Assessment of a consultation-liaison psychiatry and psychology health care program

OBJECTIVE: To investigate the relevance of subjective criteria adopted by a psychiatry and psychology consultation-liaison service, and their suitability in the evaluation of case registries and objective results. METHODS: Semi-structured interviews were conducted and all supervisors of the university hospital service were interviewed. Routinely collected case registries were also reviewed. Standardized assessment with content analysis for each category was carried out. RESULTS: The results showed distortions in the adopted service focus (doctor-patient relationship) and consultant requests. This focus is more on consulting physician-oriented interventions than on patients. DISCUSSION: Evaluation of the relevance of service criteria could help promoting quality assessment of the services provided, mainly when objective criteria have not yet been established to assure their suitability.

Inexact restoration approaches to solve mathematical program with complementarity constraints

Mathematical Program with Complementarity Constraints (MPCC) finds applica- tion in many fields. As the complementarity constraints fail the standard Linear In- dependence Constraint Qualification (LICQ) or the Mangasarian-Fromovitz constraint qualification (MFCQ), at any feasible point, the nonlinear programming theory may not be directly applied to MPCC. However, the MPCC can be reformulated as NLP problem and solved by nonlinear programming techniques. One of them, the Inexact Restoration (IR) approach, performs two independent phases in each iteration - the feasibility and the optimality phases. This work presents two versions of an IR algorithm to solve MPCC. In the feasibility phase two strategies were implemented, depending on the constraints features. One gives more importance to the complementarity constraints, while the other considers the priority of equality and inequality constraints neglecting the complementarity ones. The optimality phase uses the same approach for both algorithm versions. The algorithms were implemented in MATLAB and the test problems are from MACMPEC collection.

Concepção e instalação de tabelas multifunções para recintos desportivos cobertos

Mestrado em Engenharia Electrotécnica – Sistemas Eléctricos de Energia

Implications of the Intervention Program for Physical Activity (IPPA) in the perception of illness and wellbeing in people with Multiple Sclerosis (MS)

The aim of this study is to examine the implications of the IPPA in the perception of illness and wellbeing in MS patients. Methods - This is a quasi experimental study non-randomized study with 24 MS patients diagnosed at least 1 year before, and with an EDSS score of under 7. We used the IPPA in 3 groups of eight people in 3 Portuguese hospitals (Lisbon, Coimbra, and Porto). The sessions were held once a week for 90 minutes, over a period of 7 weeks. The instruments used were: We asked the subjects the question “Please classify the severity of your disease?” and used the Personal Wellbeing Scale (PWS) at the beginning (time A) and end (time B) of the IPPA. We used the SPSS version 20. A non-parametric statistical hypothesis test (Wilcoxon test) was used for the variable analysis. The intervention followed the recommendations of the Helsinki Declaration. Results – The results suggest that there are differences between time A and B, the perception of illness decreased (p<0.08), while wellbeing increased (p<0.01). Conclusions: The IPPA can play an important role in modifying the perception of disease severity and personal wellbeing.

Sei whale (Balaenoptera borealis) ecology and management in the North Atlantic

Tese de Doutoramento em Ciências do Mar, especialidade em Ecologia Marinha.

Severe stress urinary incontinence: pelvic floor muscle training program

International guidelines recommend a first line therapy in the treatment of female stress urinary incontinence (SUI), the pelvic floor muscle (PFM) training. This case report assesses the effects of the PFM training program in treating women with severe SUI. The urodynamic parameters allow diagnosed intrinsic sphincter deficiency and urethral hypermobility. The subjective and objective parameters were assessed at the beginning and after six-month of PFM training program. This case report confirms the efficiency of the intensive training program in severe SUI. The medical implications of the PFM training as first treatment option reflect favourable individual results and additionally contribute to the selection of the non-invasive treatment, the reduction of the incidence collateral effects, low costs and that does not prevent future treatment options.

Psychological well-being and perception of disease severity in people with multiple sclerosis, who underwent a program of self-regulation to promote physical activity

Rehabilitation is very important for in the results of treatment in individuals with multiple sclerosis. Rehabilitation processes occur through gradual changes. These changes integrate intrinsic and extrinsic mechanisms of the individual, promoting adaptations to the needs and activities of daily living according to individual goals. Recommendations for exercise in multiple sclerosis: these recommendations apply only to patients with EDSS less than 7; moderate intensity aerobic exercise for a total of 20 to 30 minutes, twice or three times for week; the resistance training with low or moderate intensity is well tolerated by patients with MS; associated with these exercises were recommended flexibility exercises of moderate intensity, as well as strengthening exercises. The aim of this study is to examine the implications of the program of self-regulation in the perception of illness and mental health (psychological well-being domain) in multiple sclerosis patients.

Importance of program physical activity in quality of life in multiple sclerosis patients, six months after the intervention

Background: Multiple Sclerosis (MS) is a chronic disease of the central nervous system that affects more often young adults in the prime of his career and personal development, with no cure and unknown causes. The most common signs and symptoms are fatigue, muscle weakness, changes in sensation, ataxia, changes in balance, gait difficulties, memory difficulties, cognitive impairment and difficulties in problem solving MS is a relatively common neurological disorder in which various impairments and disabilities impact strongly on function and daily life activities. Purpose: The aim of this study is to examine the implications of an Intervention Program of Physical Activity (IPPA) in quality of life in MS patients, six months after the intervention.

Evidence based for exercise program in physical therapy in patients with multiple sclerosis

Background: Multiple sclerosis is a disease of the central nervous system that affects more frequently young women. It is a progressive and unpredictable disease, resulting in some cases of disabilities and limitations to physical, psychological and social level. Purpose: To review the literature for evidence based of the effectiveness of physiotherapy intervention in multiple sclerosis.

Tuberculosis Control Program and patient satisfaction, Rio de Janeiro, Brazil

OBJECTIVE To evaluate factors associated with users’ satisfaction in the Tuberculosis Control Program. METHODS A cross-sectional study of 295 patients aged ≥ 18 years, with two or more outpatient visits in the Tuberculosis Control Program, in five cities in the metropolitan region of Rio de Janeiro, RJ, Southeastern Brazil, in 2010. Considering an estimated population of 4,345 patients, the sampling plan included 15 health care units participating in the program, divided into two strata: units in Rio de Janeiro City, selected with probability proportional to the monthly average number of outpatient visits, and units in the other four cities. In the units, four temporal clusters of five patients each were selected with equal probability, totaling 300 patients. A questionnaire investigating the users’ clinical and sociodemographic variables and aspects of care and service in the program relevant to user satisfaction was applied to the patients. Descriptive statistics about users and their satisfaction with the program were obtained, and the effects of factors associated with satisfaction were estimated. RESULTS Patients were predominantly males (57.7%), with a mean age of 40.9 and with low level of schooling. The mean treatment time was 4.1 months, mostly self-administered (70.4%). Additionally, 25.8% had previously been treated for tuberculosis. There was a high level of satisfaction, especially regarding medication provision, and respect to patients by the health professionals. Patients who were younger (≤ 30), those on self-administered treatment, and with graduate level, showed less satisfaction. Suggestions to improve the services include having more doctors (70.0%), and offering exams in the same place of attendance (55.1%). CONCLUSIONS Patient satisfaction with the Tuberculosis Control Program was generally high, although lower among younger patients, those with university education and those on self-administered treatment. The study indicates the need for changes to structural and organizational aspects of care, and provides practical support for its improvement.

Association between food assistance program participation and overweight

OBJECTIVE The objective of this study was to investigate the association between food assistance program participation and overweight/obesity according to poverty level. METHODS A cross-sectional analysis of data from 46,217 non-pregnant and non-lactating women in Lima, Peru was conducted; these data were obtained from nationally representative surveys from the years 2003, 2004, 2006, and 2008-2010. The dependent variable was overweight/obesity, and the independent variable was food assistance program participation. Poisson regression was used to stratify the data by family socioeconomic level, area of residence (Lima versus the rest of the country; urban versus rural), and survey year (2003-2006 versus 2008-2010). The models were adjusted for age, education level, urbanization, and survey year. RESULTS Food assistance program participation was associated with an increased risk of overweight/obesity in women living in homes without poverty indicators [prevalence ratio (PR) = 1.29; 95% confidence interval (CI) 1.06;1.57]. When stratified by area of residence, similar associations were observed for women living in Lima and urban areas; no associations were found between food assistance program participation and overweight/obesity among women living outside of Lima or in rural areas, regardless of the poverty status. CONCLUSIONS Food assistance program participation was associated with overweight/obesity in non-poor women. Additional studies are required in countries facing both aspects of malnutrition.

Política(s) de saúde no trabalho : um inquérito sociológico às empresas portuguesas

Resumo Política(s) de saúde no trabalho: um inquérito sociológico às empresas portuguesas A literatura portuguesa sobre políticas, programas e actividades de Segurança, Higiene e Saúde no Trabalho (abreviadamente, SH&ST) é ainda escassa. Com este projecto de investigação pretende-se (i) colmatar essa lacuna, (ii) melhorar o conhecimento dos sistemas de gestão da saúde e segurança no trabalho e (iii) contribuir para a protecção e a promoção da saúde dos trabalhadores. Foi construída uma tipologia com cinco grupos principais de políticas, programas e actividades: A (Higiene & Segurança no Trabalho / Melhoria do ambiente físico de trabalho); B (Avaliação de saúde / Vigilância médica / Prestação de cuidados de saúde); C (Prevenção de comportamentos de risco/ Promoção de estilos de vida saudáveis); D (Intervenções a nível organizacional / Melhoria do ambiente psicossocial de trabalho); E (Actividades e programas sociais e de bem-estar). Havia uma lista de mais de 60 actividades possíveis, correspondendo a um índice de realização de 100%. Foi concebido e desenhado, para ser auto-administrado, um questionário sobre Política de Saúde no Local de Trabalho. Foram efectuados dois mailings, e um follow-up telefónico. O trabalho de campo decorreu entre a primavera de 1997 e o verão de 1998. A amostra (n=259) é considerada representativa das duas mil maiores empresas do país. Uma em cada quatro é uma multinacional. A taxa de sindicalização rondava os 30% da população trabalhadora, mas apenas 16% dos respondentes assinalou a existência de representantes dos trabalhadores eleitos para a SH&ST. A hipótese de investigação principal era a de que as empresas com um sistema integrado de gestão da SH&ST seriam também as empresas com um (i) maior número de políticas, programas e actividades de saúde; (ii) maior índice de saúde; (iii) maior índice de realização; e (iv) maior percentagem dos encargos com a SH&ST no total da massa salarial. As actividades de tipo A e B, tradicionalmente associadas à SH&ST, representavam, só por si, mais de 57% do total. Os resultados, correspondentes às respostas da Secção C do questionário, apontam, para (i) a hipervalorização dos exames de medicina do trabalho; e por outro para (ii) o subaproveitamento de um vasto conjunto de actividades (nomeadamente as de tipo D e E), que são correntemente levadas a cabo pelas empresas e que nunca ou raramente são pensadas em termos de protecção e promoção da saúde dos trabalhadores. As actividades e os programas de tipo C (Prevenção de comportamentos de risco/Promoção de estilos de vida saudáveis), ainda eram as menos frequentes entre nós, a seguir aos Programas sociais e de bem-estar (E). É a existência de sistemas de gestão integrados de SH&ST, e não o tamanho da empresa ou outra característica sociodemográfica ou técnico-organizacional, que permite predizer a frequência de políticas de saúde mais activas e mais inovadores. Os três principais motivos ou razões que levam as empresas portuguesas a investir na protecção e promoção da saúde dos seus trabalhadores eram, por ordem de frequência, (i) o absentismo em geral; (ii) a produtividade, qualidade e/ou competitividade, e (iii) a filosofia de gestão ou cultura organizacional. Quanto aos três principais benefícios que são reportados, surge em primeiro lugar (i) a melhoria da saúde dos trabalhadores, seguida da (ii) melhoria do ambiente do ambiente de trabalho e, por fim, (iii) a melhoria da produtividade, qualidade e/ou competitividade.Quanto aos três principais obstáculos que se põem, em geral, ao desenvolvimento das iniciativas de saúde, eles seriam os seguintes, na percepção dos respondentes: (i) a falta de empenho dos trabalhadores; (ii) a falta de tempo; e (iii) os problemas de articulação/ comunicação a nível interno. Por fim, (i) o empenho das estruturas hierárquicas; (ii) a cultura organizacional propícia; e (iii) o sentido de responsabilidade social surgem, destacadamente, como os três principais factores facilitadores do desenvolvimento da política de saúde no trabalho. Tantos estes factores como os obstáculos são de natureza endógena, susceptíveis portanto de controlo por parte dos gestores. Na sua generalidade, os resultados deste trabalho põem em evidência a fraqueza teóricometodológica de grande parte das iniciativas de saúde, realizadas na década de 1990. Muitas delas seriam medidas avulsas, que se inserem na gestão corrente das nossas empresas, e que dificilmente poderão ser tomadas como expressão de uma política de saúde no local de trabalho, (i) definida e assumida pela gestão de topo, (ii) socialmente concertada, (iii) coerente, (iv) baseada na avaliação de necessidades e expectativas de saúde dos trabalhadores, (v) divulgada, conhecida e partilhada por todos, (vi) contingencial, flexível e integrada, e, por fim, (vii) orientada por custos e resultados. Segundo a Declaração do Luxemburgo (1997), a promoção da saúde engloba o esforço conjunto dos empregadores, dos trabalhadores, do Estado e da sociedade civil para melhorar a segurança, a saúde e o bem-estar no trabalho, objectivo isso que pode ser conseguido através da (i) melhoria da organização e das demais condições de trabalho, da (ii) participação efectiva e concreta dos trabalhadores bem como do seu (iii) desenvolvimento pessoal. Abstract Health at work policies: a sociological inquiry into Portuguese corporations Portuguese literature on workplace health policies, programs and activities is still scarce. With this research project the author intends (i) to improve knowledge on the Occupational Health and Safety (shortly thereafter, OSH) management systems and (ii) contribute to the development of health promotion initiatives at a corporate level. Five categories of workplace health initiatives have been identified: (i) Occupational Hygiene and Safety / Improvement of Physical Working Environment (type A programs); (ii) Health Screening, Medical Surveillance and Other Occupational Health Care Provision (type B programs); (iii) Preventing Risk Behaviours / Promoting Healthy Life Styles (type C programs); (iv) Organisational Change / Improvement of Psycho-Social Working Environment (type D programs); and (v) Industrial and Social Welfare (type E programs). A mail questionnaire was sent to the Chief Executive Officer of the 1500 largest Portuguese companies, operating in the primary and secondary sectors (≥ 100 employees) or tertiary sector (≥ 75 employees). Response rate has reached about 20% (259 respondents, representing about 300 companies). Carried out between Spring 1997 and Summer 1998, the fieldwork has encompassed two direct mailings and one phone follow-up. Sample is considered to be representative of the two thousand largest companies. One in four is a multinational. Union membership rate is about 30%, but only 16% has reported the existence of a workers’ health and safety representative. The most frequent workplace health initiatives were those under the traditional scope of the OSH field (type A and B programs) (57% of total) (e.g., Periodical Medical Examinations; Individual Protective Equipment; Assessment of Working Ability). In SMEs (< 250) it was less likely to find out some time-consuming and expensive activities (e.g., Training on OSH knowledge and skills, Improvement of environmental parameters as ventilation, lighting, heating).There were significant differences in SMEs, when compared with the larger ones (≥ 250) concerning type B programs such as Periodical medical examinations, GP consultation, Nursing care, Other medical and non-medical specialities (e.g., psychiatrist, psychologist, ergonomist, physiotherapist, occupational social worker). With regard to type C programs, there were a greater percentage of programs centred on Substance abuse (tobacco, alcohol, and drug) than on Other health risk behaviours. SMEs representatives reported very few prevention- oriented programs in the field of Drug abuse, Nutrition, Physical activity, Off- job accidents, Blood pressure or Weight control. Frequency of type D programs included Training on Human Resources Management, Training on Organisational Behaviour, Total Quality Management, Job Design/Ergonomics, and Workplace rehabilitation. In general, implementation of this type of programs (Organisational Change / Improvement of Psychosocial Working Environment) is not largely driven by health considerations. Concerning Industrial and Social Welfare (Type E programs), the larger employers are in a better position than SMEs to offer to their employees a large spectrum of health resources and facilities (e.g., Restaurant, Canteen, Resting room, Transport, Infra-structures for physical activity, Surgery, Complementary social protection, Support to recreational and cultural activities, Magazine or newsletter, Intranet). Other workplace health promotion programs like Training on Stress Management, Employee Assistance Programs, or Self-help groups are uncommon in the Portuguese worksites. The existence of integrated OSH management systems, not the company size, is the main variable explaining the implementation of more active and innovative workplace health policies in Portugal. The three main prompting factors reported by employers for health protection and promotion initiatives are: (i) Employee absenteeism; (ii) Productivity, quality and/or competitiveness; and (iii) Corporate culture/management philosophy. On the other hand, (i) Improved staff’s health, (ii) Improved working environment and (iii) Improved productivity, quality and/or competitiveness were the three main benefits reported by companies’ representatives, as a result of successful implementation of workplace health initiatives. (i) Lack of staff commitment; (ii) Lack of time; and (iii) Problems of co-operation and communication within company or establishment (iii) are perceived to be the main barriers companies must cope with. Asked about the main facilitating factors, these companies have pointed out the following ones: (i) Top management commitment; (ii) Corporate culture; and (iii) Sense of social responsibility. This sociological research report shows the methodological weaknesses of workplace health initiatives, carried out by Portuguese companies during the last ‘90s. In many cases, these programs and actions were not part of a corporate health strategy and policy, (i) based on the assessment of workers’ health needs and expectancies, (ii) advocated by the employer or the chief executive officer, (ii) planned and implemented with the staff consultation and participation or (iv) evaluated according to a cost-benefit analysis. In short, corporate health policy and action were still rather based on more traditional OSH approaches and should be reoriented towards Workplace Health Promotion (WHP) approach. According to the Luxembourg Declaration of Workplace Health Promotion in the European Union (1997), WHP is “a combination of: (i) improving the work organisation and environment; (ii) promoting active participation; (iii) encouraging personal development”.Résumée Politique(s) de santé au travail: une enquête sociologique aux entreprises portugaises Au Portugal on ne sait presque rien des politiques de santé au travail, adoptés par les entreprises. Avec ce projet de recherche, on veut (i) améliorer la connaissance sur les systèmes de gestion de la santé et de la sécurité au travail et, au même temps, (ii) contribuer au développement de la promotion de la santé des travailleurs. Une typologie a été usée pour identifier les politiques, programmes et actions de santé au travail: A. Amélioration des conditions de travail / Sécurité au travail; B. Médecine du travail /Santé au travail; C. Prévention des comportements de risque / Promotion de styles de vie sains; D. Interventions organisationnelles / Amélioration des facteurs psychosociaux au travail; E. Gestion de personnel et bien-être social. Un questionnaire postal a été envoyé au représentant maximum des grandes entreprises portugaises, industrielles (≥ 100 employés) ou des services (≥ 75 employés). Le taux de réponse a été environ 20% (259 répondants, concernant trois centaines d’entreprises et d’établissements). La recherche de champ, conduite du printemps 1997 à l’été 1998, a compris deux enquêtes postales et un follow-up téléphonique. L´échantillon est représentatif de la population des deux miles plus grandes entreprises. Un quart sont des multinationales. Le taux de syndicalisation est d’environ 30%. Toutefois, il y a seulement 16% de lieux de travail avec des représentants du personnel pour la santé et sécurité au travail. Les initiatives de santé au travail les plus communes sont celles concernant le domaine plus traditionnel (types A et B) (57% du total): par exemple, les examens de médecine du travail, l’équipement de protection individuelle, les tests d’aptitude au travail. En ce qui concerne les programmes de type C, les plus fréquents sont le contrôle et la prévention des addictions (tabac, alcool, drogue). Les interventions dans le domaine de du système technique et organisationnelle du travail peuvent comprendre les courses de formation en gestion de ressources humaines ou en psychosociologie des organisations, l’ergonomie, le travail posté ou la gestion de la qualité totale. En général, la protection et la promotion de la santé des travailleurs ne sont pas prises en considération dans l’implémentation des initiatives de type D. Il y a des différences quand on compare les grandes entreprises et les moyennes en matière de politique de gestion du personnel e du bien-être (programmes de type E, y compris l’allocation de ressources humaines ou logistiques comme, par exemple, restaurant, journal d’entreprise, transports, installations et équipements sportifs). D’autres activités de promotion de la santé au travail comme la formation en gestion du stress, les programmes d’ assistance aux employés, ou les groupes de soutien et d’auto-aide sont encore très peu fréquents dans les entreprises portugaises. C’est le système intégré de gestion de la santé et de la sécurité au travail, et non pas la taille de l’entreprise, qui aide à prédire l’existence de politiques actives et innovatrices dans ce domaine. Les trois facteurs principaux qui encouragent les actions de santé (prompting factors, en anglais) sont (i) l’absentéisme (y compris la maladie), (ii) les problèmes liés à la productivité, qualité et/ou la compétitivité, et aussi (iii) la culture de l’entreprise/philosophie de gestion. Du coté des bénéfices, on a obtenu surtout l’amélioration (i) de la santé du personnel, (ii) des conditions de travail, et (iii) de la productivité, qualité et/ou compétitivité.Les facteurs qui facilitent les actions de santé au travail sont (i) l’engagement de la direction, (ii) la culture de l’entreprise, et (iii) le sens de responsabilité sociale. Par contre, les obstacles à surmonter, selon les organisations qui ont répondu au questionnaire, seraient surtout (i) le manque d’engagement des travailleurs et de leur représentants, (ii) le temps insuffisant, et (iii) les problèmes de articulation/communication au niveau interne de l’entreprise/établissement. Ce travail de recherche sociologique montre la faiblesse méthodologique des services et activités de santé et sécurité au travail, mis en place par les entreprises portugaises dans les années de 1990, à la suite des accords de concertation sociale de 1991. Dans beaucoup de cas, (i) ces politiques de santé ne font pas partie encore d’un système intégré de gestion, (ii) il n’a pas d’évaluation des besoins et des expectatives des travailleurs, (iii) c’est très bas ou inexistant le niveau de participation du personnel, (iv) on ne fait pas d’analyse coût-bénéfice. On peut conclure que les politiques de santé au travail sont plus proches de la médecine du travail et de la sécurité au travail que de la promotion de la santé des travailleurs. Selon la Déclaration du Luxembourg sur la Promotion de la Santé au Lieu de Travail dans la Communauté Européenne (1997), celle-ci « comprend toutes les mesures des employeurs, des employés et de la société pour améliorer l'état de santé et le bien être des travailleurs » e « ceci peut être obtenu par la concentration des efforts dans les domaines suivants: (i) amélioration de l'organisation du travail et des conditions de travail ; (ii) promotion d'une participation active des collaborateurs ; (iii) renforcement des compétences personnelles ».

Implementation contexts of a Tuberculosis Control Program in Brazilian prisons

OBJECTIVE To analyze the influence from context characteristics in the control of tuberculosis in prisons, and the influence from the program implementation degrees in observed effects.METHODS A multiple case study, with a qualitative approach, conducted in the prison systems of two Brazilian states in 2011 and 2012. Two prisons were analyzed in each state, and a prison hospital was analyzed in one of them. The data were submitted to a content analysis, which was based on external, political-organizational, implementation, and effect dimensions. Contextual factors and the ones in the program organization were correlated. The independent variable was the program implementation degree and the dependent one, the effects from the Tuberculosis Control Program in prisons.RESULTS The context with the highest sociodemographic vulnerability, the highest incidence rate of tuberculosis, and the smallest amount of available resources were associated with the low implementation degree of the program. The results from tuberculosis treatment in the prison system were better where the program had already been partially implemented than in the case with low implementation degree in both cases.CONCLUSIONS The implementation degree and its contexts – external and political-organizational dimensions – simultaneously contribute to the effects that are observed in the control of tuberculosis in analyzed prisons.

Advances and challenges in oral health after a decade of the “Smiling Brazil” Program

ABSTRACT OBJECTIVE To analyze oral health work changes in primary health care after Brazil’s National Oral Health Policy Guidelines were released. METHODS A literature review was conducted on Medline, LILACS, Embase, SciELO, Biblioteca Virtual em Saúde, and The Cochrane Library databases, from 2000 to 2013, on elements to analyze work changes. The descriptors used included: primary health care, family health care, work, health care policy, oral health care services, dentistry, oral health, and Brazil. Thirty-two studies were selected and analyzed, with a predominance of qualitative studies from the Northeast region with workers, especially dentists, focusing on completeness and quality of care. RESULTS Observed advances focused on educational and permanent education actions; on welcoming, bonding, and accountability. The main challenges were related to completeness; extension and improvement of care; integrated teamwork; working conditions; planning, monitoring, and evaluation of actions; stimulating people’s participation and social control; and intersectorial actions. CONCLUSIONS Despite the new regulatory environment, there are very few changes in oral health work. Professionals tend to reproduce the dominant biomedical model. Continuing efforts will be required in work management, training, and permanent education fields. Among the possibilities are the increased engagement of managers and professionals in a process to understand work dynamics and training in the perspective of building significant changes for local realities.

National Immunization Program: Computerized System as a tool for new challenges

The scope and coverage of the Brazilian Immunization Program can be compared with those in developed countries because it provides a large number of vaccines and has a considerable coverage. The increasing complexity of the program brings challenges regarding its development, high coverage levels, access equality, and safety. The Immunization Information System, with nominal data, is an innovative tool that can more accurately monitor these indicators and allows the evaluation of the impact of new vaccination strategies. The main difficulties for such a system are in its implementation process, training of professionals, mastering its use, its constant maintenance needs and ensuring the information contained remain confidential. Therefore, encouraging the development of this tool should be part of public health policies and should also be involved in the three spheres of government as well as the public and private vaccination services.