Universal service is the focal point of the economic dilemma faced by the telecommunications industry. The advent of competition spurred by several regulatory rulings is forcing rates towards economic costs. It is feared that this movement or the erosion of the toll-to-local subsidy with concomitant increases in local prices severely threatens the concept of universal service. To adequately address these fears, accurate elasticity of demand estimates for telephone access are required. This thesis develops estimates of these demand elasticities for access. These estimates are derived consistently from an underlying theory of demand for access. Furthermore, the simultaneous access and class-of-service choice problems are addressed similarly. This consistent development facilitates model usage and interpretation. For example, the model provides the best available estimate for the size of the network externality. Taking into account the underlying demand theory and acknowledging the problems associated with the aggregated nature of the data set (census tract data from 1980 Census), a modified probit technique is developed to estimate the demand model. The estimation methodology is implemented using an iterative least square procedure. To analyze the reasonableness of the algorithm and procedure, a Monte Carlo study is performed. In addition, a jackknife technique is employed to estimate variances of coefficients when the standard measures are unavailable. The model results are used to analyze the effect of current policy decisions. For example, for a proposed doubling of access prices the demand for access elasticity is found to be quite small, about -.04. A welfare analysis is performed to discuss the costs and benefits associated with moving to cost-based rates. This analysis also provides the basis for rate recommendations to facilitate the transition to competition while attempting to preserve the concept of universal service.

Submitted by ANA PAULA FRENEDA DE FREITAS null (paulinha_botu@yahoo.com.br) on 2017-04-20T19:28:12Z No. of bitstreams: 1 Ana Paula Freneda de Freitas-Mestrado - 20-04 16-23.pdf: 1975497 bytes, checksum: 538f1ae49b2910f4b92b34b169bed6bc (MD5) / Approved for entry into archive by Luiz Galeffi (luizgaleffi@gmail.com) on 2017-04-25T18:16:35Z (GMT) No. of bitstreams: 1 freitas_apf_me_bot.pdf: 1975497 bytes, checksum: 538f1ae49b2910f4b92b34b169bed6bc (MD5) / Made available in DSpace on 2017-04-25T18:16:35Z (GMT). No. of bitstreams: 1 freitas_apf_me_bot.pdf: 1975497 bytes, checksum: 538f1ae49b2910f4b92b34b169bed6bc (MD5) Previous issue date: 2017-02-22 / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / Introdução: Acesso e acolhimento são elementos essenciais para que se possa intervir de forma satisfatória no estado de saúde da população. A literatura nacional traz poucos estudos abordando o acesso aos serviços e cuidado com a saúde entre mulheres que fazem sexo com mulheres (MSM). Objetivo: Analisar o acesso a serviços de saúde e o cuidado com a saúde sexual e reprodutiva de mulheres que fazem sexo com mulheres, sob o enfoque das políticas públicas de saúde. Método: Estudo observacional, transversal, descritivo e analítico que integra estudo mais amplo sobre acesso a serviços de saúde e saúde sexual e reprodutiva de MSM. A amostra intencional de 149 MSM foi constituída por meio da Técnica de Amostragem Bola de Neve (a Andreia pediu para retirar, acho melhor manter) indicação de profissionais de saúde e liderança LGBT (de Lésbicas, Gays, Bissexuais, Travestis e Transexuais) por procura espontânea, a partir da divulgação do projeto nas redes de sociabilidade, comunicação de massa, serviços de saúde e grupos de ativismo. As variáveis estudadas foram: sociodemográficas, consumo de substâncias, comportamento e práticas sexuais, clínico-ginecológicas e reprodutivas, relacionadas ao acesso a serviços de saúde e a variável desfecho foi escore de cuidado com a saúde sexual e reprodutiva. Os dados foram obtidos pelas pesquisadoras envolvidas no estudo mãe, de janeiro de 2015 a dezembro de 2016, por meio da aplicação de um questionário, exame ginecológico para o diagnóstico de HPV (Papiloma Vírus Humano), Chlamydia Trachomatis, Neisseria Gonorrhoeae e Trichomonas Vaginalis e coleta de sangue periférico para diagnóstico das infecções pelo HIV (Vírus da Imunodeficiência Humana), Vírus da Hepatite B, e Sífilis. Para análise dos dados empregou-se a estatística descritiva e as associações foram verificadas pelo teste de Qui Quadrado, por meio de ajustes de modelos de regressão linear, com resposta normal e de regressão linear múltipla. Resultados: Predominaram as mulheres brancas (74,5%), não unidas (73,2%), que tinham atividade remunerada (73,2%), alguma religião (74,5%) e com oito anos e mais de estudo concluídos (96,0%). A mediana de idade foi de 27 anos (18-62) e a renda familiar per capita de R$1.000,00 (133,33-15.000,00). A maioria tinha histórico de relacionamento sexual com homens durante a vida (74,2%) e, no último ano, apenas com mulheres (77,2%). A maioria utilizava o serviço público de saúde (84,0%), procurava Unidades Básicas de saúde (70,5%) e pronto-socorro (67,8%), somente quando adoeciam/sentiam algum desconforto (70,0%) e 47,6% não revelavam a prática sexual com mulheres para os profissionais de saúde. As dificuldades/barreiras encontradas na procura por serviços de saúde e/ou no atendimento dos profissionais e/ou à satisfação de necessidades pelos serviços foram relatadas por 77 (51,7%) mulheres, sendo que 66,1% delas relacionaram-se à estrutura e organização dos serviços de saúde e 33,9% à relação profissional de saúde-usuário. A mediana do escore de cuidado com a saúde sexual e reprodutiva foi de 4 pontos (0-7), tendo em vista que este poderia variar de 0-8 pontos. A maioria das mulheres não realizava atendimento ginecológico anual (54,4%), não estava com a Citologia Oncótica em dia (63,1%), tinha relação sexual após o consumo de álcool e/ou drogas ilícitas (71,8%), não utilizava preservativo nas relações sexuais anais e vaginais (87,9%), e tinha diagnóstico de alguma IST( Infecção Sexualmente Transmissível) (51,7%) e, 47,0% não havia realizado sorologia para IST/aids. A maioria das mulheres era tabagista (55,0%) e 34,9% utilizavam drogas ilícitas. As variáveis independentemente associadas ao escore de cuidado com a saúde sexual e reprodutiva foram idade, utilização de tabaco, de drogas ilícitas, ter se relacionado sexualmente com seis ou mais mulheres na vida, relação sexual após uso de álcool e/ou drogas ilícitas e uso de preservativo em todas as relações sexuais anais e vaginais. Não houve associação entre ter ou não histórico de relação sexual com homens na vida ao escore de cuidado. Diante dos resultados obtidos na presente investigação realizou-se duas oficinas de sensibilização dirigidas aos profissionais de saúde de todas as categorias, atuantes na Atenção Básica do município de Botucatu. Estas tiveram por objetivo a sensibilização dos profissionais sobre as necessidades de saúde de MSM e proporcionar reflexão referente as suas práticas em relação a esse grupo. Foram propostas várias estratégias pelos participantes como: educação permanente de todos os profissionais e educação em saúde voltada à população em geral, acerca desta temática, revisão de instrumentos de sistematização, utilizados na assistência, que favoreçam a revelação da prática sexual com mulher e organização e distribuição de material educativo sobre cuidado com a saúde para MSM, dentre outras. Conclusão: Apesar de a maioria das MSM terem acesso aos serviços de saúde, apresentaram muitas lacunas no cuidado com a saúde sexual e reprodutiva, apontando para vulnerabilidade individual, social e programática às IST, comprovada pela elevada prevalência desses agravos. Necessidades de saúde específicas deste grupo podem deixar de estar sendo identificadas e abordadas pelos profissionais de saúde, uma vez que grande parte delas não revelou a prática sexual com mulher. Desta forma, o presente estudo vem contribuir para o planejamento de ações mais abrangentes, voltadas à promoção da saúde integral de mulheres que fazem sexo com mulheres, à medida que aponta contexto de vulnerabilidade e de necessidades, relativas à saúde sexual e reprodutiva de mulheres, residentes no interior do Estado de São Paulo. / Introduction: Before proposing any intervention to improve health services of a given population, it is essential that health care is provided and the population is able to access these services. In this regard, there is a gap in the literature related to the access to health care among Brazilian women who have sex with women (WSW). Objective: The study presented here analyses the access to health services and the care given to these women, mainly concerning reproductive and sexual health. It focuses on public health policies. Methods: This study was based on the analyses of observational, transversal and descriptive studies, which are part of a research project that investigates the access that WSW have to health services, mainly reproductive and sexual health care. The sample size of 149 women was achieved through chain referral sampling mode. The participants where indicated by health professionals or LGBT activists (lesbian, gay, bisexual, transvestite and transgender). Also, some participants were volunteers interested in the project as it was promoted in social media, mainstream media, through healthcare service and activism groups. The variables in study were the following: socio-demographics, drugs consumption, behavioural, sexual practices, clinical-gynaecologist and reproductive, and those related to access to health services. The outcome variable was the reproductive and sexual health care score. The data was gathered by the researchers in the main research project during two-year period - from January 2015 until December 2016 - who applied a questionnaire, combined with gynaecologic exam and blood test used to detect infections of HIV (Human immunodeficiency virus), hepatitis B virus, HPV (Human papillomavirus), Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis and syphilis. Descriptive statistics was used to analyse the data, the associations were verified by Chi-squared test, using linear regression modelling with normal and multiple linear regression responses. Results: The data analysis showed the predominance of white women (74,5%), single (73,2%), employee (73,2%), religious (74,5%) and who had been educated during eight or more years (96,0%). The median age of the participants was 27 years old (18-62) and the family monthly income of R$1.000,00 (133,33 - 15.000,00). The majority had had men sexual partners previously (74,2%) but, in the last year woman partners only (77,2%). The majority used the public health services (84,0%), used Health Care Units (70,5%) and Hospital Emergency Units (67,8%), only when had an illness or some type of discomfort (70,0%) and 47,6% did not disclose their sexual preferences and practices to health professionals. Seventy seven women (51,7%) reported some kind of difficulties or barriers they found when seeking for health services; when being attended by health professionals and/or regarding having their needs fulfilled by the health services. Most of the barriers (66,1%) were related to the organizational structure of the health services provided, whilst 33,9% were related to the health care professional and the health care patient. The median of reproductive and sexual health care score was four points (0-7), considering that the score could vary between 0-8 points. Annual gynaecologic appointment/or exam were neglected by the majority of the women (54,4%); others did not have a valid cervical smear test (63,1%); the majority had sexual relations after alcohol and/or drugs consumption (71,8%); most did not use any preservatives in sexual relations, whether anal or vaginal (87,9%); more than a half (51,7%) had been diagnosed some kind of STI (Sexually Transmitted Infections) and; 47,0% did not take serologic blood tests to identify STI/ AIDS. It was observed among the participants a high percentile of smoker women (55,0%) and drugs users (34,9%). The independent variables associated with reproductive and sexual health care score were: age; whether they smoke; whether they use drugs; had sex with six or more women; had sexual relations after alcohol and/or drugs consumption; and, the use of preservatives in sexual relations, whether anal or vaginal. It was not found a correlation between had had men sexual partners previously and the care score. Following the analysis of the results of the present investigation, two workshops were organised targeted at health care professionals of different organisational levels of Basic Care in Botucatu municipality. The workshops were conducted to promote the health needs of WSW and to discuss the current practices related to this group. Several strategic actions were proposed by the participants of the workshop, among them were: continuous information and training to health care professionals; dissemination of WSW health care needs to wide population; review of instruments and data systematisation used to assist WSW that support the women to feel comfortable to talk about their sexual practices; organisation and distribution of informative material regarding WSW health and care. Conclusion: Although the majority of the WSW has access to health services, they did not fulfil their needs regarding reproductive and sexual health care. Therefore, they were individually, socially and programmatically vulnerable to STI, which was reflected in the high prevalence of STI among the participants. Their health care needs possibly can be neglected by health care professionals, as the majority of WSW did not reveal their sexual practices to them. In this way, by contextualising the vulnerability and needs related to reproductive and sexual health of women living in the country side of Sao Paulo province, the present study contributes to the planning of strategic actions to promote the health care services target at women who have sex with women. / FAPESP: 2015/14769-0

Timely access to child mental health services is a widespread concern. Many children with diagnosable disorders do not receive help. Untreated disorders can cause significant child and family impairment. Barriers to treatment can impede access. Few specialists, long wait lists and clinic-based services can be problematic. Families encounter treatment barriers related to travel (i.e., time off work or school; inconvenience; financial burden), stigma, and child resistance to therapy. Alternative models of care are needed. Distance telephone treatment (e.g., Strongest Families), can bridge the access gap. There is little understanding about the participants’ experience with distance treatment. The research objectives were: 1. to establish if therapeutic alliance exists between a) a parent-coach and b) a child-coach, when distance treatment is delivered by telephone with no face-to-face contact; 2. to explore the parents’ distance experiences and opinions; 3. to develop and validate the Treatment Barrier Index (TBI) scale derived from participants’ experiences; and 4. to use the TBI to examine treatment barrier differences (and therapeutic processes) between two delivery systems (Distance vs Face-to-face). Therapeutic alliance exists between adult-coach and child-coach with distance treatment. Participants found distance treatment to be more private and felt less stigmatized because of visual anonymity, compared to their opinions of face-to-face services. The TBI results indicated fewer perceived barriers with distance treatment. A significant difference was found between delivery systems in terms of perceived barriers, therapeutic alliance and self-disclosure as a group of variables. This suggests that there may be differences in therapeutic processes between systems. Therapeutic alliance scores were enhanced with distance treatment and found to positively correlate with self-disclosure and outcome scores; suggesting that these processes are important in the context of distance intervention. Cost-effective distance systems using non-professionals may be one way to increase access to child mental health services. Although some families may prefer the physical presence of face-to-face services, others prefer distance services. The results from these studies may help to inform system design improvements aimed at increasing service access. Improving models of care to meet participants’ needs could lead to increased service utilization, ultimately improving child health outcome.

The strong emphasis placed on improving equality and well-being for all in the Sustainable Development Goals underscores the importance of tackling persistent within-country disparities in maternal mortality and poor health outcomes. Addressing maternal healthcare access barriers is, thus, crucial, particularly in low-resource settings. Numerous studies investigating determinants of maternal healthcare service use in Ethiopia exist but are limited by their focus on individual and household factors, and by methodological weaknesses. A nuanced understanding of the role of socioeconomic and geographic context in influencing access to care is needed to respond effectively. Maternity waiting homes (MWHs) are a potential strategy to address geographical barriers that delay women’s access to obstetric care. However, in addition to concerns about service quality, there is limited evidence on their effectiveness and on what models meet women’s needs. My research goals were, therefore, to contribute to the understanding of what contextual factors influence maternal healthcare service use in general; and to determine whether or not upgraded MWHs operating in an enabling environment could improve delivery care use in rural Ethiopia. My primary data sources were household surveys conducted as part of a cluster-randomized controlled trial evaluating MWHs and local leader training in Jimma Zone, Ethiopia. Random effects multivariable logistic regression analysis of survey data brought to light the social and financial resources that facilitate MWH use, highlighting the need for complementary interventions to make access more equitable. Spatial analyses identified subnational variation in service use at a finer scale than routinely reported and unmasked local variation in the relevance and magnitude of associations between individual-, interpersonal-, and health system factors and maternal healthcare use. These findings have implications for relying upon homogenous national responses to improve equality in access to care and health outcomes. Finally, analysis of trial data found a non-significant effect of interventions on delivery care use likely due to implementation issues and extraneous factors. The need to generate strong evidence of effectiveness of MWHs in improving maternal healthcare service use using sustainable and equitable MWH models using methods appropriate for complex intervention evaluation remains.

Cette thèse aborde de façon systémique l’analyse de la situation des TICs en Afrique Centrale, elle identifie les problématiques liées à l’accès universel et étudie les politiques d’harmonisation des TICs. Cette analyse conduit alors à proposer une cartographie cible intégrée permettant de réduire la fracture numérique. Non seulement les différentes technologies optiques et radio large bande sont mises à contribution mais décrites en vue de relater les notions de base permettant d’appréhender les avantages et inconvénients de chaque technologie. Ceci a permis par la suite de proposer une démarche méthodologique de modélisation de l’indicateur d’accès au service universel couplée à une stratégie d’optimisation révélant, d’une part le gap technologique à combler et d’autre part, prédisant le niveau d’accès technologique à atteindre en fonction des politiques d’investissement du Fonds de Service Universel. Aussi, outre la proposition de cette démarche de modélisation cette thèse apporte une autre contribution en développant un modèle d’architecture réseau basé sur les technologies radio et en proposant une méthodologie consistant à intégrer les différents paramètres impliqués dans le choix des technologies à déployer en vue de l’accès au service universel. De plus, elle se projette dans l’évolution future de la technologie en offrant une ouverture sur les technologies hybrides. / This thesis deals systematically with the analysis of the situation of ICTs in Central Africa, it identifies the problems related to universal access and studies ICTs harmonization policies. This analysis then enables the proposal of an integrated target mapping to reduce the digital divide. Not only the different optical and radio broadband technologies are used but described to relate the basic concepts allowing to apprehend the advantages and disadvantages of each technology. This allowed us to propose a methodological approach to modeling the universal access and service indicator coupled with an optimization strategy revealing, on the one hand, the technological gap to be filled and on the other hand, predicting the access level based on technologies to achieve in accordance with the investment policies of the Universal Service Fund. Besides the proposal of this modeling approach, other contributions of this thesis is developing a network model architecture based on radio technologies and proposing a methodology consisting of integrating the various parameters involved in the choice of technologies to be deployed for access and universal service. In addition, it is projected into the future evolution of solutions that leads to hybrid technologies.