Introdução: Investigar os fatores associados à condição perineal no parto vaginal pode possibilitar modificações no cuidado com o períneo, de forma a contribuir para menores frequências de episiotomia e de lacerações perineais. Objetivos: Identificar os fatores associados à episiotomia; identificar os fatores associados à integridade perineal no parto vaginal; descrever os motivos apontados para a realização de episiotomia por enfermeiras obstétricas; e identificar as manobras de proteção perineal realizadas por enfermeiras obstétricas em um Centro de Parto Normal. Método: Estudo transversal com coleta de dados prospectiva por meio de formulário aplicado junto às enfermeiras obstétricas de um Centro de Parto Normal intra-hospitalar de São Paulo e que incluiu dados de todas as mulheres que deram à luz neste serviço no período de fevereiro de 2014 a janeiro de 2015. Na análise estatística, as associações entre as variáveis dependentes (episiotomia e integridade perineal) e as variáveis sociodemográficas, obstétricas e assistenciais foram estimadas por meio de Odds Ratios (OR), calculadas por meio de regressão logística binária univariada e múltipla com intervalos de confiança de 95 por cento (IC 95 por cento ), no programa estatístico SPSS versão 20. Foram realizadas análises separadas para cada variável dependente. Os motivos para a realização de episiotomia e o uso de manobras de proteção perineal foram descritos por meio de frequências e porcentagens. O estudo foi aprovado nos Comitês de Ética em Pesquisa das instituições proponente e coparticipante. Resultados: Foram analisados os dados de 802 mulheres (frequência de episiotomia de 23,8 por cento , 191 mulheres; integridade perineal de 25,9 por cento , 208 mulheres; laceração perineal de 50,3 por cento , 403 mulheres). Os fatores independentemente associados à episiotomia foram: não ter parto vaginal anterior (OR 26,72; IC 95 por cento 15,42-46,30), uso de ocitocina durante o trabalho de parto (OR 1,69; IC 95 por cento 1,12-2,57), puxos dirigidos (OR 2,05; IC 95 por cento 1,23-3,43), intercorrência no trabalho de parto (OR 2,61; IC 95 por cento 1,43-4,77) e posição semissentada no parto (5,45; IC 95 por cento 1,06-28,01). O uso de uma manobra de proteção perineal (OR 0,11; IC 95 por cento 0,04-0,26) ou de duas manobras ou mais (OR 0,09; IC 95 por cento 0,04-0,22) se apresentou como fator de proteção contra a episiotomia. Em relação à integridade perineal, os fatores independentemente associados foram: ter parto vaginal anterior (OR 3,88; IC 95 por cento 2,41-6,23) e cor da pele autorreferida não branca (OR 1,43; IC 95 por cento 1,01-2,04). As indicações para episiotomia incluíram, predominantemente, motivos relacionados às condições e dimensões do períneo. As manobras de proteção perineal foram utilizadas em aproximadamente 95 por cento dos partos vaginais, mas não impactaram as taxas de integridade perineal. Conclusões: As variáveis associadas à episiotomia incluíram, em sua maioria, fatores que podem ser controlados pelo profissional de saúde. Estas variáveis não impactaram as taxas de integridade perineal. Informar os profissionais que atuam na assistência ao parto e as mulheres que buscam esse atendimento sobre os fatores associados à condição perineal no parto vaginal pode contribuir para a redução da frequência de episiotomia e para preservar a integridade perineal no parto vaginal. / Introduction: To investigate factors associated with perineal condition in vaginal delivery can result in modifications in the perineal care, in order to decrease the frequency of episiotomy and perineal lacerations in the vaginal delivery. Objectives: To identify factors associated with an episiotomy; to identify factors associated with perineal integrity in vaginal delivery; to describe the reasons for performing an episiotomy by nurse-midwives; and to identify the perineal protection maneuvers performed by nurse-midwives in a Birth Centre. Methods: Cross-sectional study with prospective data collection carried out through the application of a form to nurse-midwives in an In-hospital Birth Centre located in São Paulo city, Brazil, which included all women who gave birth in this service from February 2014 to January 2015. In the statistical analysis, the associations between the outcome variables (episiotomy and perineal integrity) and the sociodemographic, obstetric and care-related variables were estimated by Odds Ratios (OR), calculated in univariate and multivariate binary logistic regression models with a 95 per cent confidence intervals (95 per cent CI), in the SPSS software, version 20. Separated analyses were performed for each one of the outcome variables. The reasons for performing an episiotomy and the use of perineal protection maneuvers were described as frequencies and percentages. The study was approved in the Research Ethics Committees of the proposing and the co-participant institutions. Results: Data of 802 women were analysed (frequency of episiotomy of 23.8 per cent , 191 women; perineal integrity of 25.9 per cent , 208 women; perineal laceration of 50.3 per cent , 403 women). Factors identified as independently associated with an episiotomy were: no previous vaginal delivery (OR 26.72; 95 per cent CI 15.42-46.30), oxytocin use during labour (OR 1.69; 95 per cent CI 1.12-2.57), coached pushing (OR 2.05; 95 per cent CI 1.23-3.43), complications during labour (OR 2.61; 95 per cent CI 1.43-4.77) and semi-sitting position at delivery (OR 5.45; 95 per cent CI 1.06-28.01). The use of a perineal protective maneuver (OR 0.11; 95 per cent CI 0.04-0.26) or two maneuvers or more (OR 0.09; 95 per cent CI 0.04-0.22) was a protective factor against an episiotomy. Regarding the perineal integrity, the factors independently associated to this condition were: a previous vaginal delivery (OR 3.88; 95 per cent CI 2.41-6.23) and self-reported non-white skin color (OR 1.43; 95 per cent CI 1.01-2.04). Most of the indications for an episiotomy included reasons related to perineal conditions and dimensions. The perineal protection maneuvers were used in nearly 95 per cent of vaginal deliveries, but did not affect the perineal integrity rates. Conclusions: Most of the variables associated with an episiotomy were related to factors that can be controlled by the professional who provides labour and birth care. These variables did not influence the perineal integrity rates. To inform childbirth care professionals and women who are users of these services about the factors associated with the perineal condition at the childbirth can contribute for reducing the frequency of episiotomy and to preserve the perineal integrity in the vaginal delivery.

Made available in DSpace on 2016-08-19T18:32:11Z (GMT). No. of bitstreams: 1 Dissertacao MARIA GLAUCIA ALVES ALBUQUERQUE.pdf: 579528 bytes, checksum: 6611a9dd5925422697c970e2c5df794d (MD5) Previous issue date: 2015-09-01 / Hospitalization for primary care sensitive conditions is an indicator that aims to track and evaluate, through a group of diagnoses, the quality of services offered in primary care and of health conditions of the population. It results in reduction of the risk of hospitalization when primary care is effective. The study s objective is to analyze the hospitalizations for primary care sensitive conditions in São Luís in the years of 2002 (beginning of the implantation of the family healthcare strategy) and 2012 (strategy already implanted). The variables were the coefficients of hospitalization for primary care sensitive conditions, groups divided by causes, gender and age. It is a transversal study, with secondary data from the hospitalizations of the public health care system. The methodology used data bases provided by the health ministry, the SIH/SUS and from IBGE. The statistical analysis was conducted with the TABWIN 3.5 and Biostat 5.0, with two independent samples and calculation of the relative risk. The differences were considered significant when p<0,05. It was shown a reduction of the hospitalizations (coefficient decreased from 8,7 in 2002 to 4,4/1000hab in 2012). The hospitalizations were more frequent in children under 5 years old, the elderly and males, in both years studied. There was a decrease in the hospitalization of both genders, with greater reduction between 15 to 24 years (coefficient went from 0,6 to 0,2/1000hab in males and from 1 to 0,3/1000hab in females). There was also a decrease in most of the diseases that caused hospitalization, with statistical significance, except bacterial pneumonia, which underwent an increase in numbers. Brain-vascular conditions, angina, epilepsy and ear, nose e throat infections maintained the same coefficients. It is concluded that even with a small cover of the family health strategy (27,53%) in 2012, the reduction of hospitalization for primary care sensitive conditions shows significant impacts in this indicator. Although the recent publication of the hospitalization list, it is a tool of great value that works as an instrument of tracking, planning and evaluation for the health actions of an integrated and universal public health system. / Internação por condições sensíveis à atenção primária (ICSAP) é um indicador, que se propõe a monitorar e a avaliar através de um grupo de diagnósticos, a qualidade dos serviços oferecidos na atenção primária e das condições de saúde da população refletindo através de seus resultados, o risco de hospitalização consideravelmente diminuídos, quando a atenção primária é adequada. O estudo objetivou analisar as ICSAPs no município de São Luís nos anos de 2002 (início da implantação da Estratégia de Saúde da Família - ESF) e 2012 (com implantação da ESF). As variáveis estudadas foram os coeficientes de internação por condições sensíveis à atenção primária (CSAP), grupos de causas, sexo e faixa etária. Trata-se de estudo de corte transversal, com dados secundários das internações por CSAP, do Sistema Único de Saúde (SUS), ocorridas no período citado. A metodologia utilizou bancos de dados disponibilizados pelo Ministério da Saúde, o Sistema de Informações Hospitalares (SIH/SUS) e do Instituto Brasileiro de Geografia e Estatística (IBGE). A análise estatística foi feita, inicialmente pelo TABWIN 3.5 e posteriormente pelo programa Biostat 5.0, com 2 amostras independentes e cálculo de risco relativo, considerando-se diferenças estatisticamente significantes, quando p<0,05. Observou-se redução das internações por CSAP, com coeficiente de 8,7 em 2002 para 4,4/1.000 habitantes em 2012. As internações foram mais frequentes em menores de cinco anos e idosos e no sexo masculino, nos dois anos estudados. Houve diminuição do número de internação, em ambos os sexos, com redução mais importante na faixa de 15 a 24 anos, quando se observou queda do coeficiente de 0,6 para 0,2/1000hab, no sexo masculino e de 1,0 para 0,3/1000hab, no sexo feminino. A maioria das patologias por CSAP sofreu redução no número de internação em 2012, com significância estatística, exceto pneumonia bacteriana, que mostrou aumento do número de internação no ano em questão, enquanto doenças cerebrovasculares, angina, epilepsias e infecções de ouvido, nariz e garganta apresentaram estabilidade no coeficiente de internação por 1000 habitantes Concluímos, que, mesmo com uma cobertura de ESF de 27,53% em 2012, a redução das internações por CSAP mostra impactos significativos neste indicador. E que mesmo com sua publicação e utilização recente, a lista ICSAP é um instrumento de grande projeção e funciona como instrumento de monitoramento, planejamento e avaliação para as ações de um SUS mais integrativo e universal.

Submitted by Verena Bastos (verena@uefs.br) on 2015-07-31T13:39:35Z No. of bitstreams: 1 DISSERTACAO DE BIANKA 2015.pdf: 1088519 bytes, checksum: 3efca07e3a24a9e6cadd7b95dbe70562 (MD5) / Made available in DSpace on 2015-07-31T13:39:35Z (GMT). No. of bitstreams: 1 DISSERTACAO DE BIANKA 2015.pdf: 1088519 bytes, checksum: 3efca07e3a24a9e6cadd7b95dbe70562 (MD5) Previous issue date: 2014-03-21 / Objective: To assess factors related to the occurrence of gender violence in a population of northeastern Bahia in 2007 and identify risk behaviors in women who have witnessed family violence during their childhood and were victims of violence in adulthood. Methods: This was a cross-sectional study conducted with 4170 individuals, of both sexes, aged 15 years and living in the city of Feira de Santana , Bahia. A probabilistic sample of clusters derived from census tracts was used. Data were collected during home visits with use of household and individual questionnaire record. Bivariate and the Chi square test analyzes were performed considering IC95 % and p ? 0.05 for statistically significant association. To verify the factors associated with violence , we used a hierarchical logistic regression analysis. Results: The prevalence of physical and / or emotional violence was 18,63%. Regarding the history of violence in childhood prevalence was equal to 12,14%. Women had a higher prevalence (19,7%) than men (16,5%) with 1,31 times higher prevalence of victimization. It was observed that women who have never been to school (15,08%), non-white (12,61%) and had an income of up to 1 minimum wage (14.17%) had a higher incidence of physical violence in childhood. The women drinkers had 1,43 times higher prevalence of experiencing violence in childhood and, in relation to smoking, this prevalence increased to 1,56. Adjusted by hierarchical logistic regression analysis showed a positive association between women suffer physical and / or emotional violence with household type (RP = 1,28; IC95%: 1,10; 1,54), type of building (RP = 1,66; IC95%: 1,14; 2,41), smoking (RP = 1,36; IC95%: 1,10; 1,70) and violence in childhood (RP = 2,13; IC95%: 1,79; 2,53). Conclusions: Gender violence is a complex problem with social roots and that deserves to be addressed as a public health problem . Thus , it is urgent policies to combat poverty , interpersonal conflicts, especially those from the interior of the family system , substance use , particularly alcohol measures as well as preparation in the care of victims of violence and the deployment of a service to protect women victimized because many remain silent for fear of reprisals from their attackers. / Objetivo: Analisar os fatores relacionados ? ocorr?ncia da viol?ncia de g?nero em uma popula??o do nordeste da Bahia no ano de 2007 e identificar os comportamentos de risco de mulheres que presenciaram viol?ncia na fam?lia durante sua inf?ncia e foram v?timas de viol?ncia na vida adulta. M?todos: Trata-se de um estudo de corte transversal realizado com 4170 indiv?duos, de ambos os sexos, com idade acima de 15 anos e residentes no munic?pio de Feira de Santana-BA. Foi utilizada uma amostra probabil?stica de conglomerados derivados de setores censit?rios. Os dados foram coletados em visitas domiciliares com uso de ficha domiciliar e question?rio individual. Foram realizadas an?lises bivariadas e Teste do Qui Quadrado de Pearson, considerando IC95% e p ? 0,05 para associa??o estatisticamente significante. Para verificar os fatores associados ? viol?ncia, empregou-se a an?lise de regress?o log?stica hierarquizada. Resultados: A preval?ncia de viol?ncia f?sica e/ou emocional foi de 18,63%. Em rela??o ? hist?ria de viol?ncia na inf?ncia a preval?ncia foi igual a 12,14%. As mulheres apresentaram preval?ncia superior (19,7%) aos homens (16,5%) com preval?ncia 1,31 vezes maior de vitimiza??o. Foi poss?vel observar que mulheres que nunca foram ? escola (15,08%), n?o brancas (12,61%) e que tinham renda de at? 1 sal?rio m?nimo (14,17%) apresentaram maior ocorr?ncia de viol?ncia f?sica na inf?ncia. As mulheres etilistas tiveram preval?ncia 1,43 vezes maior de ter sofrido viol?ncia na inf?ncia e, em rela??o ao h?bito de fumar, esta preval?ncia aumentou para 1,56. A an?lise ajustada por regress?o log?stica hierarquizada mostrou uma associa??o positiva entre a mulher sofrer viol?ncia f?sica e/ou emocional com tipo de domic?lio (RP = 1,28; IC95%: 1,10; 1,54), tipo de edifica??o (RP = 1,66; IC95%: 1,14; 2,41), tabagismo (RP = 1,36; IC95%: 1,10; 1,70) e viol?ncia na inf?ncia (RP = 2,13; IC95%: 1,79; 2,53). Conclus?es: A viol?ncia de g?nero ? um problema complexo com ra?zes sociais e que merece ser abordada como um problema de sa?de p?blica. Assim, urge medidas pol?ticas para o combate da pobreza, conflitos interpessoais, sobretudo os oriundos do interior do sistema familiar, ao consumo de subst?ncias, principalmente o ?lcool, bem como o preparo no atendimento das v?timas de viol?ncia e a implanta??o de um servi?o de prote??o ?s mulheres vitimizadas, pois muitas se calam por medo de sofrer repres?lias por parte de seus agressores.

Introdução: Em estudos de corte transversal com desfechos binários, a associação entre a exposição e o desfecho é estimada pela razão de prevalência (RP). Os modelos de regressão de Cox, log-binomial e Poisson têm sido sugeridos como bons métodos estatísticos para obter estimativas da RP ajustadas para variáveis de confusão. Objetivo: Comparar empiricamente as regressões de Cox, log-binomial, Poisson e logística para desfechos com alta prevalência, prevalência intermediária e baixa prevalência. Metodologia: Os dados foram obtidos de um estudo epidemiológico de corte transversal, de base populacional, sobre prevalência de demência e outros transtornos mentais em idosos residentes em aéreas de baixa renda da cidade de São Paulo. O diagnóstico de demência (prevalência baixa), a ocorrência de transtorno mental comum (prevalência intermediária) e a auto-percepção de saúde ruim (alta prevalência) foram escolhidos como desfechos para o estudo. Valores de referência da estimativa da razão de prevalência (RP) foram obtidos pela estratificação de Mantel-Haenszel. Estimativas da RP ajustada foram calculadas usando modelos de regressão de Cox, log-binomial e Poisson, além do OR bruto e do OR ajustado pela regressão logística. Resultados: As estimativas do ponto e do intervalo obtidas com as regressões de Poisson e Cox, com variância robusta, se aproximaram muito bem dos resultados obtidos pela estratificação de Mantel-Haenszel, independentemente da prevalência inicial do desfecho, e permitiram controlar para covariáveis contínuas. O modelo log-binomial se comportou ligeiramente pior que os modelos de Cox e Poisson quando o desfecho teve uma prevalência alta, com dificuldade de convergência. A regressão logística produziu estimativas do ponto e do intervalo sempre mais elevadas do que aquelas obtidas pelos outros métodos, e estas estimativas eram particularmente mais elevadas quando o desfecho era freqüente. Conclusão: Os modelos de regressão de Cox e Poisson, com variância robusta, são boas alternativas à regressão logística. Quanto ao modelo de regressão log-binomial, deve-se ficar atento às restrições referentes ao seu uso, pois apresenta estimativas um pouco mais distantes das geradas pelos demais métodos quando o risco inicial do desfecho de interesse é alto e apresenta também dificuldade de convergência quando temos uma covariável contínua no modelo. Ao analisar as associações em estudos de corte-transversal, os pesquisadores devem usar métodos de regressão que forneçam estimativas do ponto e do intervalo adequadas independente da prevalência do desfecho em estudo. / Introduction: In cross-sectional studies with binary outcomes, the association between exposure and outcome is estimated with the prevalence ratio (PR). Cox, log-binomial and Poisson regression models have been suggested as statistical methods that yield correct estimates of PR adjusted for confounding variables. Aim: To compare empirically Cox, log-binomial, Poisson and logistic regressions for outcomes with low, intermediate and high prevalence. Methodology: The data came from an epidemiologic population-based cross-sectional study about prevalence of dementia and other mental health problems among older persons from an economically deprived area in the city of Sao Paulo. The diagnosis of dementia (low prevalence), caseness for common mental disorders (intermediate prevalence) and poor self-rated health (high prevalence) were chosen as outcomes of the study. Reference values for point and interval estimates of PR were obtained with the Mantel-Haenszel stratification. Adjusted estimates of PR were then calculated using Cox, log-binomial and Poisson regression models. Crude and adjusted Odds Ratios (OR) were obtained with logistic regression. Results: The point and interval estimates obtained with Poisson and Cox regressions, with robust variance, approximated very well to those obtained with Mantel-Haenszel stratification, independently of the outcome base prevalence, and allowed to control for continuous covariates. The log-binomial model performed slightly worse than the Poisson and Cox models when the outcome had a high prevalence, with difficulty in convergence. Logistic regression produced point and interval estimates that were always higher than those obtained by the other methods, and were particularly higher when the outcome was frequent. Conclusion: The Cox and Poisson models, with robust variance, are good alternatives to logistic regression. Regarding the log-binomial regression model, it is necessary to be alert to restrictions in its use, since it may yield estimates slightly different from those generated by the others methods when the outcome has a high prevalence and also presents difficulty in convergence with the continuous covariate in the model. When analyzing associations in cross-sectional studies, investigators should use regression methods that yield adequate point and interval estimates regardless of the base prevalence of the outcome investigated

Introdução: Investigar os fatores associados à condição perineal no parto vaginal pode possibilitar modificações no cuidado com o períneo, de forma a contribuir para menores frequências de episiotomia e de lacerações perineais. Objetivos: Identificar os fatores associados à episiotomia; identificar os fatores associados à integridade perineal no parto vaginal; descrever os motivos apontados para a realização de episiotomia por enfermeiras obstétricas; e identificar as manobras de proteção perineal realizadas por enfermeiras obstétricas em um Centro de Parto Normal. Método: Estudo transversal com coleta de dados prospectiva por meio de formulário aplicado junto às enfermeiras obstétricas de um Centro de Parto Normal intra-hospitalar de São Paulo e que incluiu dados de todas as mulheres que deram à luz neste serviço no período de fevereiro de 2014 a janeiro de 2015. Na análise estatística, as associações entre as variáveis dependentes (episiotomia e integridade perineal) e as variáveis sociodemográficas, obstétricas e assistenciais foram estimadas por meio de Odds Ratios (OR), calculadas por meio de regressão logística binária univariada e múltipla com intervalos de confiança de 95 por cento (IC 95 por cento ), no programa estatístico SPSS versão 20. Foram realizadas análises separadas para cada variável dependente. Os motivos para a realização de episiotomia e o uso de manobras de proteção perineal foram descritos por meio de frequências e porcentagens. O estudo foi aprovado nos Comitês de Ética em Pesquisa das instituições proponente e coparticipante. Resultados: Foram analisados os dados de 802 mulheres (frequência de episiotomia de 23,8 por cento , 191 mulheres; integridade perineal de 25,9 por cento , 208 mulheres; laceração perineal de 50,3 por cento , 403 mulheres). Os fatores independentemente associados à episiotomia foram: não ter parto vaginal anterior (OR 26,72; IC 95 por cento 15,42-46,30), uso de ocitocina durante o trabalho de parto (OR 1,69; IC 95 por cento 1,12-2,57), puxos dirigidos (OR 2,05; IC 95 por cento 1,23-3,43), intercorrência no trabalho de parto (OR 2,61; IC 95 por cento 1,43-4,77) e posição semissentada no parto (5,45; IC 95 por cento 1,06-28,01). O uso de uma manobra de proteção perineal (OR 0,11; IC 95 por cento 0,04-0,26) ou de duas manobras ou mais (OR 0,09; IC 95 por cento 0,04-0,22) se apresentou como fator de proteção contra a episiotomia. Em relação à integridade perineal, os fatores independentemente associados foram: ter parto vaginal anterior (OR 3,88; IC 95 por cento 2,41-6,23) e cor da pele autorreferida não branca (OR 1,43; IC 95 por cento 1,01-2,04). As indicações para episiotomia incluíram, predominantemente, motivos relacionados às condições e dimensões do períneo. As manobras de proteção perineal foram utilizadas em aproximadamente 95 por cento dos partos vaginais, mas não impactaram as taxas de integridade perineal. Conclusões: As variáveis associadas à episiotomia incluíram, em sua maioria, fatores que podem ser controlados pelo profissional de saúde. Estas variáveis não impactaram as taxas de integridade perineal. Informar os profissionais que atuam na assistência ao parto e as mulheres que buscam esse atendimento sobre os fatores associados à condição perineal no parto vaginal pode contribuir para a redução da frequência de episiotomia e para preservar a integridade perineal no parto vaginal. / Introduction: To investigate factors associated with perineal condition in vaginal delivery can result in modifications in the perineal care, in order to decrease the frequency of episiotomy and perineal lacerations in the vaginal delivery. Objectives: To identify factors associated with an episiotomy; to identify factors associated with perineal integrity in vaginal delivery; to describe the reasons for performing an episiotomy by nurse-midwives; and to identify the perineal protection maneuvers performed by nurse-midwives in a Birth Centre. Methods: Cross-sectional study with prospective data collection carried out through the application of a form to nurse-midwives in an In-hospital Birth Centre located in São Paulo city, Brazil, which included all women who gave birth in this service from February 2014 to January 2015. In the statistical analysis, the associations between the outcome variables (episiotomy and perineal integrity) and the sociodemographic, obstetric and care-related variables were estimated by Odds Ratios (OR), calculated in univariate and multivariate binary logistic regression models with a 95 per cent confidence intervals (95 per cent CI), in the SPSS software, version 20. Separated analyses were performed for each one of the outcome variables. The reasons for performing an episiotomy and the use of perineal protection maneuvers were described as frequencies and percentages. The study was approved in the Research Ethics Committees of the proposing and the co-participant institutions. Results: Data of 802 women were analysed (frequency of episiotomy of 23.8 per cent , 191 women; perineal integrity of 25.9 per cent , 208 women; perineal laceration of 50.3 per cent , 403 women). Factors identified as independently associated with an episiotomy were: no previous vaginal delivery (OR 26.72; 95 per cent CI 15.42-46.30), oxytocin use during labour (OR 1.69; 95 per cent CI 1.12-2.57), coached pushing (OR 2.05; 95 per cent CI 1.23-3.43), complications during labour (OR 2.61; 95 per cent CI 1.43-4.77) and semi-sitting position at delivery (OR 5.45; 95 per cent CI 1.06-28.01). The use of a perineal protective maneuver (OR 0.11; 95 per cent CI 0.04-0.26) or two maneuvers or more (OR 0.09; 95 per cent CI 0.04-0.22) was a protective factor against an episiotomy. Regarding the perineal integrity, the factors independently associated to this condition were: a previous vaginal delivery (OR 3.88; 95 per cent CI 2.41-6.23) and self-reported non-white skin color (OR 1.43; 95 per cent CI 1.01-2.04). Most of the indications for an episiotomy included reasons related to perineal conditions and dimensions. The perineal protection maneuvers were used in nearly 95 per cent of vaginal deliveries, but did not affect the perineal integrity rates. Conclusions: Most of the variables associated with an episiotomy were related to factors that can be controlled by the professional who provides labour and birth care. These variables did not influence the perineal integrity rates. To inform childbirth care professionals and women who are users of these services about the factors associated with the perineal condition at the childbirth can contribute for reducing the frequency of episiotomy and to preserve the perineal integrity in the vaginal delivery.

Secondhand smoke (SHS) is a harmful mixture of over 4000 chemicals released from the burning of a cigarette. It has been classified as a Class A carcinogen and exposure to SHS has been proven to be related to negative health effects in humans. Children exposed to SHS are more susceptible to negative health effects because they have higher breathing rates and immature, developing bodies. SHS has been associated with many childhood diseases, including asthma, inner ear infections, and pneumonia. SHS exposure in confined areas, such as inside a motor vehicle, is of concern due to the increased toxicity level of the SHS. The purpose of this cross-sectional study was to assess the factors associated with those who smoke in a car containing children and to determine if the estimated prevalence of those who smoke in a vehicle with children has decreased since legislation was passed in Farmington Maine in 2008. Observations were taken at different times of the day and in different seasons. Each observation period consisted of a pair of researchers whom stood at the edge of the roadside, at 7 observations sites located throughout Farmington, Maine. When a vehicle passed, the researchers recorded the child passenger(s) estimated age(s), and the adult passenger(s) estimated age(s), gender, and smoking status. Site locations were chosen based upon ease of observation and neighborhood characteristics that were used as a proxy for socioeconomic status (SES) to the location. Adult data (n=3937) were used to calculate the estimated prevalence and factors of violation. Of all adult observations from 2008 to 2010, 8.26% were observed smoking in a vehicle containing a child, 63.38% of which were male. The estimated prevalence of those smoking in a vehicle containing children decreased from 13.08% (P < .0001), when the law was first enacted in the fall of 2008, to 7.40% (P < .0001) in the fall of 2010. Smoking in vehicles containing children was observed more frequently at sites that were estimated to have a lower SES near them, such as the fairgrounds [(OR=4.48, CI95 (2.49-8.09)] and at the tobacco store location [(OR=7.47, CI95 (4.29-13.01)]. In the final model, gender was found to be significantly associated with smoking in a vehicle containing a child, with males having increased odds of violation [OR=3.13, CI95 (2.44-4.01)]. However, when stratifying by gender, there were significant differences between site locations, dates, and time of the day that males or females were observed smoking. After adjusting for gender, site location, and age, adults observed in the Fall of 2008 were significantly more likely to be smoking in vehicle than those observed in the Fall of 2010 [OR=2.25, CI95 (1.64-3.09)]. The change in prevalence between dates indicates that smoking in a vehicle not only decreased over time, but also that season could have an effect on smoking in vehicle containing children behavior.

Effective nursing care can be threatened when nurses are not culturally attuned with their patients. Associate degree nursing (ADN) students receive information about diverse ethnicities in the nursing curriculum, but it may not be sufficient to provide the expertise necessary to care for patients of various cultural backgrounds. The purpose of this quantitative study was to explore the 2nd year ADN students' levels of cultural competence and their perceptions of self-efficacy in working with Caucasian, African American, Native American, Hispanic, and Asian ethnicities. The study used a cross-sectional survey design to determine if a relationship existed between the students' reported cultural competencies and their self-efficacy scores while providing care to patients of these diverse cultures. The process of cultural competence in the delivery of health care services was used as the theoretical framework for this study. A volunteer convenience sample of 64 2nd-year ADN students completed the Nurse Cultural Competence Scale and the Cultural Self-Efficacy Scale. The Pearson-Product Moment correlation revealed a significant negative, moderate relationship between self-efficacy and the students' perceptions of cultural competence. A project was designed to enhance skills and knowledge to improve the students' cultural competency while caring for patients of Asian, Native American, and Hispanic cultures because minimal familiarity of those cultures contributed most to the negative correlation. Research on methods to improve cultural competence among health care professionals should be continued. Positive social change will occur as nursing students gain proficiency in their abilities to provide culturally appropriate care to patients of diverse ethnic backgrounds.

Le multiparasitisme et surtout les associations qui en découlent, ont une grande influence sur l’écologie des parasites concernés. Elle est d’autant plus grande que les parasites peuvent interagir et ainsi modifier leurs effets sur les hôtes. Cependant, l’identification des associations et interactions de parasites est complexe au niveau populationnel. Notre objectif était de modéliser les associations et les interactions multiparasitaires, notamment dans le cadre des parasites d’importance médicale, vétérinaire ou agronomique. Nous avons tout d’abord réalisé une revue bibliographique sur les différentes causes et conséquences du multiparasitisme ainsi que sur les méthodes et outils disponibles pour comprendre les phénomènes qui le génèrent. Dans un second temps, nous nous sommes intéressés tout particulièrement à la détection des associations multiparasitaires. Nous avons développé une nouvelle méthode « de screening des associations » pour tester statistiquement la présence d’associations de parasites à une échelle globale. Nous avons utilisé cette méthode pour identifier les associations et pour révéler précisément les parasites associés au sein de diverses populations d’hôtes. Puis, nous avons étudié les interactions entre les parasites. Nous avons développé un modèle pour identifier les interactions entre deux parasites vectorisés et persistants chez un hôte, à partir de données issues d’études transversales. L’une des voies de progression de la connaissance sur les interactions est la prise en compte des facteurs de risque communs. La prise en compte des interactions contribue à améliorer le diagnostic, les traitements et la prévention des maladies infectieuses. / Multiparasitism and specifically statistical associations among parasites, have a strong influence on the ecology of parasites. This influence reinforced when parasites interact and thus modify their effect on hosts. However, the identification of associations and interactions between parasites is complex at the population level. Our aim was to model multi-parasite associations and interactions, in particular for parasites of medical, veterinary or agricultural importance. We first present a review of the literature on the different causes and consequences of multiparasitism and the methods and tools available to better understand the phenomena that generate them. In a second step we worked on the detection of multi-parasite associations. We developed a new approach « association screening » to statistically test the presence of multi-parasite associations on a global scale. We used this method to identify associations and to reveal precisely associated parasites in different host populations. Then, we focused on the study of interactions between parasites. We developed a model to identify the interactions between two vector-borne and persistent parasites in a host, using data from cross-sectional studies. One way to increase our capacity to detect parasite interactions in populations is the taking into account common risk factors. Taking into account interactions increases diagnosis, treatments and prevention of infectious diseases.

Entre os temas de Anatomia Animal, a neuroanatomia apresenta-se como um dos conteúdos mais complexos, no qual os métodos tradicionais de ensino não fornecem aos estudantes sua efetiva compreensão, o que implica na necessidade de abordagens complementares para otimizar sua aprendizagem. Este trabalho objetivou a elaboração de uma ferramenta de ensino-aprendizagem para o estudo da neuroanatomia, utilizando uma coleção de lâminas seccionais transversais do Sistema Nervoso Central (SNC) da espécie Equina. Foram utilizadas lâminas seccionais transversais já preparadas, coradas pela técnica de coloração de Pal-Weigert modificada, de modo a realizar a identificação das estruturas neuroanatômicas, e associar a neuroanatomia às síndromes neurológicas desta espécie. Ainda, foram realizadas ilustrações esquemáticas para indicar os locais acometidos por afecções neurológicas e para representação dos cortes seccionais transversais do equino. Foi elaborado, também, um protótipo de website afim de exemplificar a utilização de tecnologias educacionais, como o uso de softwares e computadores como facilitadores para a compreensão das estruturas neuroanatômicas e suas relações clínicas. A utilização das lâminas seccionais transversais do SNC da espécie Equina permitiu a identificação das estruturas anatômicas, a divisão de sua totalidade em intervalos sequenciais para demonstrar a abrangência e topografia das estruturas do SNC, assim como possibilitou embasar a relação entre a neuroanatomia e as síndromes neurológicas. Além disso, foi possível manter e preservar o acervo de lâminas seccionais de SNC do Laboratório de Neuroanatomia Comparada do Departamento de Cirurgia da Faculdade de Medicina Veterinária e Zootecnia da Universidade de São Paulo. Por meio deste estudo buscamos ampliar as discussões acerca da utilização de técnicas tradicionais de estudo em anatomia animal, aliadas às novas tecnologias educacionais e métodos complementares de ensino, uma vez que podem ser desenvolvidas ferramentas de ensino-aprendizagem visando o ensino de graduação, a distância ou presencial, ou ainda por meio da educação continuada. / Among the topics of Animal Anatomy, neuroanatomy is presented as one of the most complex contents, in which traditional teaching methods dont allow students to have effective comprehension, and implies the need for complementary approaches to optimize their learning. This work aimed at the development of a teaching & learning tool for the study of neuroanatomy, using a collection of cross-sectional slides of the Central Nervous System (CNS) of the horse. Cross-sectional slides already prepared, stained with the modified Pal-Weigert staining technique, were used to identify neuroanatomic structures and to associate neuroanatomy with neurological syndromes of this species. In addition to this, schematic illustrations were performed to indicate the sites affected by neurological disorders and to represent the cross-sectional sections of the horse. A website prototype was also developed to exemplify the use of educational technologies, such as the use of softwares and computers as facilitators for the understanding of neuroanatomic structures and their clinical relationships. The use of the cross sectional slides of the CNS of the horse allowed the identification of anatomical structures, dividing their totality into sequential intervals to demonstrate the comprehensiveness and topography of CNS structures, as well as supporting the relationship between neuroanatomy and neurological syndromes. Furthermore, it was possible to maintain and preserve the collection of CNS sectional slides from the Laboratory of Comparative Neuroanatomy of the Department of Surgery of the Faculty of Veterinary Medicine and Animal Science of the University of São Paulo. Through this study we seek to broaden the discussions about the use of traditional techniques of study in animal anatomy, allied to new educational technologies and complementary teaching methods, once teaching and learning tools can be developed aiming at undergraduate teaching, at a distance or face- to-face, or even through continuing education.

<p>A cross- sectional descriptive study using a self-administered close-ended questionnaire was conducted with pupils in standards four to seven (aged 10 &ndash / 17 years) in ten government primary schools in Meru District. The sample of 400 school pupils was obtained by a simple random sampling technique. Data analysis was done using Statistical Package for Social Sciences SPSS (version 15) computer software and the results were presented in frequencies using simple percentages, tables and graphs. The Chi-square test was used to assess the significance where a p-value of &lt / 0.05 was considered statistically significant. In conclusion, Primary school pupils in Meru district engage in several risky sexual behaviors including substance use, sexual coercion, early sexual debut and engaging in various sexual practices. This calls for a more comprehensive approach in the fight against HIV among primary school children in Tanzania, which could include life skill training at an early age, behaviour change communication interventions, advocacy activities to influence policy formulation, condom promotion and incorporating key stakeholders in the rollout of school based HIV programmes such as parents, community leaders and faith-based organizations leaders.</p>