Criminal Solicitation, Entrapment, and the Enforcement of Law

This paper examines the optimal use of criminal solicitation as a law enforcement strategy. The benefits are greater deterrence of crime (due to the greater likelihood of apprehension), and the savings in social harm and apprehension costs as some offenders are diverted away from committing actual crimes through solicitation. The costs are the expense of hiring undercover cops and the greater likelihood of punishment. The optimal use of solicitation balances these factors. The paper also examines the justification for, and impact of, the entrapment defense, which exonerates those caught in a solicitation but otherwise not predisposed to commit a crime.

Last Hired, First Fired? Black-White Unemployment and the Business Cycle

Past studies have tested the claim that blacks are the last hired during periods of economic growth and the first fired in recessions by examining the movement of relative unemployment rates over the business cycle. Any conclusion drawn from this type of analysis must be viewed as tentative because the cyclical movements in the underlying transitions into and out of unemployment are not examined. Using Current Population Survey data matched across adjacent months from 1989 to 2004, this paper examines labor market transitions for prime age males to test this hypothesis. Considerable evidence is presented that blacks are the first fired as the business cycle weakens. However, no evidence is found that blacks are the last hired. Instead, blacks are initially hired from the ranks of the unemployed early in the business cycle and later are drawn from non-participation. Narrowing of the racial unemployment gap near the peak of the business cycle is driven by a reduction in the rate of job loss for blacks rather than increases in hiring. There is also evidence that residual differences in the racial unemployment gap vary systematically over the business cycle in a manner consistent with discrimination being more evident in the economy at times when its cost is lower.

Everyone is; should healthcare? Outsourcing: Issues in strategic planning, organizational culture, and organizational ethics

Expenditures for personal health services in the United States have doubled over the last decade. They continue to outpace the growth rate of the gross national product. Costs for medical care have steadily increased at an annual rate well above the rate of inflation and have gradually outstripped payers' ability to meet their premiums. This limitation of resources justifies the ongoing healthcare reform strategies to maximize utilization and minimize costs. The majority of the cost-containment effort has focused on hospitals, as they account for about 40 percent of total health expenditures. Although good patient outcomes have long been identified as healthcare's central concern, continuing cost pressures from both regulatory reforms and the restructuring of healthcare financing have recently made improving fiscal performance an essential goal for healthcare organizations. ^ The search for financial performance, quality improvement, and fiscal accountability has led to outsourcing, which is the hiring of a third party to perform a task previously and traditionally done in-house. The incomparable nature and overwhelming dissimilarities between health and other commodities raise numerous administrative, organizational, policy and ethical issues for administrators who contemplate outsourcing. This evaluation of the outsourcing phenomenon, how it has developed and is currently practiced in healthcare, will explore the reasons that healthcare organizations gravitate toward outsourcing as a strategic management tool to cut costs in an environment of continuing escalating spending. ^ This dissertation has four major findings. First, it suggests that U.S. hospitals in FY2000 spent an estimated $61 billion in outsourcing. Second, it finds that the proportion of healthcare outsourcing highly correlates with several types of hospital controlling authorities and specialties. Third, it argues that healthcare outsourcing has implications in strategic organizational issues, professionalism, and organizational ethics that warrant further public policy discussions before expanding its limited use beyond hospital “hotel functions” and back office business processes. Finally, it devises an outsourcing suitability scale that organizations can utilize to ensure the most strategic option for outsourcing and concludes with some public policy implications and recommendations for its limited use. ^

Cultural competence in an HIV dedicated dental clinic: Application of the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS)

This dissertation investigated perspectives on cultural competence among African-American women patients, staff, and the administrator of a dental clinic serving people living with HIV/AIDS; and evaluated the role of the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS) in advancing the provision of culturally competent care in the clinic. ^ The study was qualitative with data collection via focus groups and individual interviews with a sample of African-American women patients, and individual interviews with a sample of staff and the clinic administrator. Transcripts were coded and themes identified using the software program ATLAS.ti. A cultural audit template was developed and applied to evaluate cultural competency. ^ Among attitudes and behaviors that contributed to the provision of culturally competent care at the clinic were respect and empathic communication. Formal cultural competency was not featured strongly in the methods by which the staff learned to work with diverse populations. Instead cultural competence among the staff was based on thoughtful hiring practices, natural aptitude and a climate that encouraged learning through informal sharing of experiences. The staff and administrator felt that an African-American dentist would be an asset in improving culturally competent care at the clinic. Previous research and national policy also promote the provider-patient racial/ethnic concordance to improve care. In this study, however, the patients were happy with the care provided regardless of the race/ethnicity of the staff, probably reflecting the well developed cultural competence skills of clinic staff overall. ^ The clinic administrator was unaware of the CLAS standards although the clinic was implicitly operated under their mandates. This occurred because the clinic is supported by federal funding and the CLAS standards were incorporated into the requirements. Incorporation into and monitoring of the CLAS standards in federally funded programs therefore appears to be an effective means for ensuring that they are implemented. ^ This study illustrates that cultural competence, though not universally understood, can be systematically investigated to identify what constitutes appropriate care and the factors that support or inhibit it. Among important elements of culturally competent care are respect and empathic communication. ^

The success of worksite nutrition and physical activity interventions with environmental modifications A systematic review

Background: As obesity increases among U.S. workers, employers are implementing programs to increase physical activity and improve diets. Although programs to address individual determinants of obesity have been evaluated, less is known about the effects of workplace programs that change environmental factors, because most reviews have not isolated environmental programs; the one that did was published in 2005. ^ Objective: To update the 2005 review to determine the effectiveness of workplace environmental interventions. ^ Methods: The Medline database was searched for published English language reports (2003-2011) of randomized controlled (RCTs) or quasi-experimental trials (NRCTs) that evaluated strategies to modify physical activity opportunities or food services, targeting employees at least 18 years, not including retirees and that provided data for at least one physical activity, dietary, or health risk indicator. Three coders independently extracted study characteristics and scored the quality of study methods. Program effectiveness was determined using the 2005 review's best evidence approach. ^ Results: Seven studies represented in nine reports met eligibility criteria; three focused on diet and the remainder targeted diet and physical activity interventions. All but one study received a high quality score for internal validity. The evidence for the effectiveness of workplace environmental interventions was at best, inconclusive for diet and physical activity and limited for health risk indicators. The outcome constructs were inconsistent across the studies. ^ Conclusions: Limitations in the methods of the 2005 review made it challenging to draw conclusions about findings for this review that include: variation in outcome measures, reliance on distal measures without proximal behavior change measures, no distinction between changes at the workplace versus outside the workplace, and inappropriate analyses of cluster designs that biased findings toward statistical significance. The best evidence approach relied on vote-counting, using statistical significance alone rather than effect size and confidence intervals. Future research should address these limitations and use more rigorous methods; systematic reviews should use methods of meta-analysis to summarize study findings. These recommendations will help employers to better understand how environmental modifications in the workplace can support their efforts to combat the effects of obesity among employees.^

Las tierras pblicas en el sudeste bonaerense: los partidos de Arenales y Ayacucho, 1850-1880

Este trabajo da cuenta del traspaso de tierras pblicas a manos privadas en dos partidos del nuevo sur bonaerense, Arenales y Ayacucho, entre 1850 y 1880. En l se toma el contexto de revisin de la legislacin rosista sobre tierras y de la aplicacin de las leyes de arrendamientos pblicos y ventas posteriores. Cul fue el impacto de estas leyes en estos territorios; quines fueron sus beneficiarios; cmo afectaron la trama de derechos en torno al acceso a la tierra, son algunos de los interrogantes que se intentan responder.

Las tierras pblicas en el sudeste bonaerense: los partidos de Arenales y Ayacucho, 1850-1880

Este trabajo da cuenta del traspaso de tierras pblicas a manos privadas en dos partidos del nuevo sur bonaerense, Arenales y Ayacucho, entre 1850 y 1880. En l se toma el contexto de revisin de la legislacin rosista sobre tierras y de la aplicacin de las leyes de arrendamientos pblicos y ventas posteriores. Cul fue el impacto de estas leyes en estos territorios; quines fueron sus beneficiarios; cmo afectaron la trama de derechos en torno al acceso a la tierra, son algunos de los interrogantes que se intentan responder.

Las tierras pblicas en el sudeste bonaerense: los partidos de Arenales y Ayacucho, 1850-1880

Este trabajo da cuenta del traspaso de tierras pblicas a manos privadas en dos partidos del nuevo sur bonaerense, Arenales y Ayacucho, entre 1850 y 1880. En l se toma el contexto de revisin de la legislacin rosista sobre tierras y de la aplicacin de las leyes de arrendamientos pblicos y ventas posteriores. Cul fue el impacto de estas leyes en estos territorios; quines fueron sus beneficiarios; cmo afectaron la trama de derechos en torno al acceso a la tierra, son algunos de los interrogantes que se intentan responder.

What motivates female operators to enter the garment industry in Pakistan in the post-MFA period?

Pakistan's knitwear exports had been struggling since the quota phase-out until 2009. A particular feature of Pakistan's garment industry is that hiring more male sewing operators at piece rates. Recently, a few surviving knitwear factories have adopted a strategy of shifting from male piece-rate operators to salaried female operators. In Pakistan, female participation in general workforce is very limited and hiring salaried female operators requires management effort and expertise. However, even in the factories with such management skills, household factors prevent females from working outside because Pakistani culture disrespects women working in factories. Our survey reveals that financial motives compel female household members to work outside their homes and that female operators contribute substantially to their households' finances.

A mathematical model of a criminal-prone society

Criminals are common to all societies. To fight against them the community takes different security measures as, for example, to bring about a police. Thus, crime causes a depletion of the common wealth not only by criminal acts but also because the cost of hiring a police force. In this paper, we present a mathematical model of a criminal-prone self-protected society that is divided into socio-economical classes. We study the effect of a non-null crime rate on a free-of-criminals society which is taken as a reference system. As a consequence, we define a criminal-prone society as one whose free-of-criminals steady state is unstable under small perturbations of a certain socio-economical context. Finally, we compare two alternative strategies to control crime: (i) enhancing police efficiency, either by enlarging its size or by updating its technology, against (ii) either reducing criminal appealing or promoting social classes at risk

The future obligations of "project manager" as construction integral director (DIPE) in the law of buildings construction in spain (LOE)

In the year 1999 approves the Law of Construction Building (LOE, in Spanish) to regulate a sector such as construction, which contained some shortcomings from the legal point of view. Currently, the LOE has been in force 12 years, changing the spanish world of the construction, due to influenced by internationalization. Within the LOE, there regulating the different actors involved in the construction building, as the Projects design, the Director of Construction, the developer, The builder, Director of execution of the construction (actor only in Spain, similar as construcion engineer and abroad in), control entities and the users, but lacks figure Project manager will assume the delegation of the promoter helping and you organize, direct and management the process. This figure assumes that the market and contracts are not legally regulated in Spain, then should define and establish its regulation in the LOE. (Spain Construction Law) The translation in spanish of the words "Project Manager is owed to Professor Rafael de Heredia in his book Integrated Project Management, as agent acting on behalf of the organization and promoter assuming control of the project, ie Integraded Project Management . Already exist in Spain, AEDIP (Spanish Association Integrated of Project Construction management) which comprises the major companies in “Project Management” in Spain, and MeDIP (Master in Integrated Construction Project) the largest and most advanced studies at the Polytechnic University of Madrid, in "Construction Project Management" they teach which is also in Argentina. The Integrated Project ("Project Management") applied to the construction process is a methodological technique that helps to organize, control and manage the resources of the promoters in the building process. When resources are limited (which is usually most situations) to manage them efficiently becomes very important. Well, we find that in this situation, the resources are not only limited, but it is limited, so a comprehensive control and monitoring of them becomes not only important if not crucial. The alternative of starting from scratch with a team that specializes in developing these follow directly intervening to ensure that scarce resources are used in the best possible way requires the use of a specific methodology (Manual DIP, Matrix Foreign EDR breakdown structure EDP Project, Risk Management and Control, Design Management, et ..), that is the methodology used by "Projects managers" to ensure that the initial objectives of the promoters or investors are met and all actors in process, from design to construction company have the mind aim of the project will do, trying to get their interests do not prevail over the interests of the project. Among the agents listed in the building process, "Project Management" or DIPE (Director Comprehensive building process, a proposed name for possible incorporation into the LOE, ) currently not listed as such in the LOE (Act on Construction Planning ), one of the agents that exist within the building process is not regulated from the legal point of view, no obligations, ie, as is required by law to have a project, a builder, a construction management, etc. DIPE only one who wants to hire you as have been advanced knowledge of their services by the clients they have been hiring these agents, there being no legal obligation as mentioned above, then the market is dictating its ruling on this new figure, as if it were necessary, he was not hired and eventually disappeared from the building process. As the aim of this article is regular the process and implement the name of DIPE in the Spanish Law of buildings construction (LOE)

Diseño y configuración de una red de comunicaciones en un Centro de Contactos - Contact Center

Este proyecto muestra una solución de red para una empresa que presta servicios de Contact Center desde distintas sedes distribuidas geográficamente, utilizando la tecnología de telefonía sobre IP. El objetivo de este proyecto es el de convertirse en una guía de diseño para el despliegue de soluciones de red utilizando los actuales equipos de comunicaciones desarrollados por el fabricante Cisco Systems, Inc., los equipos de seguridad desarrollados por el fabricante Fortinet y los sistemas de telefonía desarrollados por Avaya Inc. y Oracle Corporation, debido a su gran penetración en el mercado y a las aportaciones que cada uno ha realizado en el sector de Contact Center. Para poder proveer interconexión entre las sedes de un Contact Center se procede a la contratación de un acceso a la red MPLS perteneciente a un operador de telecomunicaciones, quien provee conectividad entre las sedes utilizando la tecnología VPN MPLS con dos accesos diversificados entre sí desde cada una de las sedes del Contact Center. El resultado de esta contratación es el aprovechamiento de las ventajas que un operador de telecomunicaciones puede ofrecer a sus clientes, en relación a calidad de servicio, disponibilidad y expansión geográfica. De la misma manera, se definen una serie de criterios o niveles de servicio que aseguran a un Contact Center una comunicación de calidad entre sus sedes, entendiéndose por comunicación de calidad aquella que sea capaz de transmitirse con unos valores mínimos de pérdida de paquetes así como retraso en la transmisión, y una velocidad acorde a la demanda de los servicios de voz y datos. Como parte de la solución, se diseña una conexión redundante a Internet que proporciona acceso a todas las sedes del Contact Center. La solución de conectividad local en cada una de las sedes de un Contact Center se ha diseñado de manera general acorde al volumen de puestos de usuarios y escalabilidad que pueda tener cada una de las sedes. De esta manera se muestran varias opciones asociadas al equipamiento actual que ofrece el fabricante Cisco Systems, Inc.. Como parte de la solución se han definido los criterios de calidad para la elección de los Centros de Datos (Data Center). Un Contact Center tiene conexiones hacia o desde las empresas cliente a las que da servicio y provee de acceso a la red a sus tele-trabajadores. Este requerimiento junto con el acceso y servicios publicados en Internet necesita una infraestructura de seguridad. Este hecho da lugar al diseño de una solución que unifica todas las conexiones bajo una única infraestructura, dividiendo de manera lógica o virtual cada uno de los servicios. De la misma manera, se ha definido la utilización de protocolos como 802.1X para evitar accesos no autorizados a la red del Contact Center. La solución de voz elegida es heterogénea y capaz de soportar los protocolos de señalización más conocidos (SIP y H.323). De esta manera se busca tener la máxima flexibilidad para establecer enlaces de voz sobre IP (Trunk IP) con proveedores y clientes. Esto se logra gracias a la utilización de SBCs y a una infraestructura interna de voz basada en el fabricante Avaya Inc. Los sistemas de VoIP en un Contact Center son los elementos clave para poder realizar la prestación del servicio; por esta razón se elige una solución redundada bajo un entorno virtual. Esta solución permite desplegar el sistema de VoIP desde cualquiera de los Data Center del Contact Center. La solución llevada a cabo en este proyecto está principalmente basada en mi experiencia laboral adquirida durante los últimos siete años en el departamento de comunicaciones de una empresa de Contact Center. He tenido en cuenta los principales requerimientos que exigen hoy en día la mayor parte de empresas que desean contratar un servicio de Contact Center. Este proyecto está dividido en cuatro capítulos. El primer capítulo es una introducción donde se explican los principales escenarios de negocio y áreas técnicas necesarias para la prestación de servicios de Contact Center. El segundo capítulo describe de manera resumida, las principales tecnologías y protocolos que serán utilizados para llevar a cabo el diseño de la solución técnica de creación de una red de comunicaciones para una empresa de Contact Center. En el tercer capítulo se expone la solución técnica necesaria para permitir que una empresa de Contact Center preste sus servicios desde distintas ubicaciones distribuidas geográficamente, utilizando dos Data Centers donde se centralizan las aplicaciones de voz y datos. Finalmente, en el cuarto capítulo se presentan las conclusiones obtenidas tras la elaboración de la presente memoria, así como una propuesta de trabajos futuros, que permitirían junto con el proyecto actual, realizar una solución técnica completa incluyendo otras áreas tecnológicas necesarias en una empresa de Contact Center. Todas las ilustraciones y tablas de este proyecto son de elaboración propia a partir de mi experiencia profesional y de la información obtenida en diversos formatos de la bibliografía consultada, excepto en los casos en los que la fuente es mencionada. ABSTRACT This project shows a network solution for a company that provides Contact Center services from different locations geographically distributed, using the Telephone over Internet Protocol (ToIP) technology. The goal of this project is to become a design guide for performing network solutions using current communications equipment developed by the manufacturer Cisco Systems, Inc., firewalls developed by the manufacturer Fortinet and telephone systems developed by Avaya Inc. and Oracle Corporation, due to their great market reputation and their contributions that each one has made in the field of Contact Center. In order to provide interconnection between its different sites, the Contact Center needs to hire the services of a telecommunications’ operator, who will use the VPN MPLS technology, with two diversified access from each Contact Center’s site. The result of this hiring is the advantage of the benefits that a telecommunications operator can offer to its customers, regarding quality of service, availability and geographical expansion. Likewise, Service Level Agreement (SLA) has to be defined to ensure the Contact Center quality communication between their sites. A quality communication is understood as a communication that is capable of being transmitted with minimum values of packet loss and transmission delays, and a speed according to the demand for its voice and data services. As part of the solution, a redundant Internet connection has to be designed to provide access to every Contact Center’s site. The local connectivity solution in each of the Contact Center’s sites has to be designed according to its volume of users and scalability that each one may have. Thereby, the manufacturer Cisco Systems, Inc. offers several options associated with the current equipment. As part of the solution, quality criteria are being defined for the choice of the Data Centers. A Contact Center has connections to/from the client companies that provide network access to teleworkers. This requires along the access and services published on the Internet, needs a security infrastructure. Therefore is been created a solution design that unifies all connections under a single infrastructure, dividing each services in a virtual way. Likewise, is been defined the use of protocols, such as 802.1X, to prevent unauthorized access to the Contact Center’s network. The voice solution chosen is heterogeneous and capable of supporting best-known signaling protocols (SIP and H.323) in order to have maximum flexibility to establish links of Voice over IP (IP Trunk) with suppliers and clients. This can be achieved through the use of SBC and an internal voice infrastructure based on Avaya Inc. The VoIP systems in a Contact Center are the key elements to be able to provide the service; for this reason a redundant solution under virtual environment is been chosen. This solution allows any of the Data Centers to deploy the VoIP system. The solution carried out in this project is mainly based on my own experience acquired during the past seven years in the communications department of a Contact Center company. I have taken into account the main requirements that most companies request nowadays when they hire a Contact Center service. This project is divided into four chapters. The first chapter is an introduction that explains the main business scenarios and technical areas required to provide Contact Center services. The second chapter describes briefly the key technologies and protocols that will be used to carry out the design of the technical solution for the creation of a communications network in a Contact Center company. The third chapter shows a technical solution required that allows a Contact Center company to provide services from across geographically distributed locations, using two Data Centers where data and voice applications are centralized. Lastly, the fourth chapter includes the conclusions gained after making this project, as well as a future projects proposal, which would allow along the current project, to perform a whole technical solution including other necessary technologic areas in a Contact Center company All illustrations and tables of this project have been made by myself from my professional experience and the information obtained in various formats of the bibliography, except in the cases where the source is indicated.

A QUALIFICAÇÃO E A INSERÇÃO NO MUNDO DO TRABALHO DA PESSOA PORTADORA DE DEFICIÊNCIA: UM ESTUDO SOBRE O IMPACTO DA EXTINÇÃO DA LEI 6.297/75

O presente estudo tem como objetivo, analisar sobre as dificuldades enfrentadas tanto pelas Empresas em cumprir a Legislação de Cotas, como também da Pessoa Portadora de Deficiência (PPDs) em ser inserida no mercado de trabalho, devido a falta de qualificação dos candidatos. Através da pesquisa literária ficou claro que nossa Legislação demonstra de forma evidente que o legislador pretendeu assegurar aos PPDs, as condições mínimas de participação influente na vida ativa da sociedade brasileira e num avanço sem precedentes, criaram-se as linhas básicas do processo de integração do deficiente à sociedade e ao mercado produtivo nacional. Verificou-se também que as empresas estão em busca de profissionais dentre o universo dos PPDs, já qualificados, o que normalmente não encontram. As Organizações do Direito Privado também já desenvolveram alguns projetos para a qualificação desses PPDs. A Lei 6.297/75 que garantia às empresas o desconto em dobro no IR dos gastos com treinamento, foi extinta em 12 de Dezembro de 1990. As empresas precisam de um incentivo financeiro para que possam tratar da qualificação desses profissionais, não mais como um peso, mas sim como um projeto social. Caso as empresas fossem beneficiadas por incentivos fiscais, assim como eram na vigência dessa Lei, teriam as empresas uma visão diferenciada por ocasião da contratação dos PPDs? A metodologia de pesquisa prevê um levantamento bibliográfico e uma pesquisa exploratória que será feita em empresas privadas, instituições que visam ajudar na inserção dos PPDs e nas Organizações do Direito Privado tais como Senai, Sesi, Força Sindical, Fiesp. Verificou-se, mediante a pesquisa, que há uma preocupação por parte de todos os envolvidos, em encontrar meios eficazes para garantir a inserção dos PPDs no mercado de trabalho, embora a falta de qualificação ainda seja o maior problema. A criação de Leis similares à Lei 6.297/75 foi apontada como uma grande ajuda às empresas, já que a elas foi imposta essa responsabilidade.(AU)

A QUALIFICAÇÃO E A INSERÇÃO NO MUNDO DO TRABALHO DA PESSOA PORTADORA DE DEFICIÊNCIA: UM ESTUDO SOBRE O IMPACTO DA EXTINÇÃO DA LEI 6.297/75

O presente estudo tem como objetivo, analisar sobre as dificuldades enfrentadas tanto pelas Empresas em cumprir a Legislação de Cotas, como também da Pessoa Portadora de Deficiência (PPDs) em ser inserida no mercado de trabalho, devido a falta de qualificação dos candidatos. Através da pesquisa literária ficou claro que nossa Legislação demonstra de forma evidente que o legislador pretendeu assegurar aos PPDs, as condições mínimas de participação influente na vida ativa da sociedade brasileira e num avanço sem precedentes, criaram-se as linhas básicas do processo de integração do deficiente à sociedade e ao mercado produtivo nacional. Verificou-se também que as empresas estão em busca de profissionais dentre o universo dos PPDs, já qualificados, o que normalmente não encontram. As Organizações do Direito Privado também já desenvolveram alguns projetos para a qualificação desses PPDs. A Lei 6.297/75 que garantia às empresas o desconto em dobro no IR dos gastos com treinamento, foi extinta em 12 de Dezembro de 1990. As empresas precisam de um incentivo financeiro para que possam tratar da qualificação desses profissionais, não mais como um peso, mas sim como um projeto social. Caso as empresas fossem beneficiadas por incentivos fiscais, assim como eram na vigência dessa Lei, teriam as empresas uma visão diferenciada por ocasião da contratação dos PPDs? A metodologia de pesquisa prevê um levantamento bibliográfico e uma pesquisa exploratória que será feita em empresas privadas, instituições que visam ajudar na inserção dos PPDs e nas Organizações do Direito Privado tais como Senai, Sesi, Força Sindical, Fiesp. Verificou-se, mediante a pesquisa, que há uma preocupação por parte de todos os envolvidos, em encontrar meios eficazes para garantir a inserção dos PPDs no mercado de trabalho, embora a falta de qualificação ainda seja o maior problema. A criação de Leis similares à Lei 6.297/75 foi apontada como uma grande ajuda às empresas, já que a elas foi imposta essa responsabilidade.(AU)

Contribuição da consulta de enfermagem na adesão ao tratamento do diabetes mellitus na estratégia saúde da família do município de Ribeirão Preto, SP

Trata-se de estudo de intervenção tipo antes e depois, no qual o sujeito é seu próprio controle, fator que permite identificar os efeitos na adesão ao tratamento e controle dos níveis glicêmicos. Teve como objetivo avaliar a contribuição da consulta de enfermagem na adesão ao tratamento do diabetes mellitus tipo 2, em uma Unidade Saúde da Família, de acordo com o \"Protocolo de atendimento as pessoas com diabetes mellitus,\" em Ribeirão Preto, SP. A coleta de dados foi realizada no período de setembro de 2014 a janeiro de 2015. O trabalho foi aprovado pelo Comitê de Ética em Pesquisa da Escola de Enfermagem de Ribeirão Preto, SP, sob Parecer nº 648.970. Participaram 31 pessoas com diabetes mellitus, por meio de três consultas de enfermagem, na unidade de saúde e no domicílio, com intervalo de um mês entre as três consultas de todos os participantes. Foi utilizado um roteiro contendo variáveis sociodemográficos e clínicas e o teste de Medida de Adesão ao Tratamento. Para a análise da adesão, durante e após a intervenção, utilizou-se a estatística descritiva e o teste de Mann- Whitney; para a comparação do antes e após a intervenção, utilizou-se o teste de Wilcoxon; para análise de correlação com as variáveis numéricas, o coeficiente de correlação de Spearman e o teste Q de Cochran, para a comparação dos exames nos momentos anterior, durante e posterior à intervenção. Os resultados mostraram que os participantes tinham entre 33 e 79 anos, sendo 58,1% do sexo feminino; 71% tinham companheiro; renda familiar de 1 a 3 salários-mínimos (83,9%); 80,6% referiram ser profissionalmente inativos (aposentados, pensionistas ou do lar); média de 5,68 anos de estudo e predomínio de menos de 8 anos de estudo (67,7%). Em relação aos valores da pressão arterial sistêmica constatou hipertensão arterial sistêmica grau I em 25,8% das pessoas com diabetes mellitus, 90,3% com índice de massa corporal apresentando excesso de peso, quanto à circunferência abdominal, 32,2% dos homens estavam com valores maiores que 102 cm e 45,2% das mulheres com valores acima de 88 cm. A avaliação dos pés, com uso do monofilamento Semmes-Weinstein de 10g, apresentou 9,7% das pessoas com diabetes mellitus com pé em risco para ulceração e diminuição ou ausência de sensibilidade tátil pressórica protetora dos pés. O tempo de diagnóstico do diabetes mellitus tipo 2 variou entre 1 a 39 anos, predominando as comorbidades hipertensão arterial (83,9%), dislipidemia (58,1%) e obesidade (41,8%). Quanto aos exames laboratoriais, observa-se que, em 64,5% da população estudada, os níveis da glicemia de jejum estavam acima de 100 mg/dL , ocorrendo pequena redução para 61,3% nos casos de pessoas com diabetes mellitus durante a intervenção e se manteve após. No que se refere à glicemia pós-prandial, os casos das pessoas com diabetes mellitus com valores iguais ou acima de 160 mg/dL, antes da intervenção era de 45,2% e durante e após a intervenção caiu para 38,7%. Em contrapartida, aumentou o número de pessoas com diabetes mellitus durante e após a intervenção, com valores da glicemia pós-prandial abaixo de 160 mg/dL, de 54,8% para 61,3%. E, em relação à hemoglobina glicada, foi observado que em 61,3% das pessoas com diabetes mellitus os valores antes da intervenção eram iguais ou acima de 7%. Durante a intervenção, caiu para 19,3% e após a intervenção o número de pessoas com diabetes mellitus, com a hemoglobina glicada igual ou superior a 7%, chegou a 38,7%. Quanto aos valores abaixo de 7%, observou-se aumento de 38,7% antes da intervenção para 80,6 e 61,3% respectivamente, durante e após a intervenção, com diferença estatisticamente significante (p< 0,001). As pessoas com diabetes mellitus desse estudo, apresentaram 83,87% de adesão ao tratamento antes da intervenção, e esses escores subiram para 96,78% após a intervenção, fato corroborado pelo teste de Wilcoxon que mostrou escores estatisticamente significantes (p<0,001), entre antes e após a intervenção. Esse estudo contribui para ressaltar a importância do enfermeiro, enquanto integrante da equipe multiprofissional, seguindo as orientações do \"Protocolo de atendimento ao indivíduo com diabetes\", tanto no atendimento individual quanto em grupo, reorganizando o processo de trabalho, contribuindo para maior adesão ao tratamento e controle dos níveis glicêmicos, ao minimizar a fragmentação e assegurar a continuidade na assistência, por meio de abordagem integral ao diabético