Persuasive system design methods to deliver a cardio-rehabilitation program of post mi outpatients

Las enfermedades no transmisibles provocan cada ano 38 millones de fallecimientos en el mundo. Entre ellas, tan solo cuatro enfermedades son responsables del 82% de estas muertes: las enfermedades cardiovasculares, las enfermedades crónicas respiratorias, la diabetes, y el cáncer. Se prevé que estas cifras aumenten en los próximos anos, ya que las tendencias indican que en el año 2030 las muertes por esta causa ascenderán a 53 millones de personas. La Organización Mundial de la Salud (OMS) considera importante buscar soluciones para afrontar esta situación y ha solicitado a los gobiernos del mundo la implementación de intervenciones para mejorar los hábitos de vida de las personas y reducir así el riesgo de desarrollo de enfermedades no trasmisibles. Cada año se producen 32 millones de infartos de miocardio y derrames celebrales, de los cuales 12.5 son mortales. En el mundo entre el 40% y 75% de la víctimas de un infarto de miocardio mueren antes de su ingreso en el hospital. En los casos que sobreviven, la adopción de un estilo de vida saludable puede evitar infartos sucesivo, y supone un ahorro potencial de 6 billones de euros al año. La rehabilitación cardiaca es un programa individualizado que aplica un método multidisciplinar para ayudar al paciente a recuperar su condición física, a gestionar la enfermedad cardiovascular y sus comorbilidades, a adoptar hábitos de vida saludables, y a promover su salud mental. La rehabilitación cardiaca requiere la total involucración y motivación del paciente, solo de esta manera se podrán promover hábitos saludables y mejorar la gestión y prevención de su enfermedad. Aunque la participación en los programas de rehabilitación cardiaca es baja, hoy en día existen programas de rehabilitación cardiaca que el paciente puede realizar en su casa. Estos suponen una solución prometedora para aumentar la participación. La rehabilitación cardiaca se considera una intervención integral donde los modelos de psicología de la salud son aplicados para promover un cambio en el estilo de vida de las personas así como para ayudarles a afrontar su propia enfermedad. Existen métodos para implementar cambios de hábitos y de aptitud, y también se considera muy relevante promover no solo el bienestar físico sino también el mental. Existen tecnologías que promueven los cambios de comportamientos en los seres humanos. En concreto, las tecnologías persuasivas y los sistemas de apoyo al cambio de comportamientos modelan las características, las estrategias y los métodos de diseño para promover cambios usando la tecnología. Pero estos modelos tienen algunas limitaciones: todavía no se ha definido que rol tienen las emociones en el cambio de comportamientos y como traducir los métodos de la psicología de la salud en la tecnología. Esta tesis se centra en tres elementos que tienen un rol clave en los cambios de hábitos y actitud: el estado físico, el estado mental, y la tecnología. -Estado de salud: un estado de salud critico puede modificar la actitud del ser humano respecto al cambio. A la vez un buen estado de salud hace que la necesidad del cambio sea menos percibida. -Estado emocional: la actitud tiene un componente afectivo. Los estados emocionales negativos pueden reducir la habilidad de una persona para adoptar nuevos comportamientos. La salud mental es la situación ideal donde los individuos tienen predisposición a los cambios. La tecnología puede ayudar a las personas a adoptar nuevos hábitos, así como a mantener una salud física y mental. Este trabajo de investigación se centra en el diseño de tecnologías para la mejora del estado físico y emocional de las personas. Se ha propuesto un marco de diseño llamado “Well.Be.Sign”. El marco se basa en tres aspectos: El marco teórico: representa los elementos que se tienen que definir para diseñar tecnologías para promover el bienestar de las personas. -El diagrama de influencia: presenta las fuerzas de ‘persuasión’ en el contexto de la salud. El rol de las tecnologías persuasivas ha sido contextualizado en una dimensión donde otros elementos influencian el usuario.  El proceso de diseño: describe el proceso de diseño utilizando una metodología iterativa e incremental que aplica una combinación de métodos de diseño existentes (Diseño Orientado a Objetivos, Diseño de Sistemas Persuasivos) así como elementos originales de este trabajo de investigación. Los métodos se han aplicados para diseñar un sistema que ofrezca un programa de tele-rehabilitación cardiaca. Inicialmente se ha diseñado un prototipo de acuerdo con las necesidades del usuario. En segundo lugar, el prototipo se ha extendido especificando la intervención requerida para al programa de rehabilitación cardiaca. Finalmente el sistema se ha desarrollado y validado en un ensayo clínico con grupo control, donde se observaron las variaciones del estado cardiovascular, el nivel de conocimiento acerca de la enfermedad, la percepción de la enfermedad, la persistencia de hábitos saludables, y la aceptabilidad del sistema. Los resultados muestran que el grupo de intervención tiene una superior capacidad cardiovascular, mejor conocimiento acerca de la enfermedad, y más percepción de control de la enfermedad. Asimismo, en algunos casos se ha registrado persistencia de los hábitos de ejercicios 6 meses después del uso del sistema. Otros dos estudios se han presentado para demonstrar la relevancia del estado emocional del usuario en el diseño de aplicaciones para la promoción del bienestar.  En personas con una grave enfermedad crónica como la insuficiencia cardiaca, donde se ha presentado las conexiones entre estado de salud y estado emocional. En el estudio se ensena la relaciones que tienen los síntomas y las emociones negativas y como un estado negativo emocional puede empeorar la condición física del paciente. -Personas con trastornos del humor: el estudio muestra como las emociones pueden tener un impacto en la percepción de la tecnología por parte del usuario. ABSTRACT Noncommunicable diseases (NCDs) cause the death of 38 million people every year. Four major NCDs are responsible for 82% of these deaths: cardio vascular disease, chronic respiratory disease, diabetes and cancer. These pandemic numbers are projected to raise to 53 million deaths in 2030, and for this reason the assembly of the World Health Organization (WHO) considers communicable diseases as an urgent need to be addressed. It is also a trend to advocate the adoption of mobile technology to deliver health services and to promote healthy behaviours among citizens, but adopting healthS promoting lifestyle is still a difficult task facing human tendencies. Within this context, there is a promising opportunity: persuasive technologies. These technologies are intentionally designed to change a person’s attitudes or behaviours; when applied in this context, than can be used to change health-related attitudes, beliefs, and behaviours. Each year there are 32 million heart attacks and strokes globally, of which about 12.5 million are fatal. Worldwide between 40 and 75% of all heart-attack victims die before reaching hospital. Avoiding a second heart attack by improving adherence to lifestyle and medication regimens has a cost saving potential of around €6 billion per year. In most of the cases the cardiovascular event has been provoked by unhealthy lifestyle. Furthermore, after an MI event the patient's decision to adopt or not healthier behaviour will influence the progress of the disease. Cardio-rehabilitation is an individualized program that follows a multidisciplinary approach to support the user to recover from the Myocardial Infarction, manage the Cardio Vascular Disease and the comorbidities, adopt healthy habits, and cope with any emotional distress. Cardio- rehabilitation requires patient participation and willingness to perform behavioral modifications and change the attitude toward the management and prevention of the disease. Participation in the Cardio Rehabilitation program is not high; the home-based rehabilitation program is a promising solution to increase participation. Nowadays cardio rehabilitation is considered a comprehensive intervention in which models of health psychology are applied to promote the behaviour change of the individuals. Relevant methods that have been successfully applied to foster healthy habits include the Health Belief Model and the Trans Theoretical Model. Studies also demonstrate the importance to promote not only the physical but also the mental well being of the individuals. The idea of also promoting behaviour change using technologies has been defined by the literature as persuasive technologies or behaviour change support systems, in which the features, the strategies and the design method have been modelled to foster the behaviour change using technology. Limitations have been found in this model: there is still research to be done on the role of the emotions and how psychological health intervention can be translated into computer methods. This research focuses on three elements that could foster behaviour change in individuals: the physical and emotional status of the person, and the technology. Every component can influence the user's attitude and behaviour in the following ways: ' Physical status: bad physical status could change human attitude toward the necessity to adopt health behaviours; at the same time, good health status reduces the need to adopt healthy habits. ' Emotional status: the attitude has an affective component, negative emotional state can reduce the ability of a person to adopt new behaviours, and mental well being is the ideal situation in which individuals have a predisposition to adopt healthy behaviours. ' Technology: it can help users to adopt new behaviours and can also be support to promote physical and emotional status. Following this approach the idea driven in this research is that technology that is designed to improve the physical status and the emotional status of the individual could better foster behaviour change. According to this principle, the Well.Be.Sign framework has been proposed. The framework is based on three views: ' The theoretical framework: it represents the patterns that have to be defined to design the technologies to promote well being. ' The influence diagram: it shows the persuasive forces in the context of health care. The role of the persuasive technologies is contextualized in a wider universe where other factors and persuasive forces influence a patient. ' The design process: it shows the process of design using an iterative, incremental methodology that applies a combination of existing methodologies (Goal Directed Design and Persuasive System Design) and others that are original to this research. The methods have been applied to design a system to deliver cardio rehabilitation at home: first a prototype has been defined according to the user’s needs, then it has been extended with the specific intervention required for the cardio–rehabilitation, finally the system has been developed and validated in a controlled clinical study in which the cardiovascular fitness, the level of knowledge, the perception of the illness, the persistence of healthy habits and the system acceptance (only the intervention group) were measured. The results show that the intervention group increased cardiovascular capacity, knowledge, feeling of control of illness and perceived benefits of exercise at the end of the study. After six months of the study, a followSup of the exercise habits was performed. Some individuals of the intervention group continued to be engaged in the running exercise sessions promoted in the designed system. Two other cases have been presented to demonstrate the foundations of the Well.Be.Sign’s approach to promote both physical and emotional status: ' People affected by Heart Failure, in which a bidirectional connection between health status and emotions has been discussed with patients. Two correlations were demonstrated: the relationship between symptoms and negative emotional response, and that negative emotional status is correlated with worsening of chronic conditions. ' People with mood disorders: the study shows that emotions could also impact how the user perceives the technology.

Changes in the governance system for higher education in Peru to meet the challenges of the 21st century

The competition in markets, the distribution of limited resources based on productivity and performance, and the efficient management of universities are changing the criteria of trust and legitimacy of the educational system in Peru. Universities are perceived more as institutions of the public sector, while the services they offer must rather contribute to the modernization of the emerging society and the knowledge economy. Higher Educations reforms - initiated in the 1980s - have been inspired by the successful university organizations that have managed to change their governance and addressed to transform certain bureaucratic institutions into organizations capable of playing active role in this global competition for resources and best talent. Within this context, Peruvian universities are facing two major challenges: adapting themselves to new global perspectives and being able to develop a better response to society demands, needs and expectations. This article proposes a model of governance system for higher education in Peru that gives a comprehensive solution to these challenges, allowing dealing with the problems of universities for their development and inclusion within the global trends. For this purpose, a holistic and qualitative methodologic approach was developed, considering an integrated method which considered educational reality as a whole, understanding its facts, components and elements that affects its outcomes. It is proposed to define a policy for university education in Peru that permeates society, by changing the planning model from a social reform model to a policy analysis model, where the Peruvian State acts as sole responsible for responding to the demanding society as its legal representative complemented with some external and independent bodies that define the basis of best practice, as it is being done in many university models worldwide.

Cross-lineage expression of Ig-β (B29) in thymocytes: Positive and negative gene regulation to establish T cell identity

Developmental commitment involves activation of lineage-specific genes, stabilization of a lineage-specific gene expression program, and permanent inhibition of inappropriate characteristics. To determine how these processes are coordinated in early T cell development, the expression of T and B lineage-specific genes was assessed in staged subsets of immature thymocytes. T lineage characteristics are acquired sequentially, with germ-line T cell antigen receptor-β transcripts detected very early, followed by CD3ɛ and terminal deoxynucleotidyl transferase, then pTα, and finally RAG1. Only RAG1 expression coincides with commitment. Thus, much T lineage gene expression precedes commitment and does not depend on it. Early in the course of commitment to the T lineage, thymocytes lose the ability to develop into B cells. To understand how this occurs, we also examined expression of well defined B lineage-specific genes. Although λ5 and Ig-α are not expressed, the μ0 and Iμ transcripts from the unrearranged IgH locus are expressed early, in distinct patterns, then repressed just before RAG1 expression. By contrast, RNA encoding the B cell receptor component Ig-β was found to be transcribed in all immature thymocyte subpopulations and throughout most thymocyte differentiation. Ig-β expression is down-regulated only during positive selection of CD4+CD8– cells. Thus several key participants in the B cell developmental program are expressed in non-B lineage-committed cells, and one is maintained even through commitment to an alternative lineage, and repressed only after extensive T lineage differentiation. The results show that transcriptional activation of “lymphocyte-specific” genes can occur in uncommitted precursors, and that T lineage commitment is a composite of distinct positive and negative regulatory events.

Rapid elimination of mature autoreactive B cells demonstrated by Cre-induced change in B cell antigen receptor specificity in vivo

Developing autoreactive B cells edit their B cell antigen receptor (BCR) in the bone marrow and are clonally deleted when they fail to reexpress an innocent BCR. Here, inducible Cre-loxP-mediated gene inversion is used to change the specificity of the BCR on mature IgM+ IgD+ B cells in vivo to address the fate of lymphocytes encountering self-antigens at this developmental stage. Expression of an autoreactive BCR on mature B cells leads to their rapid elimination from the periphery, a process that is inhibited by constitutive bcl-2 transgene expression in an antigen dose-dependent manner. Thus, selection of mature B cells into the long-lived peripheral pool does not prevent their deletion upon encounter of self-antigens.

Genetic instability of cancer cells is proportional to their degree of aneuploidy

Genetic and phenotypic instability are hallmarks of cancer cells, but their cause is not clear. The leading hypothesis suggests that a poorly defined gene mutation generates genetic instability and that some of many subsequent mutations then cause cancer. Here we investigate the hypothesis that genetic instability of cancer cells is caused by aneuploidy, an abnormal balance of chromosomes. Because symmetrical segregation of chromosomes depends on exactly two copies of mitosis genes, aneuploidy involving chromosomes with mitosis genes will destabilize the karyotype. The hypothesis predicts that the degree of genetic instability should be proportional to the degree of aneuploidy. Thus it should be difficult, if not impossible, to maintain the particular karyotype of a highly aneuploid cancer cell on clonal propagation. This prediction was confirmed with clonal cultures of chemically transformed, aneuploid Chinese hamster embryo cells. It was found that the higher the ploidy factor of a clone, the more unstable was its karyotype. The ploidy factor is the quotient of the modal chromosome number divided by the normal number of the species. Transformed Chinese hamster embryo cells with a ploidy factor of 1.7 were estimated to change their karyotype at a rate of about 3% per generation, compared with 1.8% for cells with a ploidy factor of 0.95. Because the background noise of karyotyping is relatively high, the cells with low ploidy factor may be more stable than our method suggests. The karyotype instability of human colon cancer cell lines, recently analyzed by Lengnauer et al. [Lengnauer, C., Kinzler, K. W. & Vogelstein, B. (1997) Nature (London) 386, 623–627], also corresponds exactly to their degree of aneuploidy. We conclude that aneuploidy is sufficient to explain genetic instability and the resulting karyotypic and phenotypic heterogeneity of cancer cells, independent of gene mutation. Because aneuploidy has also been proposed to cause cancer, our hypothesis offers a common, unique mechanism of altering and simultaneously destabilizing normal cellular phenotypes.

Plo1 Kinase Recruitment to the Spindle Pole Body and Its Role in Cell Division in Schizosaccharomyces pombe

Polo kinases execute multiple roles during cell division. The fission yeast polo related kinase Plo1 is required to assemble the mitotic spindle, the prophase actin ring that predicts the site for cytokinesis and for septation after the completion of mitosis (Ohkura et al., 1995; Bahler et al., 1998). We show that Plo1 associates with the mitotic but not interphase spindle pole body (SPB). SPB association of Plo1 is the earliest fission yeast mitotic event recorded to date. SPB association is strong from mitotic commitment to early anaphase B, after which the Plo1 signal becomes very weak and finally disappears upon spindle breakdown. SPB association of Plo1 requires mitosis-promoting factor (MPF) activity, whereas its disassociation requires the activity of the anaphase-promoting complex. The stf1.1 mutation bypasses the usual requirement for the MPF activator Cdc25 (Hudson et al., 1990). Significantly, Plo1 associates inappropriately with the interphase SPB of stf1.1 cells. These data are consistent with the emerging theme from many systems that polo kinases participate in the regulation of MPF to determine the timing of commitment to mitosis and may indicate that pole association is a key aspect of Plo1 function. Plo1 does not associate with the SPB when septation is inappropriately driven by deregulation of the Spg1 pathway and remains SPB associated if septation occurs in the presence of a spindle. Thus, neither Plo1 recruitment to nor its departure from the SPB are required for septation; however, overexpression of plo1+ activates the Spg1 pathway and causes transient Cdc7 recruitment to the SPB and multiple rounds of septation.

Restrictions to Carbon Dioxide Conductance and Photosynthesis in Spinach Leaves Recovering from Salt Stress

Salt accumulation in spinach (Spinacia oleracea L.) leaves first inhibits photosynthesis by decreasing stomatal and mesophyll conductances to CO2 diffusion and then impairs ribulose-1,5-bisphosphate carboxylase/oxygenase (S. Delfine, A. Alvino, M. Zacchini, F. Loreto [1998] Aust J Plant Physiol 25: 395–402). We measured gas exchange and fluorescence in spinach recovering from salt accumulation. When a 21-d salt accumulation was reversed by 2 weeks of salt-free irrigation (rewatering), stomatal and mesophyll conductances and photosynthesis partially recovered. For the first time, to our knowledge, it is shown that a reduction of mesophyll conductance can be reversed and that this may influence photosynthesis. Photosynthesis and conductances did not recover when salt drainage was restricted and Na content in the leaves was greater than 3% of the dry matter. Incomplete recovery of photosynthesis in rewatered and control leaves may be attributed to an age-related reduction of conductances. Biochemical properties were not affected by the 21-d salt accumulation. However, ribulose-1,5-bisphosphate carboxylase/oxygenase activity and content were reduced by a 36- to 50-d salt accumulation. Photochemical efficiency was reduced only in 50-d salt-stressed leaves because of a decrease in the fraction of open photosystem II centers. A reduction in chlorophyll content and an increase in the chlorophyll a/b ratio were observed in 43- and 50-d salt-stressed leaves. Low chlorophyll affects light absorptance but is unlikely to change light partitioning between photosystems.

Characteristics of the deep ocean carbon system during the past 150,000 years: ΣCO2 distributions, deep water flow patterns, and abrupt climate change

Studies of carbon isotopes and cadmium in bottom-dwelling foraminifera from ocean sediment cores have advanced our knowledge of ocean chemical distributions during the late Pleistocene. Last Glacial Maximum data are consistent with a persistent high-ΣCO2 state for eastern Pacific deep water. Both tracers indicate that the mid-depth North and tropical Atlantic Ocean almost always has lower ΣCO2 levels than those in the Pacific. Upper waters of the Last Glacial Maximum Atlantic are more ΣCO2-depleted and deep waters are ΣCO2-enriched compared with the waters of the present. In the northern Indian Ocean, δ13C and Cd data are consistent with upper water ΣCO2 depletion relative to the present. There is no evident proximate source of this ΣCO2-depleted water, so I suggest that ΣCO2-depleted North Atlantic intermediate/deep water turns northward around the southern tip of Africa and moves toward the equator as a western boundary current. At long periods (>15,000 years), Milankovitch cycle variability is evident in paleochemical time series. But rapid millennial-scale variability can be seen in cores from high accumulation rate series. Atlantic deep water chemical properties are seen to change in as little as a few hundred years or less. An extraordinary new 52.7-m-long core from the Bermuda Rise contains a faithful record of climate variability with century-scale resolution. Sediment composition can be linked in detail with the isotope stage 3 interstadials recorded in Greenland ice cores. This new record shows at least 12 major climate fluctuations within marine isotope stage 5 (about 70,000–130,000 years before the present).

Redesigning secondary structure to invert coenzyme specificity in isopropylmalate dehydrogenase.

Rational engineering of enzymes involves introducing key amino acids guided by a knowledge of protein structure to effect a desirable change in function. To date, all successful attempts to change specificity have been limited to substituting individual amino acids within a protein fold. However, the infant field of protein engineering will only reach maturity when changes in function can be generated by rationally engineering secondary structures. Guided by x-ray crystal structures and molecular modeling, site-directed mutagenesis has been used to systematically invert the coenzyme specificity of Thermus thermophilus isopropylmalate dehydrogenase from a 100-fold preference for NAD to a 1000-fold preference for NADP. The engineered mutant, which is twice as active as wild type, contains four amino acid substitutions and an alpha-helix and loop that replaces the original beta-turn. These results demonstrate that rational engineering of secondary structures to produce enzymes with novel properties is feasible.

Study of the role of retinoblastoma protein in terminal differentiation of murine erythroleukemia cells.

Hexamethylenebisacetamide-induced terminal differentiation of Friend virus-transformed murine erythroleukemia (MEL) cells can be inhibited by okadaic acid, an inhibitor of type 1 and type 2A protein phosphatases. The inhibition is shown to be correlated with prevention of dephosphorylation of retinoblastoma protein (pRB) in cells and bypass of G1 prolongation in the cell cycle. These results suggest that pRB-mediated G1 prolongation is necessary for MEL cells to commit to terminal differentiation. However, further experiments demonstrate that the simple cell cycle exit is not sufficient for commitment to terminal differentiation. Induction of dephosphorylation of pRB and subsequent G1 prolongation by forskolin does not lead MEL cells to differentiate. Additional pRB has been expressed in MEL cells by transfection with a neo-resistant plasmid containing RB cDNA under the control of a cytomegalovirus promoter. Exogenously expressed pRB is hyperphosphorylated in logarithmically growing MEL cells without any noticeable change in growth rate between the transfected cell line and the parental cell line. This result suggests that pRB in MEL cells is regulated by protein kinases and protein phosphatases and not by transcription.

Volunteer Engagement: Does Engagement Predict the Degree of Satisfaction among New Volunteers and the Commitment of Those who have been Active Longer?

This study examines the concept of engagement in samples of volunteers from different non-profit organisations. Study 1 analyzes the psychometric properties of the abbreviated version of the Utrecht Work Engagement Scale (UWES) (Schaufeli, Bakker, & Salanova, 2006a). Two factorial structures are examined: one-dimensional and three-dimensional structures. Based on the Three-Stage Model of Volunteers’ Duration of Service (Chacón, Vecina, & Dávila, 2007), Study 2 investigates the relationship between engagement, volunteer satisfaction, and intention to remain in a sample of new volunteers and the relationship between engagement, organisational commitment, and intention to remain in a sample of veteran volunteers. Moderated mediation analysis is provided using duration of service as a moderator in order to set a splitting point between new and veteran volunteers. The results of the confirmatory factor analysis suggest that the three-factor model fits better to the data. Regarding the structural models, the first one shows that engagement is crucial to volunteer satisfaction during the first stage, while volunteer satisfaction is the key variable in explaining intention to continue. The second structural model shows that engagement reinforces the participant’s commitment to the organisation, while organizational commitment predicts intention to continue. Both models demonstrate a notable decline when samples are changed.

A integralidade no cuidado das pessoas vivendo com HIV e AIDS: a experiência do Centro de Referência e Treinamento em DST/AIDS da SES-SP

Ao assumir o compromisso com a prevenção e tratamento, baseada no princípio da integralidade, a estratégia brasileira, fez a diferença na resposta nacional à aids nas décadas de 1980/90 e criou um novo paradigma que mostrou-se avançado do ponto de vista técnico, ético e político, contribuindo para a mudança nas recomendações das agências internacionais (OMS\\Banco Mundial) - do \"não tratar e só prevenir\" do início dos anos 1990, para o \"Tratamento como Prevenção\", base da atual proposta dos 90/90/90. Essa estratégia de controle da epidemia concentra responsabilidade na Rede de Serviços, em um período de discussão sobre mudanças no modelo de atenção a ser priorizado no país. Características relevantes dos contextos político e programáticos permitiram uma maior efetivação do cuidado às PVHA no Estado de São Paulo. O objetivo do presente estudo é recuperar a história do Centro de Referência e Treinamento em DST/Aids (CRT) na gestão e organização programática do cuidado em HIV/Aids no Estado de São Paulo, no período de 1988 a 2015, interpretando-a sob a perspectiva dos aspectos facilitadores e limitadores da incorporação prática do princípio da integralidade às ações de saúde. Realizou-se, nesse sentido, uma revisão narrativa da literatura sobre o tema da integralidade no campo da Saúde Coletiva Brasileira nas últimas cinco décadas. Tomando por base o cotejamento com esse desenvolvimento conceitual, a trajetória do CRT foi analisada por meio de entrevistas com atores-chaves no processo da gestão e organização programática do cuidado das PVHA no Estado de São Paulo, e análise dos documentos produzidos no processo. Esta análise foi organizada em torno de dois grandes eixos temáticos: (1) a criação e estruturação do CRT, e (2) as relações entre o CRT, os Programas Municipais de DST/aids e a rede de serviços assistenciais no Estado de São Paulo. Entre os resultados do estudo, destacam-se o resgate e reflexão crítica sobre o desenvolvimento dos discursos tecnocientíficos sobre integralidade no contexto das propostas de reforma da saúde no Brasil; a incorporação desses construtos às propostas desenvolvidas pelo CRT, especialmente em torno aos conceitos de vulnerabilidade, cuidado, clínica ampliada e direitos humanos em saúde; e a identificação de arranjos institucionais, estratégias técnicas e configurações políticas que permitiram ao CRT o exercício articulado de três níveis de gestão do cuidado (das PVHA, dos serviços e da Rede) numa mesma plataforma. Conclui-se apontando alcances e limites na efetivação da integralidade, que se mostraram desiguais nos três níveis de gestão do cuidado. Aponta-se maiores avanços na dimensão gerencial da rede e as maiores dificuldades na efetivação da integralidade no cuidado das PVHA e na gestão dos serviços de saúde

O Guesa em New York: republicanismo e americanismo em Sousândrade

Esta tese analisa a poesia de Joaquim de Sousa Andrade (1832-1902), ou Sousândrade, e tem por objetivo discutir o imaginário político republicano como elo de ligação entre os poemas O Guesa, especialmente o Canto Décimo (1877), Novo Éden: Poemeto da adolescência, 1888-1889 (1893), Harpa de Ouro (189?) e a continuação O Guesa, o Zac (1902). A cronologia dessas obras indica que é a partir dos anos vividos por Sousândrade nos Estados Unidos que as figurações da República passam a permear os seus escritos. No Canto Décimo, gestado em Nova York, Sousândrade traça um panorama da sociedade estadunidense na década de 1870 e, embora haja críticas à certas práticas econômicas nesse canto, conforme discutiremos com vagar, destaca-se a emulação do poeta em exaltar aquele modelo sociopolítico. Essa atitude do escritor maranhense afinava-se com a visão de brasileiros imigrados nos Estados Unidos naquele mesmo período, os quais formavam uma rede de pensadores liberais comprometidos com a modernização do Brasil. Esse diálogo transatlântico que começa a ser traçado entre Estados Unidos e Brasil caracteriza uma alternativa ao modelo de civilização europeu até então em voga, tema ainda pouco explorado pela historiografia literária. De volta a pátria, Sousândrade dá prosseguimento ao seu fazer poético e, além do seu engajamento na nova conjuntura política do país, dedica-se à construção do mito fundador da República brasileira nos poemas concebidos desde 1893. A trajetória do poeta republicano foi marcada pelo seu anseio de progresso e modernização do Brasil, tarefa na qual ele empenhou-se política e literariamente.

Reducing Stigma toward Sexual Minorities: Acceptance-Based versus Traditional Safe Zone Training.

Homophobia continues to exist in society. Homonegative attitudes are often implicit and can be acquired without direct training, which makes them particularly resistant to change. Relational Frame Theory (RFT) is a behavior analytic account of learning processes and can explain these processes of indirect learning. RFT also suggests therapeutic processes for dismantling stigma using a therapy model named Acceptance and Commitment Therapy (ACT). This paper reviews previous research on traditional multicultural training, and addresses its shortcomings. Specifically, this paper makes the argument that traditional models encourage experiential avoidance and thus further perpetuate the processes that maintain stigma. While a handful of studies have examined stigma interventions using ACT, no ACT studies have been completed specifically on the stigma towards gay and lesbian individuals. This paper concludes with a research proposal for such a study.

Don’t Let Me Down: An Autoethnography of an Urban Teacher

Students in urban schools who are negatively impacted need stability and continuity the most. However, at least half of new teachers leave their profession within five years. In order for this situation to change, support is needed for new teachers and encouragement is needed for experienced teachers. The purpose of the study is to offer a first-hand description of factors that affect the profession of teaching and especially teachers who may be wondering how to stay in teaching for more than five years. Veteran teachers gain the opportunity to reflect, validate, and (probably) celebrate their own journey through this profession. This autoethnography uses my experience of a 29-year veteran teacher, who started with an alternative teaching license, to mirror what researchers have identified as key factors for sustainability and how they affected my continued commitment to teaching in urban schools. The following questions framed the study: 1. Why did I choose teaching as a career? 2. What supportive factors contributed to my decision to continue teaching in an urban school rather than leave the profession? 3. What internal and external struggles have I encountered in teaching and what strategies did I use to overcome them? 4. What beliefs and experiences led to my steadfast commitment to teaching in an urban setting? 5. How do I define success as an urban teacher? 6. What are the implications of my story for urban education? This autoethnography involves data collection and in-depth analysis of documents and artifacts that were generated during my teaching career as an urban educator. These documents and artifacts come from both internal and external sources. The study’s implications reach beyond teachers and include two sub-groups: teacher education programs and school administrators. The implication for teachers is the importance of a two-fold support system in order to thrive: first teachers need spiritual support and second they need to surround themselves with likeminded teachers. The implications for teacher education programs include making pre-service teachers aware of the realities of urban settings and provide them with resources, which could help overcome the attrition rate. Additionally, pre-service teachers need to know how to form credible relationships with their students. This study also reveals the important role that school principals play in the success of their teachers. First, principals are responsible for creating a positive school climate that promotes a professional learning community. Second, they need to establish relational trust in their building. Third, they need to nourish their staff both physically and emotionally. Finally, the implications of autoethnography for teachers and researchers are also discussed.