concerns, the quality of interactions with state agencies, and treatment-specific issues. Results are presented along with suggestions for counselors and future research.

Les patients atteints de mono-traumatisme à un membre doivent consulter un médecin de première ligne qui assurera la prise en charge initiale et référera au besoin le patient vers un orthopédiste. L‟objectif principal de cette étude est de décrire ce mécanisme de référence envers un Service d‟orthopédie affilié à un Centre de traumatologie Niveau 1. La collecte de données concernant l‟accès aux soins spécialisés et la qualité des soins primaires a été faite lors de la visite en orthopédie. Nous avons étudié 166 patients consécutifs référés en orthopédie sur une période de 4 mois. Avant leur référence en orthopédie, 23 % des patients ont dû consulter 2 médecins de première ligne ou plus pour leur blessure. Le temps entre la consultation en première ligne et la visite en orthopédie (68 heures) dépasse le temps compris entre le traumatisme et l‟accès au généraliste (21 heures). Parmi les cas jugés urgents, 36 % n‟ont pas été vus dans les temps recommandés. La qualité des soins de première ligne fut sous-optimale chez 49 % des patients concernant l‟analgésie, l‟immobilisation et/ou l‟aide à la marche. Les facteurs associés à une diminution d‟accès en orthopédie et/ou une qualité de soins inférieure sont : tabagisme, jeune âge, habiter loin de l‟hôpital, consulter initialement une clinique privée, avoir une blessure au membre inférieur ou des tissus mous et une faible sévérité de la blessure selon le patient. Ces résultats démontrent qu‟il faut mieux cibler l‟enseignement relié aux mono-traumatismes envers les médecins de première ligne afin d‟améliorer le système de référence. / Patients with isolated traumatic limb injuries usually consult primary care for first line treatment. The primary care physician will often refer the patient to an orthopaedic surgeon when needed. The research objective was to study the referral mechanism to an Orthopaedic Service in a Level 1 Trauma Center for patients with an isolated limb injury. Access to specialized care and quality of primary care are used to describe the referral mechanism. We studied 166 consecutives patients referred to orthopaedic surgery over a 4 months period. Before the orthopaedic visit, 23 % had seen 2 or more doctors for their injury. The time between the first primary care visit and the orthopaedic evaluation was greater (68 hours) then the interval between the injury and the visit with primary care (21 hours). Among the cases that were considered urgent, 36 % had not been seen within the recommended delay. Quality of initial care was judged sub optimal for 49 % of patients in terms of immobilization, analgesia and/or walking aids. Factors associated with decreased access or quality of care are: smoking, younger age, living far from the hospital, consulting first in a private clinic, lower limb or soft tissue injury and a patient‟s low self-perception of severity. These results underline the necessity of targeting primary care education and improving the referral mechanism for patients with isolated limb injuries.

La mortalité maternelle et périnatale est un problème majeur de santé publique dans les pays en développement. Elle illustre l’écart important entre les pays développés et les pays en développement. Les interventions techniques pour améliorer la santé maternelle et périnatale sont connues dans les pays en développement, mais ce sont la faiblesse des systèmes de santé et les défis liés aux ressources qui freinent leur généralisation. L’objectif principal de ce travail était de mieux comprendre le rôle des ressources humaines en particulier ceux de la première ligne dans la performance d’un système de référence maternelle. Au Mali, la mise en place d’un système de référence maternelle, système de référence-évacuation « SRE », fait partie des mesures nationales de lutte contre la mortalité maternelle et périnatale. Les trois composantes du SRE, soit les caisses de solidarité, le transport et la communication et la mise à niveau des soins obstétricaux, permettent une action simultanée du côté de la demande et de l’offre de soins maternels et périnatals. Néanmoins, la pénurie de personnel qualifié a conduit à des compromis sur la qualification du personnel dans l’implantation de ce système. La région de Kayes, première région administrative du Mali, est une région de forte émigration. Elle dispose d’une offre de soins plus diversifiée qu’ailleurs au Mali, grâce à l’appui des Maliens de l’extérieur. Son SRE offre ainsi un terrain d’études adéquat pour l’analyse du rôle des professionnels de première ligne. De façon plus spécifique, ce travail avait pour objectifs 1) d’identifier les caractéristiques des équipes de soins de première ligne qui sont associées à une meilleure performance du SRE en termes de survie simultanée de la mère et du nouveau-né et 2) d’approfondir la compréhension des pratiques de gestion des ressources humaines, susceptibles d’expliquer les variations de la performance du SRE de Kayes. Pour atteindre ces objectifs, nous avons, à partir du cadre de référence de Michie et West modélisé les facteurs liés aux ressources humaines qui ont une influence potentielle sur la performance du SRE de Kayes. L’exploration des variations du processus motivationnel a été faite à partir de la théorie de l’attente de Vroom. Nous avons ensuite combiné une revue de la littérature et un devis de recherche mixte (quantitative et qualitative). Les données pour les analyses quantitatives proviennent d’un système d’enregistrement continu de toutes les urgences obstétricales (GESYRE : Gestion du Système de Référence Évacuation mis en place depuis 2004 dans le cadre du suivi et de l’évaluation du SRE de Kayes) et des enquêtes à passages répétés sur les données administratives et du personnel des centres de santé. Un modèle de régression biprobit a permis d’évaluer les effets du niveau d’entrée dans le SRE et des équipes de soins sur la survie jointe de la mère et du nouveau-né. A l’aide d’entrevues semi-structurées et d’observations, nous avons exploré les pratiques de gestion des personnes dans des centres de santé communautaires « CScom » sélectionnés par un échantillonnage raisonné. Les résultats de ce travail ont confirmé que la main d’œuvre humaine demeure cruciale pour la performance du SRE. Les professionnels de première ligne ont influencé la survie des femmes et des nouveau-nés, à morbidités égales, et lorsque la distance parcourue est prise en compte. La meilleure survie de la mère et du nouveau-né est retrouvée dans les cas d’accès direct à l’hôpital régional. Les femmes qui sont évacuées des centres de première ligne où il y a plus de professionnels ou un personnel plus qualifié avaient un meilleur pronostic materno-fœtal que celles qui ont consulté dans des centres qui disposent de personnel peu qualifié. Dans les centres de première ligne dirigés par un médecin, des variations favorables à la performance comme une implication directe des médecins dans les soins, un environnement de soins concurrentiel ont été retrouvés. Concernant les pratiques de gestion dans les centres de première ligne, les chefs de poste ont mis en place des incitatifs pour motiver le personnel à plus de performance. Le processus motivationnel demeure toutefois très complexe et variable. La désirabilité de bons résultats des soins (valence) est élevée pour tous les professionnels ; cependant les motifs étaient différents entre les catégories de personnel. Par ailleurs, le faible niveau d’équipements et la multiplicité des acteurs ont empêché l’établissement d’un lien entre l’effort fourni par les professionnels et les résultats de soins. Cette compréhension du rôle des professionnels de première ligne pourra aider le personnel administratif à mieux cibler le monitorage de la performance du SRE. Le personnel de soins pourra s’en servir pour reconnaitre et appliquer les pratiques associées à une bonne performance. Dans le domaine de la recherche, les défis de recherche ultérieurs sur les facteurs humains de la performance du SRE seront mieux identifiés. / Although proven effective interventions have been transferred from the developed world, developing countries still face high maternal and perinatal deaths. Weak health systems and human resources crisis hinder the scaling up of those interventions. This study is aimed at improving the understanding of the role of human resources, especially the first line staff in a maternal referral system, the evacuation and referral system (ERS) of Kayes (Mali). The implantation of the ERS as part of major strategies for fighting maternal and perinatal deaths has been generalised in Mali’s eight administrative regions. The ERS main components are: upgrading of emergency obstetric care (EmOC); funding by a solidarity fund; and improving transport and communication by ambulance. These components allows for joint action regarding the supply and the use of maternal and perinatal services. Yet, due to the shortages in skilled birth attendants, the extension of the coverage in emergency obstetric services has been made with less qualified staff. Kayes is Mali’s first administrative region and a cradle of emigration. It therefore offers, with the support of its immigrants, a more diversified primary care provision than elsewhere in Mali. This gives an opportunity of studying the role of primary care staff in the ERS performance. More precisely, the objectives of this research were to: 1 identify characteristics of primary care teams that influenced the ERS performance assessed by the joint mother-child survival and 2) improve the understanding of human resources practices associated with ERS performance. We combined a systematic literature review with a mixed quantitative and qualitative research design. Kayes ERS performance was modelised using Michie and West conceptual framework and the motivational process was explored with Vroom’s expectancy theory. Data for the quantitative analyses derived from an ongoing system of registering all obstetric emergencies implemented since 2004 (GESYRE: Gestion du Système de Référence Évacuation / Management of the Evacuation Referral System) and periodic surveys. A biprobit regression model has been fitted to estimate the effects of the point of entry in the ERS and the primary care team composition on the joint mother-newborn survival. We also conducted semi structured interviews and non participant observations in order to explore human resources practices in purposely selected community health centers. This research confirmed the importance of human resources in ERS performance. When women’ individual risk factors are controlled for, there is a combined effect of distance traveled and the point of entry in the ERS on one side and the community health centers staff on the other hand, on the mother-child joint survival. The best prognosis of care was found in women who directly accessed care at the regional hospital. Having been transferred from a community health center where there is a physician or more than three professionals increased the mother-child survival probability. Physicians in community health centers develop strategies for a better performance of the health centers they managed: direct implication in care and a competitive care environment. Primary care managers set up incentives to motivate staff. The motivation process remains however a variable and complex one. The desirability of good results was common for all staff though its motivations varied according to the type of staff. Besides, due to insufficiency of material and multiples intermediate factors, perception of a linkage between effort and result was low. This increased understanding of the role of primary care human resources in the ERS performance would focus the management of ERS performance on targeted but effective interventions. The workforce could benefit from the study conclusions in identifying and applying best practices. Further research challenges would also be more precisely identified.