14 resultados para level of propositions
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Dissertao apresentada na Faculdade de Cincias e Tecnologia da Universidade Nova de Lisboa para obteno do grau de Mestre em Engenharia Electrotcnica e de Computadores
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A Work Project, presented as part of the requirements for the Award of a Masters Degree in Management from the NOVA School of Business and Economics
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RESUMO: Resumo Uma prestao de servios de sade mental para crianas e adolescentes (CAMHS) oportuna, eficaz e baseada na evidncia pode evitar incapacidade a longo prazo. No entanto, estes servios so criticamente sub-financiados em todo o mundo. um imperativo garantir que este precioso recurso no seja desperdiado. Os governos e outras partes interessadas relevantes na rea da sade mental precisam de conhecer o estado de sade mental da populao, quais os recursos disponveis e como melhor utilizar os recursos disponveis para orientar uma poltica e decises efectivas sobre os nveis de servios. Objetivo: O objetivo deste artigo explorar o papel da acuidade, gravidade e complexidade na determinao dos cuidados em sade mental especializados recebidos por crianas e adolescentes que sofrem perturbaes mentais. Mtodos: Este estudo exploratrio envolvendo uma reviso sistemtica da literatura. Foi realizada uma pesquisa com palavras-chave utilizando bases de dados PsychINFO, EMBASE, PubMed e MEDLINE. A literatura cinzenta tambm foi investigada com um enfoque nas abordagens sistmicas, organizacionais e polticas para a organizao e comissionamento de CAMHS. Foram selecionados apenas documentos escritos em Ingls. Trs pases, Blgica, Reino Unido e Estados Unidos, todos eles com modelos muito diferentes de organizao de CAMHS, foram revistos para investigar de que forma os conceitos de acuidade, gravidade e complexidade foram utilizados na sua concepo de servios para determinar o nvel da assistncia prestada. Resultados: Nem a Blgica, nem o modelo norte-americano de CAMHS organizao de servio parecem estar alinhados com os principais conceitos na determinao do nvel de prestao de servios. O sistema de servios do Reino Unido de CAMHS est mais estreitamente alinhado com esses conceitos e tem uma alocao de recursos mais equilibrada entre o hospital e a comunidade. O seu ponto fraco est na falta de flexibilidade entre os nveis de servio e na falta de apoio para com o sector dos cuidados de sade primrios. Concluses: A variabilidade na alocao de recursos a diferentes nveis especializados de CAMHS (em regime de internamento, ambulatrio, e na comunidade) e o modelo diferente de estrutura de servios entre os pases estudados indica uma inconsistncia na forma como as crianas e adolescentes que apresentam aos CAMHS so referenciados para os cuidados que recebem. Isto pe em questo se as crianas e adolescentes com perturbaes mentais esto a receber o nvel e tipo de cuidados concordantes com as suas necessidades. A concepo e o comissionamento de sistemas de CAMHS levam-nos discusso de uma srie de princpios fundamentais que devem ser considerados. O sistema perfeito no entanto, ainda est para ser encontrado. -------------------------------- ABSTRACT: Provision of timely, effective, evidence based mental health services to children and adolescents can prevent long term impairment, but they are critically underfunded across the globe. There is an imperative to ensure this precious resource is not wasted. Governments and other relevant mental health stakeholders need to know the mental health status of the population, what resources are available and how best to use the resources available to guide effective policy and decisions about service levels. Aim: The aim of this paper is to explore the role of acuity, severity and complexity in determining the specialist mental health care that children and adolescents experiencing mental disorders receive. Methods: This study is exploratory involving a systematic scan of the literature. A key word search was conducted using databases PSYCHINFO, EMBASE, PUBMED and MEDLINE. Grey literature was also searched to focus on systemic, organisational and policy approaches to the organisation and commissioning of CAMHS. Only documents written in English were selected. Three countries Belgium, UK and the US all with very different models of service organisation for CAMHS were reviewed to investigate how well the concepts of acuity, severity and complexity were used to determine the level of care delivered in their service design. Findings: Neither the Belgium nor the US model of CAMHS service organisation appear to align with the key concepts driving intensity of level of service provision. The UK CAMHS service system most closely aligns with the concepts. It has a more balanced resource allocation between hospital and community. Its downfall is in its lack of flexibility between service levels and its lack of support for the primary care sector. Conclusions: The variability in resource allocation to different service levels (inpatient, outpatient, community) within specialist CAMHS and the differing model of service structure across countries indicates an inconsistency in how children and adolescents presenting to CAMHS are allocated to the care they receive. This puts into question whether children and adolescent with mental disorders are receiving a level and type of care commensurate with their needs. In commissioning and designing CAMHS systems a number of key principles that should be considered are discussed. The perfect system however, is yet to be found.
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The purpose of this thesis is to investigate how far the education level of the second or third generation of publicly traded German family firms affects the post-succession firm performance. By conducting a correlational and regression design, the aim is to examine how several variables influence the performance of family firms. Performance measures, for example ROA and Tobins q and variables, like Education level and succession periods, examine analytically that a positive succession trend will occur. However, with the used model, only a less rigid model shows empirical evidence.
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In order to maximize their productivity, inter-disciplinary multi-occupation teams of professionals need to maximize inter-occupational cooperation in team decision making. Cooperation, however, is challenged by status anxiety over organizational careers and identity politics among team members who differ by ethnicity-race, gender, religion, nativity, citizenship status, etc. The purpose of this paper is to develop hypotheses about how informal and formal features of bureaucracy influence the level of inter-occupation cooperation achieved by socially diverse, multi-occupation work teams of professionals in bureaucratic work organizations. The 18 hypotheses, which are developed with the heuristic empirical case of National Science Foundation-sponsored university school partnerships in math and science curriculum innovation in the United States, culminate in the argument that cooperation can be realized as a synthesis of tensions between informal and formal features of bureaucracy in the form of participatory, high performance work systems.
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This paper provides a longitudinal, empirical view of the multifaceted and reciprocal processes of organizational learning in a context of self-managed teams. Organizational learning is seen as a social construction between people and actions in a work setting. The notion of learning as situated (Brown & Duguid 1989, Lave& Wenger 1991, Gherardi & al. 1998, Easterby-Smith & Araujo 1999, Abma 2003) opens up the possibility for placing the focus of research on learning in the community rather than in individual learning processes. Further, in studying processes in their social context, we cannot avoid taking power relations into consideration (Contu & Willmott 2003). The study is based on an action research with a methodology close to the democratic dialogue presented by Gustavsen (2001). This gives a ground for research into how the learning discourse developed in the case study organization over a period of 5 years, during which time the company abandoned a middle management level of hierarchy and the teams had to figure out how to work as self-managed units. This paper discusses the (re)construction of power relations and its role in organizational learning. Power relations are discussed both in vertical and horizontal work relations. A special emphasis is placed on the dialectic between managerial aims and the space for reflection on the side of employees. I argue that learning is crucial in the search for the limits for empowerment and that these limits are negotiated both in actions and speech. This study unfolds a purpose-oriented learning process, constructing an open dialogue, and describes a favourable context for creative, knowledge building communities.
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Dissertation submitted in partial fulfilment of the requirements for the Degree of Master of Science in Geospatial Technologies
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Microbiology, 154
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Arquivos de Medicina 1998; 12(4): 246-248
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Journal of Bacteriology (Junho 2008) 4272-4280
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Dissertao apresentada na Faculdade de Cincias e Tecnologia da Universidade Nova de Lisboa para obteno do grau de Mestre em Engenharia do Ambiente, perfil de Engenharia Ecolgica
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Resumo: Com base no conceito de implementao de intenes (Gollwitzer, 1993, 1999) e na teoria do contexto de resposta de Kirsch & Lynn (1997), o presente trabalho testou a eficcia de uma interveno combinada de implementao de intenes com hipnose e sugesto ps-hipntica na promoo da adeso a uma tarefa simples (avaliao do humor) e uma tarefa difcil (actividade fsica). Os participantes so estudantes universitrios de uma universidade na Nova Jrsia, (N=124, Estudo 1, EUA) e em Lisboa (N=323, Estudo 2, Portugal). Em ambos os estudos os participantes foram seleccionados a partir de uma amostra mais vasta baseado num escrutnio da sua sugestibilidade hipntica avaliada por meio da Escala de Grupo de Sugestibilidade Hipntica de Waterloo-Stanford (WSGC): Forma C. O Estudo 1 usou um desenho factorial do tipo 2x2x3 (tipo de inteno formada x hipnose x nvel de sugestionabilidade) e o Estudo 2 usou um desenho factorial do tipo 2 x 2x 2 x 4 (tipo de tarefa x tipo de inteno formada x hipnose x nvel de sugestionabilidade). No Estudo 1 foi pedido aos participantes que corressem todos os dias e durante trs semanas durante 5 minutos, que medissem a sua pulsao antes e depois da actividade fsica e que mandassem um e-mail ao experimentador, fornecendo assim uma medida comportamental e uma medida de auto-relato. Aos participantes no grupo de intenes de meta foi apenas pedido que corressem todos os dias. Aos participantes no grupo de implementao de intenes foi pedido que especificasses com exactido quando e onde iriam correr e enviar o e-mail. Para alm disso, cerca de metade dos participantes foram hipnotizados e receberam uma sugesto ps-hipntica em que lhes foi sugerido que o pensamento de correr todos os dias lhes viria mente sem esforo no momento apropriado. A outra metade dos participantes no recebeu qualquer sugesto hipntica. No Estudo 2 foi seguido o mesmo procedimento, mas a cerca de metade dos participantes foi atribuda uma tarefa fcil (enviar um Adherence to health-related behaviors ix SMS com a avaliao diria do seu estado de humor naquele momento) e outra metade da amostra foi atribuda a tarefa de exerccio fsico atrs descrita (tarefa difcil). Os resultados do estudo 1 mostraram uma interaco significativa entre o nvel de sugestionabilidade dos participantes e a sugesto ps-hipntica (p<.01) indicando que a administrao da sugesto ps-hipntica aumentou a adeso nos participantes muito sugestionveis, mas baixou a adeso nos participantes pouco sugestionveis. No se encontraram diferenas entre os grupos que formaram intenes de meta e os que formaram implementao de intenes. No Estudo 2 os resultados indicaram que os participantes aderiram significativamente mais tarefa fcil do que tarefa difcil (p<.001). Os resultados no revelaram diferenas significativas entre as condies implementaes de intenes, hipnose e as duas estratgias combinadas, indicando que a implementao de intenes no foi eficaz no aumento da adeso s duas tarefas propostas e no beneficiou da combinao com as sugestes ps-hipnticas. A utilizao da hipnose com sugesto ps-hipntica significativamente reduziu a adeso a ambas as tarefas. Dado que no existiam instrumentos em Portugus destinados a avaliar a sugestionabilidade hipntica, traduziu-se e adaptou-se para Portugus Escala de Grupo de sugestibilidade hipntica de Waterloo-Stanford (WSGC): Forma C. A amostra Portuguesa (N=625) apresentou resultados semelhantes aos encontrados nas amostras de referncia em termos do formato da distribuio dos padres da pontuao e do ndice de dificuldade dos itens. Contudo, a proporo de estudantes portugueses encontrada que pontuaram na zona superior de sugestionabilidade foi significativamente inferior proporo de participantes na mesma zona encontrada nas amostras de referncia. No sentido de lanar alguma luz sobre as razes para este resultado, inquiriu-se alguns dos participantes acerca das suas atitudes face hipnose utilizando uma verso portuguesa da Escala de Valncia de Atitudes e Crenas face Hipnose e comparou-se com a opinio de Adherence to health-related behaviors xAbstract: On the basis of Gollwitzers (1993, 1999) implementation intentions concept, and Kirsch & Lynns (1997) response set theory, this dissertation tested the effectiveness of a combined intervention of implementation intentions with hypnosis with posthypnotic suggestions in enhancing adherence to a simple (mood report) and a difficult (physical activity) health-related task. Participants were enrolled in a university in New Jersey (N=124, Study 1, USA) and in two universities in Lisbon (N=323, Study 2, Portugal). In both studies participants were selected from a broader sample based on their suggestibility scores using the Waterloo-Stanford Group C (WSGC) scale of hypnotic susceptibility and then randomly assigned to the experimental groups. Study 1 used a 2x2x3 factorial design (instruction x hypnosis x level of suggestibility) and Study 2 used a 2 x 2x 2 x 4 factorial design (task x instructions x hypnosis x level of suggestibility). In Study 1 participants were asked to run in place for 5 minutes each day for a three-week period, to take their pulse rate before and after the activity, and to send a daily email report to the experimenter, thus providing both a self-report and a behavioral measure of adherence. Participants in the goal intention condition were simply asked to run in place and send the e-mail once a day. Those in the implementation intention condition were further asked to specify the exact place and time they would perform the physical activity and send the e-mail. In addition, half of the participants were given a post-hypnotic suggestion indicating that the thought of running in place would come to mind without effort at the appropriate moment. The other half did not receive a posthypnotic suggestion. Study 2 followed the same procedure, but additionally half of the participants were instructed to send a mood report by SMS (easy task) and half were assigned to the physical activity task described above (difficult task). Adherence to health-related behaviors vii Study 1 results showed a significant interaction between participants suggestibility level and posthypnotic suggestion (p<.01) indicating that posthypnotic suggestion enhanced adherence among highly suggestible participants, but lowered it among low suggestible individuals. No differences between the goal intention and the implementation intentions groups were found. In Study 2, participants adhered significantly more (p<.001) to the easy task than to the difficult task. Results did not revealed significant differences between the implementation intentions, hypnosis and the two conditions combined, indicating that implementation intentions was not enhanced by hypnosis with posthypnotic suggestion, neither was effective as single intervention in enhancing adherence to any of the tasks. Hypnosis with posthypnotic suggestion alone significantly reduced adherence to both tasks in comparison with participants that did not receive hypnosis. Since there were no instruments in Portuguese language to asses hypnotic suggestibility, the Waterloo-Stanford Group C (WSGC) scale of hypnotic susceptibility was translated and adapted to Portuguese and was used in the screening of a sample of college students from Lisbon (N=625). Results showed that the Portuguese sample has distribution shapes and difficulty patterns of hypnotic suggestibility scores similar to the reference samples, with the exception of the proportion of Portuguese students scoring in the high range of hypnotic suggestibility, that was found lower than the in reference samples. In order to shed some light on the reasons for this finding participants attitudes toward hypnosis were inquired using a Portuguese translation and adaptation of the Escala de Valencia de Actitudes y Creencias Hacia la Hipnosis, Versin Cliente, and compared with participants with no prior hypnosis experience (N=444). Significant differences were found between the two groups with participants without hypnosis experience scoring higher in factors indicating misconceptions and negative attitudes about hypnosis.
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Critical Issues in Environmental Taxation: International and Comparative Perspectives: Volume VI, 699-715
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RESUMO: A tese de doutoramento visa demonstrar duas proposies: a comorbilidade de 4 situaes de doena prevalentes, hipertenso arterial (HTA), diabetes (DM), doena cardaca isqumica (DCI) e asma um assunto importante em Medicina Geral e Familiar e o seu estudo tem diversas implicaes na forma como os cuidados de sade so prestados, na sua organizao e no ensino-aprendizagem da disciplina. O documento encontra-se dividido em 4 partes: 1) justificao do interesse do tema e finalidades da dissertao; 2) reviso sistemtica de literatura publicada entre 1992 e 2002; 3) apresentao de dois trabalhos de investigao, descritivos e exploratrios que se debruam sobre a mesma populao de estudo, o primeiro intitulado Comorbilidade de quatro doenas crnicas e sua relao com factores scio demogrficos e o segundo, Diferenas entre doentes, por mdico e por sub-regio, na comorbilidade de 4 doenas crnicas; 4) concluses e implicaes dos resultados dos estudos na gesto da prtica clnica, nos servios, no ensino da disciplina da MGF e no desenvolvimento posterior de uma linha de investigao nesta rea. O primeiro estudo tem como objectivos: descrever a prevalncia da comorbilidade entre as 4 doenas-ndice; verificar se existe relao entre o tempo da primeira doena e o tempo decorrido at ao aparecimento da 2 e da 3 doena, nas 4 doenas; determinar a comorbilidade associada s 4 doenas; identificar eventuais agrupamentos de doenas e verificar se existe relao entre comorbilidade e factores sociais e demogrficos. O segundo estudo pretende verificar se existem diferenas na comorbilidade a nvel local, por mdico, e por Sub-Regio de Sade. O trabalho emprico descritivo e exploratrio. A populao constituda pelos doentes, com pelo menos uma das 4 doenas crnicas ndice, das listas de utentes de 12 Mdicos de Famlia a trabalharem em Centros de Sade urbanos, suburbanos e rurais dos distritos de Lisboa e Beja. Os dados foram colhidos durante um ano atravs dos registos mdicos. As variveis scio demogrficas estudadas so: sexo, idade, etnia/raa, escolaridade, situao profissional, estado civil, tipo de famlia, funcionalidade familiar, condies de habitao. A comorbilidade definida pela presena de duas ou mais doenas e estudada pelo nmero de doenas coexistentes. O tempo de durao da doena definido como o nmero de anos decorridos entre o ano de diagnstico e 2003. Os problemas de sade crnicos so classificados pela ICPC2. Nas comparaes efectuadas aplicaram-se os testes de Mann-Whitney e de Friedman, de homogeneidade e de anlise de resduos. A Anlise Classificatria Hierrquica foi utilizada para determinar o agrupamento de doenas e a Anlise de Regresso Categrica e Anlise de Correspondncias na relao entre as caractersticas scio demogrficas e a comorbilidade. Identificaram-se 3998 doentes. A idade mdia de 64,3 anos (DP=15,70). H uma correlao positiva significativa (r =0,350 r=0) entre anos com a primeira doenae idade dos doentes em todos os indivduos (homens r=0,129 mulheres r=0,231). A comorbilidade entre as quatro doenas crnicas ndice est presente em 1/3 da populao. As associaes mais prevalentes so HTA+DM (14,3%) e HTA+DCI (6,25%). Existe correlao positiva, expressiva, entre a durao da primeira doena, quando esta a HTA ou a DM, e o intervalo de tempo at ao aparecimento da 2 e da 3 doenas. Identificaram-se 18 655 problemas crnicos de sade que se traduziram em 244 cdigos da ICPC2. O nmero mdio de problemas foi de 5,94 (DP=3,04). A idade, a actividade profissional, a funcionalidade familiar e a escolaridade foram as variveis que mais contriburam para diferenciar os indivduos quanto comorbilidade. Foram encontradas diferenas significativas entre mdicos(c2=1165,368 r=0) e entre os agrupamentos de doentes por Sub-Regio de Sade (c2= 157,108 r=0) no respeitante comorbilidade. Na partio por Lisboa o nmero mdio de problemas de 6,45 e em Beja de 5,35. Deste trabalho ressaltam vrias consequncias para os profissionais, para os servios, para o ensino e para a procura de mais saber nesta rea. Os mdicos, numa gesto eficiente de cuidados so chamados a desempenhar um papel de gestores da complexidade e de coordenadores assim como a trabalhar num modelo organizativo apoiado numa colaborao em equipa. Por sua vez os servios de sade tm que desenvolver medidas de avaliao de cuidados que integrem a comorbilidade como medida de risco. O contexto social da cronicidade e da comorbilidade dever ser includo como rea de ensino. A concluir analisa-se o impacto do estudo nos colaboradores e o possvel desenvolvimento da investigao nesta rea.----------------------------------------ABSTRACT: The PhD Thesis has two propositions, co-morbidity of four chronic conditions (hypertension, asthma, diabetes, cardiac ischaemic disease) is a prevalent and complex issue and its study has several implications in the way care is provided and organised as well as in the learning and teaching of the discipline of General Practice. In the first part of the document arguments of different nature are given in order to sustain the dissertation aims; the second part describes a systematic study of literature review from 1992 to 2002; the third presents two research studies "Comorbidity of four chronic diseases and its relation with socio demographic factors and Differences between patients among GPs at local and regional level; implications of study results for practice management, teaching and research are presented in the last part. The prevalence of the four chronic diseases co-morbidity, the relation of the first disease duration with the time of diagnose of the next index condition, the burden of co-morbidity in the four chronic diseases, the clustering of those diseases, the relation between demographic and social characteristics and co-morbidity, are the objectives of the first study. The second intends to verify differences in comorbidity between patients at local and regional level of practice. Research studies were descriptive and exploratory. The population under study were patients enlisted in 12 GPs working in urban and rural health centres, in Lisbon and Beja districts, with at least one of the four mentioned diseases. Data were collected through medical records during one year (2003) and 3998 patients were identified. The social demographic variables were: sex, age, ethnicity/race, education, profession, marriage status, family status, family functionality, home living conditions. Co-morbidity is defined by the presence of two or more diseases, and studied by the number of co-existing diseases. The time duration of the disease is defined by the number of years between the diagnostic year and 2003. The chronic disease problems are classified in accord with ICPC2. The characterization of population is descriptive. The effected comparisons applied the Mann-Whitney, Friedman, homogeneity and analysis of residuals tests. The Classificatory Hierarchy Analysis was utilized to determine the grouping of diseases and the Regression Categorization and Correspondences Analysis was used to study the relation of socio-demographic and co-morbidity. The median age of the population under study is 64,3 (SD= 15,70). There is a significant positive correlation (r =0,350 r=0)between years with the first disease and patient age for all individuals (men r=0,129 women r=0,231). Co-morbidity of the four index diseases is present in 1/3 of the studied population. The most prevalent associations for the four diseases are HTA+DM (14,03%) and HTA+IHD (6,25%). Expressive positive correlation between the duration of the first disease and the second and the third index disease interval is found. For the 3988 patients, 18 655 chronic health problems, translated in 244 ICPC2 codes, were identified. The mean number of problems is 5,94 (SD=3,04). Age, professional activity, family functionality and education level are the socio demographic characteristics that most contribute to differentiate individuals concerning the overall co-morbidity. Significant differences in co-morbidity between GP patients at local (c2=1165,368 r=0) and regional level (c2= 157,108 r=0) are found. This study has several consequences for professionals, for services, for the teaching and learning of General Practice and for the pursuit of knowledge in this area. New competences and performances have to be implemented. General Practitioners, assuming a role of co-ordination, have to perform the role of complexity managers in patient's care, working in practices supported by a strong team in collaboration with other specialists. In order to assess provided care, services have to develop tools where co-morbidity is included as a risk measure. The social context of comorbidity and chronicity has to be included in the curricula of General Practice learning and teaching areas. The dissertation ends describing the added value to participant's performance for their participation in the research and an agenda for further research, in this area, based on a community of practice.--------RSUM:Cette thse de doctorat prtend dmontrer deux postulats : le premier, que la comorbidit de quatre maladies frquentes, hypertension artrielle (HTA), diabte (DM), maladie cardiaque ischmique (DCI) et asthme, est un thme important en Mdecine Gnrale et Familiale et que son tude a plusieurs implications au niveau de l'approche pour dispenser les soins, de leur organisation et de l'enseignement/apprentissage de la discipline. Le document comprend quatre parties distinctes : 1) justification de l'intrt du sujet et objectifs de la dissertation ; 2) tude systmatique de publications dites entre 1992 et 2002 ; 3) prsentation de deux travaux de recherche, descriptifs et exploratoires, un premier intitule Comorbidit de quatre maladies chroniques et leur relation avec des facteurs sociodmographiques et un deuxime Diffrences entre malades, selon le mdecin et la sous rgion, dans la comorbilit de quatre maladies chroniques ; 4) conclusions et consquences des rsultats des tudes dans la gestion de la pratique clinique, dans les services, dans l'enseignement de la discipline de MGF et dans le dveloppement postrieur de la recherche dans ce domaine. Les objectifs de la premire tude sont les suivants : dcrire la prvalence de la comorbidit entre les quatre maladies chroniques, vrifier s'il existe une relation entre temps de dure de la premire maladie et l'espace de temps jusqu' le diagnostic de la 2me ou 3me maladie; dterminer la comorbidit entre les 4 maladies ; identifier d'ventuelles groupements de maladies et vrifier s'il existe une relation entre comorbidit et facteurs sociodmographiques. La deuxime tude prtend vrifier s'il existe des diffrences de comorbidit entre mdecins et par groupement rgional. Le travail empirique est descriptif et exploratoire. La population est compose des malades ayant au moins une des quatre maladies chroniques parmi les listes de malades de douze Mdecins de Famille qui travaillent dans des Centres de Sant urbains, suburbains et ruraux (Districts de Lisbonne et Beja). Les donnes ont t extraites pendant l'anne 2003 des registres des mdecins. Les variables sociodmographiques tudies sont : le sexe, l'ge, l'ethnie/race, la scolarit, la situation professionnelle, l'tat civil, le type de famille, sa fonctionnalit, les conditions de logement. La comorbidit est dfinie lorsqu'il existe deux ou plusieurs maladies et est tudie d'aprs le nombre de maladies coexistantes. La dure de la maladie est tablie en comptant le nombre d'annes coules entre le diagnostique et 2003. Les problmes de sant chroniques sont classs par l'ICPC 2. Pour les comparaisons les tests de Mann-Whitney et Friedman, de homognit et analyse de rsidues ont t appliqus. L'Analyse de Classification Hirarchique a t utilise pour procder au regroupement des maladies et l'Analyse de Rgression Catgorique et l'Analyse de Correspondances pour tudier la relation entre les caractristiques sociodmographiques et la comorbilit. Les principaux rsultats sont les suivants : les 3998 malades identifis ont 64,3 ans d'ge moyen (DP=15,70). Il existe une corrlation positive significative (r =0,350 r=0) entre les annes avec la premire maladie et l'ge des malades , chez tous les individus (hommes r=0,129 femmes r=0,231). La comorbidit entre les quatre maladies chroniques est une ralit chez 1/3 des patients. Les associations les plus frquentes sont HTA+DM (14%) et HTA+DCI (6,25%). Il existe une corrlation positive significative entre la dure de la premire maladie, HTA ou DM, et l'cart jusqu' l'apparition de la deuxime et de la troisime maladie. Chez les malades, 18.655 problmes chroniques de sant ont t identifis et traduits en 244 codes de l'ICPC2. La moyenne des problmes a t de 5,94 (DP=3,04). L'ge, l'activit professionnelle, la fonctionnalit familiale et la scolarit sont les variables qui ont le plus contribu diffrencier les individus face la comorbilit. Des diffrences notoires ont t trouves entre mdecins (c2=1165,368 r=0) et entre les groupements rgionaux (c2=157,108 r=0) en ce qui concerne la comorbidit. Dans le groupe de patients de Lisbonne, le chiffre moyen de problmes est de 6,45 et Beja il est de 5,35. Cette tude met en vidence plusieurs consquences pour les professionnels, les services, l'enseignement et l'largissement du savoir dans ce domaine. Les mdecins, soucieux de grer efficacement les soins sont appels jouer un rle de gestionnaires de la complexit et de coordinateurs, de mme qu' travailler dans un modle d'organisation soutenus par un travail d'quipe. D'autre part, les services de sant doivent eux aussi dvelopper des mesures d'valuation des soins qui intgrent la comorbidit comme mesure de risque. Le contexte social de la chronicit et de la comorbidit devra tre inclus comme domaines tudier. La fin de cette thse dcrit l'impact de cette tude sur les collaborateurs et le dveloppement futur de la recherche dans ce domaine.
