Modelos de gestão pública e as opções de reforma do XIX governo constitucional: análise do discurso

Dissertação de Mestrado em Gestão e Políticas Públicas

Assessment of Youth-Friendly Postabortion Care Services: A Global Tool for Assessing and Improving Postabortion Care for Youth

This tool is designed to help assessment teams, project managers, supervisors, and providers collect detailed information on the quality of Postabortion Care (PAC) services provided to adolescents at a given facility in order to make services more youth-friendly. It can also be used before PAC services have been established to see how best to design PAC services to meet youth’s needs. The assessment process facilitates the development of action plans for quality improvement that can help facilities address policy, operations, training, and other program areas needing adjustments and change. The tool also provides essential baseline information, allowing for repeated applications to measure changes and the impact of program interventions. Although the tool is primarily for use by a team, it may also be used by an individual.

The relative benefits of endurance and strength training on the metabolic factors and muscle function of people with type 2 diabetes mellitus

Objective: To compare the effects of a 4-month strength training (ST) versus aerobic endurance training (ET) program on metabolic control, muscle strength, and cardiovascular endurance in subjects with type 2 diabetes mellitus (T2D). Design: Randomized controlled trial. Setting: Large public tertiary hospital. Participants: Twenty-two T21) participants (I I men, I I women; mean age +/- standard error, 56.2 +/- 1.1 y; diabetes duration, 8.8 +/- 3.5y) were randomized into a 4-month ST program and 17 T2D participants (9 men, 8 women; mean age, 57.9 +/- 1.4y; diabetes duration, 9.2 +/- 1.7y) into a 4-month ET program. Interventions: ST (up to 6 sets per muscle group per week) and ET (with an intensity of maximal oxygen consumption of 60% and a volume beginning at 15min and advancing to a maximum of 30min 3X/wk) for 4 months. Main Outcome Measures: Laboratory tests included determinations of blood glucose, glycosylated hemoglobin (Hb A(1c)), insulin, and lipid assays. Results: A significant decline in Hb A, was only observed in the ST group (8.3% +/- 1.7% to 7.1% +/- 0.2%, P=.001). Blood glucose (204 +/- 16mg/dL to 147 +/- 8mg/dL, P <.001) and insulin resistance (9.11 +/- 1.51 to 7.15 +/- 1.15, P=.04) improved significantly in the ST group, whereas no significant changes were observed in the ET group. Baseline levels of total cholesterol (207 +/- 8mg/dL to 184 +/- 7mg/dL, P <.001), low-density lipoprotein cholesterol (120 +/- 8mg/dL to 106 +/- 8mg/dL, P=.001), and triglyceride levels (229 +/- 25mg/dL to 150 +/- 15mg/dL, P=.001) were significantly reduced and high-density lipoprotein cholesterol (43 +/- 3mg/dL to 48 +/- 2mg/dL, P=.004) was significantly increased in the ST group; in contrast, no such changes were seen in the ET group. Conclusions: ST was more effective than ET in improving glycemic control. With the added advantage of an improved lipid profile, we conclude that ST may play an important role in the treatment of T2D.

Políticas públicas, desenvolvimento local e participação social nas instâncias de governança associadas ao turismo no Rio Grande do Norte

In contemporary dynamics, a change is observed in the institutional structure of the state, culminating in several policies for the tourist sector which promote a new management format. The from this view, the Tourism Regionalization Macro Program (TRP), considered a significant program to Ministry of Tourism, arose as an answer to this new reality, having as strategy a joint working of structuring and promotion turned at decentralization of actions, valuing the residents participation in the search of the permanent dialogue between peers and revaluation of places and territories, based in the regionalization process. Based on this bias, this study aims to examine the role of the Tourism State Council of Rio Grande do Norte, with regard to the tourism planning, trying to understand it and solve it as governance Instance, through the Tourism Regionalization Program interventions, given the participation context of its actors and agents. For purposes of this study is delimited as time frame the year 2007 at 2014, understanding that it was this time, there was greater council members accession, as well as different types of sectors representation of civil society, as a result of a tourism public policy based on principles of innovation and participation. In relation to the research problem, this study is conceptualized as a qualitative and the chosen method is the materialist dialectic. Still on the methodological options, utilize the Content Analysis. The results show that the institutionalization of governance instance as the Conetur does not contributes, ideally, in the planning and management process of participatory and integrated tourist activity, facing a fair direction of your space production. The research indicates that there are debates, discussions and guidelines (still in a timely and targeted form), but not reverberates practical effects, by act in a conjuncture that Is strategically designed for political and economic power game, setting the hegemonic actors performance, which uses this arena to instill personal desires and wishes, that are decided in absentia to the council.

Training civic bridge builders: Outcomes of community leadership development programs

As rural communities experience rapid economic, demographic, and political change, program interventions that focus on the development of community leadership capacity could be valuable. Community leadership development programs have been deployed in rural U.S. communities for the past 30 years by university extension units, chambers of commerce, and other nonprofit foundations. Prior research on program outcomes has largely focused on trainees’ self-reported change in individual leadership knowledge, skills, and attitudes. However, postindustrial leadership theories suggest that leadership in the community relies not on individuals but on social relationships that develop across groups akin to social bridging. The purpose of this study is to extend and strengthen prior evaluative research on community leadership development programs by examining program effects on opportunities to develop bridging social capital using more rigorous methods. Data from a quasi-experimental study of rural community leaders (n = 768) in six states are used to isolate unique program effects on individual changes in both cognitive and behavioral community leadership outcomes. Regression modeling shows that participation in community leadership development programs is associated with increased leadership development in knowledge, skills, attitudes, and behaviors that are a catalyst for social bridging. The community capitals framework is used to show that program participants are significantly more likely to broaden their span of involvement across community capital asset areas over time compared to non-participants. Data on specific program structure elements show that skills training may be important for cognitive outcomes while community development learning and group projects are important for changes in organizational behavior. Suggestions for community leadership program practitioners are presented.

What Are Effective Program Characteristics of Self-Management Interventions in Patients With Heart Failure? : An Individual Patient Data Meta-analysis

Background To identify those characteristics of self-management interventions in patients with heart failure (HF) that are effective in influencing health-related quality of life, mortality, and hospitalizations. Methods and Results Randomized trials on self-management interventions conducted between January 1985 and June 2013 were identified and individual patient data were requested for meta-analysis. Generalized mixed effects models and Cox proportional hazard models including frailty terms were used to assess the relation between characteristics of interventions and health-related outcomes. Twenty randomized trials (5624 patients) were included. Longer intervention duration reduced mortality risk (hazard ratio 0.99, 95% confidence interval [CI] 0.97–0.999 per month increase in duration), risk of HF-related hospitalization (hazard ratio 0.98, 95% CI 0.96–0.99), and HF-related hospitalization at 6 months (risk ratio 0.96, 95% CI 0.92–0.995). Although results were not consistent across outcomes, interventions comprising standardized training of interventionists, peer contact, log keeping, or goal-setting skills appeared less effective than interventions without these characteristics. Conclusion No specific program characteristics were consistently associated with better effects of self-management interventions, but longer duration seemed to improve the effect of self-management interventions on several outcomes. Future research using factorial trial designs and process evaluations is needed to understand the working mechanism of specific program characteristics of self-management interventions in HF patients.

Oral Health Promotion Through an Online Training Program for Medical Students

The objective of this study was to compare the impact on knowledge and counseling skills of face-to-face and Internet-based oral health training programs on medical students. Participants consisted of 148 (82 percent) of the 180 invited students attending their fifth academic year at the Faculty of Medicine, University of Sao Paulo, Brasil, in 2007. The interventions took place during a three-month training period in the clinical Center for Health Promotion, which comprised part of a clerkship in Internal Medicine. The students were divided into four groups: 1) Control Group (Control), with basic intervention; 2) Brochure Group (Br), with basic intervention plus complete brochure with oral health themes; 3) Cybertutor Group (Cy), with basic intervention plus access to an Internet-based training program about oral health themes; and 4) Cybertutor + Contact Group (Cy+C), the same as Cy plus brief proactive contact with a tutor. The impact of these interventions on student knowledge was measured with pre- and post assessments, and student skills in asking and counseling about oral health were assessed with an objective structured clinical examination (OSCE). Multivariate logistic regression models were applied to identify the odds ratios of scoring above Control's medians on the final assessment and the OSCE. In the results, Cy+C performed significantly better than Control on both the final assessment (OR 9.4; 95% CI 2.7-32.8) and the OSCE (OR 5.6; 95% CI 1.9-16.3) and outperformed all the other groups. The Cy+C group showed the most significant increase in knowledge and the best skills in asking and counseling about oral health.

Friere`s Dialogic Concept Enables Family Health Program Teams to Incorporate Health Promotion

Objective The study analyzes the possibility of incorporating health promotion measures into the work processes of Family Health Program teams at a primary health care clinic in Brazil. Design and Sample We used the participatory research concept developed in 1968 by Freire. The study sample comprised the end-users of the health care system, together with 3 multidisciplinary teams. A total of 77 health care users and 55 health professionals participated in the study. Measures Culture circles composed of health care professionals, and users from different areas investigated generative topics, encoded/decoded topics, and engaged in critical probing for clarification. Topics affecting quality of life and health were heuristically evaluated. Results Although most topics were related to changing the focus of health care facilities, some were related to subsidizing community-based interventions, improving environmental strategies, individual skills, and public policies. Incorporating the novel health promotion measures and creating an expanded full-treatment clinic are important steps toward that goal. Conclusions Topics that can stimulate dialogue among the members of the culture circles include creating an environment of closer cultural contact, with repercussions for work processes, family health models, and general health models, as well as the inclusion of social aspects in the decision-making processes related to health issues that affect the living conditions of the population.

Effect of a 36-month pharmaceutical care program on pharmacotherapy adherence in elderly diabetic and hypertensive patients

Objective: The primary objective of this study was to evaluate the effect of a pharmaceutical care program on pharmacotherapy adherence in elderly diabetic and hypertensive patients. The clinical outcomes of this pharmacotherapy adherence approach were the secondary objective of the study. Setting: Public Primary Health Care Unit in a municipality in the Brazilian State of Sao Paulo. Method: A 36-month randomized, controlled, prospective clinical trial was carried out with 200 patients divided into two groups: control (n = 100) and intervention (n = 100). The control group received the usual care offered by the Primary Health Care Unit (medical and nurse consultancies). The patients randomized into the intervention group received pharmaceutical care intervention besides the usual care offered. Main outcome measure: Pharmacotherapy adherence (Morisky-Green test translated into Portuguese and computerized dispensed medication history) and clinical measurements (blood pressure, fasting glucose, A1C hemoglobin, triglycerides and total cholesterol) were evaluated at the baseline and up to 36 months. A P value < 0.05 was considered statistically significant. Results: A total of 97 patients from the intervention group and 97 patients from the control group completed the study (n = 194). Significant improvements in the pharmacotherapy adherence were verified for the intervention group according to the Morisky-Green test (50.5% of adherent patients at baseline vs. 83.5% of adherent patients after 36 months; P < 0.001) and the computerized dispensed medication history (52.6% of adherent patients at baseline vs. 83.5% of adherent patients after 36 months; P < 0.001); no significant changes were verified in the control group. Significant improvements in the number of patients reaching adequate values for their blood pressure (26.8% at baseline vs. 86.6% after 36-months; P < 0.001), fasting glucose (29.9% at baseline vs. 70.1% after 36 months; P < 0.001), A1C hemoglobin (3.3% at baseline vs. 63.3% after 36 months; P < 0.001), triglycerides (47.4% at baseline vs. 74.2% after 36 months; P < 0.001) and total cholesterol (59.8% at baseline vs. 80.4% after 36 months; P = 0.002) were verified in the intervention group, but remained unchanged in the control group. Conclusion: These results indicated the effectiveness of pharmaceutical care in improving pharmacotherapy adherence, with positive effects in the clinical outcomes of the patients studied.

Effects of interventions in health care settings on physical activity or cardiorespiratory fitness

Introduction: This paper reviews studies of physical activity interventions in health care settings to determine effects on physical activity and/or fitness and characteristics of successful interventions. Methods: Studies testing interventions to promote physical activity in health care settings for primary prevention (patients without disease) and secondary prevention (patients with cardiovascular disease [CVD]) were identified by computerized search methods and reference lists of reviews and articles. Inclusion criteria included assignment to intervention and control groups, physical activity or cardiorespiratory fitness outcome measures, and, for the secondary prevention studies, measurement 12 or more months after randomization. The number of studies with statistically significant effects was determined overall as well as for studies testing interventions with various characteristics. Results: Twelve studies of primary prevention were identified, seven of which were randomized. Three of four randomized studies with short-term measurement (4 weeks to 3 months after randomization), and two of five randomized studies with long-term measurement (6 months after randomization) achieved significant effects on physical activity. Twenty-four randomized studies of CVD secondary prevention were identified; 13 achieved significant effects on activity and/or fitness at twelve or more months. Studies with measurement at two time points showed decaying effects over time, particularly if the intervention were discontinued. Successful interventions contained multiple contacts, behavioral approaches, supervised exercise, provision of equipment, and/or continuing intervention. Many studies had methodologic problems such as low follow-up rates. Conclusion: Interventions in health care settings can increase physical activity for both primary and secondary prevention. Long-term effects are more likely with continuing intervention and multiple intervention components such as supervised exercise, provision of equipment, and behavioral approaches. Recommendations for additional research are given.

Reaching those most in need: a review of diabetes self-management interventions in disadvantaged populations

There has been increased recognition of the importance of developing diabetes self-management education (DSME) interventions that are effective with under-served and minority populations. Despite several recent studies in this area, there is to our knowledge no systematic review or synthesis of what has been learned from this research. An electronic literature search identified five formative evaluations and ten controlled DSME intervention trials focused on under-served (low-income, minority or aged) populations. The RE-AIM (Reach, Efficacy, Adoption, Implementation, Maintenance) evaluation framework was used to evaluate the controlled studies on the dimensions of reach, efficacy, adoption, implementation, and maintenance. Fifty percent of the studies identified reported on the percentage of patients who participated, and the percentages were highly variable. The methodological quality of the articles was generally good and the short-term results were encouraging, especially on behavioral outcomes. Data on adoption (representativeness of settings and clinicians who participate) and implementation were almost never reported. Studies of modalities in addition to group meetings are needed to increase the reach of DSME with under-served populations. The promising formative evaluation work that has been conducted needs to be extended for more systematic study of the process of intervention implementation and adaptation with special populations. Studies that explicitly address the community context and that address multiple issues related to public health impact of DSME interventions are recommended to enhance long-term results. Copyright (C) 2002 John Wiley Sons, Ltd.

Program sustainability of a community-based intervention to prevent falls among older Australians

Multi-strategy interventions have been demonstrated to prevent falls among older people, but studies have not explored their sustainability. This paper investigates program sustainability of Stay on Your Feet (SOYF), an Australian multi-strategy falls prevention program (1992-1996) that achieved a significant reduction in falls-related hospital admissions. A series of surveys assessed recall, involvement and current falls prevention activities, 5 years post-SOYF in multiple original SOYF stakeholder groups within the study area [general practitioners (GPs), pharmacists, community health (CH) staff shire councils (SCs) and access committees (ACs)]. Focus groups explored possible behavioural changes in the target group. Surveys were mailed, except to CH staff and ACs. who participated in guided group sessions and were contacted via the telephone, respectively. Response rates were: GPs. 67% (139/209); pharmacists, 79% (53/67); CH staff, 63% (129/204); SCs, 90% (9/10); ACs, 80% (8/10). There were 73 older people in eight focus groups. Of 117 GPs who were practising during SOYF 80% recalled SOYF and 74% of these reported an influence on their practice. Of 46 pharmacists operating a business during SOYF, 45% had heard of SOYF and 79% of these reported being 'somewhat' influenced. Of 76 community health staff (59%) in the area at that time, 99% had heard of SOYF and 82% reported involvement. Four SCs retained a SOYF resource, but none thought current activities were related. Seven ACs reported involvement, but no activities were sustained. Thirty-five focus group participants (48%) remembered SOYF and reported a variety of SOYF-initiated behaviour changes. Program sustainability was clearly demonstrated among health practitioners. Further research is required to assess long-term effect sustainability.

Evaluation of interventions to reduce catheter-associated bloodstream infection: Continuous tailored education versus one basic lecture

Background: This study evaluated the impact of 2 models of educational intervention on rates of central venous catheter-associated bloodstream infections (CVC-BSIs). Methods: This was a prospective observational study conducted between January 2005 and June 2007 in 2 medical intensive care units (designated ICU A and ICU B) in a large teaching hospital. The study was divided into in 3 periods: baseline (only rates were evaluated), preintervention (questionnaire to evaluate knowledge of health care workers [HCWs] and observation of CVC care in both ICUs), and intervention (in ICU A, tailored, continuous intervention; in ICU B, a single lecture). The preintervention and intervention periods for each ICU were compared. Results: During the preintervention period, 940 CVC-days were evaluated in ICUA and 843 CVC-days were evaluated in ICU B. During the intervention period, 2175 CVC-days were evaluated in ICUA and 1694 CVC-days were evaluated in ICU B. Questions regarding CVC insertion, disinfection during catheter manipulation, and use of an alcohol-based product during dressing application were answered correctly by 70%-100% HCWs. Nevertheless, HCWs` adherence to these practices in the preintervention period was low for CVC handling and dressing, hand hygiene (6%-35%), and catheter hub disinfection (45%-68%). During the intervention period, HCWs` adherence to hand hygiene was 48%-98%, and adherence to hub disinfection was 82%-97%. CVC-BSI rates declined in both units. In ICUA, this decrease was progressive and sustained, from 12CVC-BSIs/1000 CVC-days at baseline to 0 after 9 months. In ICU B, the rate initially dropped from 16.2 to 0 CVC-BSIs/1000 CVC-days, but then increased to 13.7 CVC-BSIs/1000 CVC-days. Conclusion: Personal customized, continuous intervention seems to develop a ""culture of prevention"" and is more effective than single intervention, leading to a sustained reduction of infection rates.