Articulação das ações e interação dos Agentes Comunitários de Saúde na equipe de Saúde da Família

O estudo de abordagem qualitativa teve como objetivo compreender as relações sociais entre o Agente Comunitário de Saúde (ACS) e a equipe de Saúde da Família (SF), nesse sentido, destaca-se a articulação das ações e a interação entre trabalhadores. Foram realizadas 23 observações participantes e 11 entrevistas semiestruturadas com uma equipe de SF em um município do interior de São Paulo, Brasil. Identificou-se que o ACS, como elo, desenvolve ações operacionais para agilizar o trabalho da equipe. Como laços de ligação, desempenham ações articuladas ao trabalho da equipe, interagindo com os trabalhadores, construindo planos assistenciais em comum, aproximando equipe e comunidade, adequando ações de cuidado às necessidades das pessoas. Na prática comunicativa, ao falarem de si, falam da própria comunidade, pois é seu representante e porta-voz na equipe. Concluiu-se que o Agente Comunitário de Saúde pode ser um trabalhador estratégico se suas ações compreenderem uma dimensão mais política e social do trabalho em saúde.

A educação em saúde no cuidado de usuários do Programa Automonitoramento Glicêmico

O trabalho relata, de maneira sistematizada e crítica, a experiência de um Projeto de Extensão no período de 2010 a 2011. Teve como foco ações de educação em saúde como estratégia para melhorar a adesão das pessoas com diabetes mellitus e insulinodependentes, de uma Unidade Básica de Saúde do município de São Paulo, ao Programa Automonitoramento Glicêmico. Além disso, pretendeu-se contribuir na reorganização do processo de trabalho em relação ao Programa na unidade. Foram utilizadas estratégias de educação em saúde em grupos educativos e visitas domiciliares, assim, possibilitando cuidados mais singulares. Dados dos usuários foram organizados em planilha e em pastas para as equipes de Saúde da Família, facilitando na identificação dos usuários, inclusive os faltosos, e auxiliando na descentralização do cuidado. Com as ações de educação em saúde, pretendeu-se contribuir para um cuidado mais integral e emancipatório aos usuários, para um contínuo refletir dos trabalhadores quanto a suas práticas.

Agentes comunitárias de saúde e a atenção à saúde sexual e reprodutiva de jovens na estratégia saúde da família

As DST/HIV e a gestação não-planejada entre jovens têm exigido o incremento da atenção em saúde sexual e reprodutiva, desafiando a formação profissional tradicional, os processos de trabalho e gestão na atenção primária. Este estudo etnográfico (observação e entrevistas) foi realizado em duas unidades básicas de município turístico do Estado do Rio de Janeiro, focalizando o trabalho das agentes comunitárias de saúde. As agentes abordavam a sexualidade jovem, principalmente das garotas; orientavam o fluxo de ações e influenciavam as estratégias de prevenção e cuidado, enfatizando "gravidez precoce" e "promiscuidade sexual". A saúde de jovens não era considerada integralmente, embora o trabalho das agentes constituísse uma tecnologia de processo com grande potencial na atenção à saúde sexual de jovens. A juventude se beneficia da atuação dessas profissionais, que podem ter seu saber prático mais valorizado. Sugere-se a formação em abordagens baseadas nos direitos humanos e na construção social da sexualidade.

E' possibile giustificare moralmente l'obiezione di coscienza in campo medico?

Scopo di questa tesi di dottorato è stabilire se l’obiezione di coscienza in ambito medico sia moralmente giustificabile. Esistono essenzialmente tre tipi di rifiuto motivati dall’obiezione di coscienza (1) rifiuto di informare un paziente relativamente alle opzioni terapeutiche come ad esempio l’uso di un contraccettivo di emergenza o l’interruzione volontaria di gravidanza (2) rifiuto di rinviare un paziente che chiede un particolare intervento (o terapia) presso un collega non obiettore (3) rifiuto di svolgere in prima persona una certa attività richiesta dal paziente Per rispondere a questo interrogativo si è svolta un’analisi filosofico-morale dei principali argomenti utilizzati dalla letteratura su questo tema per giustificare o per negare un diritto morale all’obiezione di coscienza degli operatori sanitari. Il diritto degli operatori sanitari all’integrità morale e a non essere complici di attività ritenute immorali dev’essere infatti confrontato con il diritto dei pazienti ad avere un’assistenza sanitaria efficiente, a poter compiere scelte autonome riguardo alla propria salute e ad essere informati relativamente a tutte le opzioni terapeutiche disponibili. Nel corso dell’intero lavoro è stato dimostrato come suddetti diritti dei pazienti sono facilmente e frequentemente violati a causa dell’incidenza dell’obiezione di coscienza in ambito medico. L’analisi condotta nel corso del lavoro di tesi si concentra fondamentalmente su quattro importanti aspetti del problema quali diritto all’integrità morale dell’ operatore sanitario, obblighi professionali, cooperazione al male e laicità dello stato. Alla fine del lavoro di analisi si è giunti alla conclusione che: le obiezioni di tipo (1) e (2) non sono mai moralmente giustificabili perché comportano sempre una violazione dei diritti fondamentali del paziente. Le obiezioni di coscienza di tipo (3) sono moralmente accettabili solo quando non impongono un peso eccessivo al paziente, vale a dire quando il rinvio presso un collega non obiettore è veloce, sicuro e agevole. Tuttavia le condizioni ideali in cui vengono rispettati i criteri minimi di ammissibilità dell’obiezione di coscienza di tipo (3) non si verificano quasi mai nella realtà dei fatti (per ragioni ampiamente spiegate nel corso del lavoro), per cui tali obiezioni risultano in pratica solo raramente accettabili da un punto d vista morale.

A Swiss neighbourhood index of socioeconomic position: development and association with mortality

Area-based measures of socioeconomic position (SEP) suitable for epidemiological research are lacking in Switzerland. The authors developed the Swiss neighbourhood index of SEP (Swiss-SEP).

STrengthening the Reporting of OBservational studies in Epidemiology: Molecular Epidemiology STROBE-ME. An extension of the STROBE statement

Advances in laboratory techniques have led to a rapidly increasing use of biomarkers in epidemiological studies. Biomarkers of internal dose, early biological change, susceptibility, and clinical outcomes are used as proxies for investigating the interactions between external and/or endogenous agents and the body components or processes. The need for improved reporting of scientific research led to influential statements of recommendations such as STrengthening Reporting of Observational studies in Epidemiology (STROBE) statement. The STROBE initiative established in 2004 aimed to provide guidance on how to report observational research. Its guidelines provide a user-friendly checklist of 22 items to be reported in epidemiological studies, with items specific to the three main study designs: cohort studies, case-control studies and cross-sectional studies. The present STrengthening the Reporting of OBservational studies in Epidemiology - Molecular Epidemiology (STROBE-ME) initiative builds on the STROBE Statement implementing 9 existing items of STROBE and providing 17 additional items to the 22 items of STROBE checklist. The additions relate to the use of biomarkers in epidemiological studies, concerning collection, handling and storage of biological samples; laboratory methods, validity and reliability of biomarkers; specificities of study design; and ethical considerations. The STROBE-ME recommendations are intended to complement the STROBE recommendations.

Marital status, living arrangement and mortality: does the association vary by gender?

Men appear to benefit more from being married than women with respect to mortality in middle age. However, there is some uncertainty about gender differences in mortality risks in older individuals, widowed, divorced and single individuals and about the impact of living arrangements.

Nursing Homes as a Setting for Psychological Practice: Public Policy Perspectives.

Recent federal legislation has provided renewed interest in improving the quality of nursing home care. The lack of both funding and personnel are significant barriers that may keep psychology's disciplinary expertise from being fully used in nursing homes. Nursing homes may be forced to undertake mandated activities (e.g., preadmission screening, nurses aides' training, and evaluation) without psychologists' expertise, relying either on medical practitioners with little knowledge of mental health interventions or on minimally qualified, entry-level mental health workers. Advocates for improved nursing home care must see the links among basic disciplinary skills, interdisciplinary collaboration, and improved care for mentally impaired elderly individuals.

2013 Massachusetts Family Impact Seminar: Youth at Risk, Part 2

The youth of Massachusetts are of primary concern to legislators and citizens. This briefing report features three essays by experts — Fern Johnson, Deborah Frank, and Donna Haig Friedman — who focus on three aspects of children in need: children in foster care who need adoption, children who are hungry, and children who are homeless. Each report has further and more detailed suggestions for helping these children in need; below is a summary of the problems we face.

Using contingent valuation to estimate willingness to pay for improved water source in rural Uganda

This research was conducted in August of 2011 in the villages of Kigisu and Rubona in rural Uganda while the author was serving as a community health volunteer with the U.S. Peace Corps. The study used the contingent valuation method (CVM) to estimate the populations’ willingness to pay (WTP) for the operation and maintenance of an improved water source. The survey was administered to 122 households out of 400 in the community, gathering demographic information, health and water behaviors, and using an iterative bidding process to estimate WTP. Households indicated a mean WTP of 286 Ugandan Shillings (UGX) per 20 liters for a public tap and 202 UGX per 20 liters from a private tap. The data were also analyzed using an ordered probit model. It was determined that the number of children in the home, and the distance from the existing source were the primary variables influencing households’ WTP.

Retrofitting boreholes contaminated with iron in rural Uganda

During my Peace Corps service as a community health liaison in rural Uganda I noticed that many improved water wells in our area had been abandoned. The communities described the water in these wells as being reddish in color, having a foul taste and odor, discoloring clothes and food, and not able to produce lather for washing. Personal investigations and an initial literature search suggested that the primary contaminant was iron. The water in these wells had a low pH and a rusty metallic smell. The water produced early in the morning appeared very red but the water became more transparent as pumping continued. The iron components of many of these wells experienced accelerated corrosion resulting in frequent pump failure. This rapid corrosion coupled with the timing of the onset of iron contamination (months to years after these wells were completed) suggests that the most likely cause of the poor quality water was iron related bacteria and/or sulphate reducing bacteria. This report describes a remedy for iron contamination employed at 5 wells. The remedy involved disinfecting the wells with chlorine and replacing iron pump components with plastic and stainless steel. Iron concentrations in the wells were less than 1 mg/L when the wells were drilled but ranged from 2.5 to 40 mg/L prior to the remedy. After the remedy was applied, the total iron concentrations returned to levels below 1 mg/L. The presence of iron related bacteria was measured in all of these wells using Biological Activity Reaction Tests. Although IRB are still present in all the wells, the dissolved iron concentrations remain less than 1 mg/L. This remedy is practical for rural areas because the work can be performed with only hand tools and costs less than US $850. Because the source of iron contamination is removed in this approach, substantial follow-up maintenance is not necessary.

POST-PROJECT ASSESSMENT OF PIT LATRINES IN RURAL PANAMA

In Panama, one of the Environmental Health (EH) Sector’s primary goals is to improve the health of rural Panamanians by helping them to adopt behaviors and practices that improve access to and use of sanitation systems. In complying with this goal, the EH sector has used participatory development models to improve hygiene and increase access to latrines through volunteer managed latrine construction projects. Unfortunately, there is little understanding of the long term sustainability of these interventions after the volunteers have completed their service. With the Peace Corps adapting their Monitoring, Reporting, and Evaluation procedures, it is appropriate to evaluate the sustainability of sanitation interventions offering recommendations for the adaptions of the EH training program, project management, and evaluation procedures. Recognizing the need for evaluation of past latrine projects, the author performed a post project assessment of 19 pit latrine projects using participatory analysis methodologies. First, the author reviewed volunteers’ perspectives of pit latrine projects in a survey. Then, for comparison, the author performed a survey of latrine projects using a benchmarking scoring system to rate solid waste management, drainage, latrine siting, latrine condition, and hygiene. It was observed that the Sanitation WASH matrix created by the author was an effective tool for evaluating the efficacy of sanitation interventions. Overall more than 75%, of latrines constructed were in use. However, there were some areas where improvements could be made for both latrine construction and health and hygiene. The latrines scored poorly on the indicators related to the privacy structure and seat covers. Interestingly those are the two items least likely to be included in project subsidies. Furthermore, scores for hygiene-related indicators were low; particularly those related to hand washing and cleanliness of the kitchen, indicating potential for improvement in hygiene education. Based on these outcomes, the EH sector should consider including subsidies and standardized designs for privacy structures and seat covers for latrines. In addition, the universal adoption of contracts and/or deposits for project beneficiaries is expected to improve the completion of latrines. In order to address the low scores in the health and hygiene indicators, the EH sector should adapt volunteer training, in addition to standardizing health and hygiene intervention procedures. In doing so, the sector should mimic the Community Health Club model that has shown success in improving health and hygiene indicators, as well as use a training session plan format similar to those in the Water Committee Seminar manual. Finally, the sector should have an experienced volunteer dedicated to program oversight and post-project monitoring and evaluation.

Culture, risk factors and mortality: can Switzerland add missing pieces to the European puzzle?

BACKGROUND: The aim was to compare cause-specific mortality, self-rated health (SRH) and risk factors in the French and German part of Switzerland and to discuss to what extent variations between these regions reflect differences between France and Germany. METHODS: Data were used from the general population of German and French Switzerland with 2.8 million individuals aged 45-74 years, contributing 176 782 deaths between 1990 and 2000. Adjusted mortality risks were calculated from the Swiss National Cohort, a longitudinal census-based record linkage study. Results were contrasted with cross-sectional analyses of SRH and risk factors (Swiss Health Survey 1992/3) and with cross-sectional national and international mortality rates for 1980, 1990 and 2000. RESULTS: Despite similar all-cause mortality, there were substantial differences in cause-specific mortality between Swiss regions. Deaths from circulatory disease were more common in German Switzerland, while causes related to alcohol consumption were more prevalent in French Switzerland. Many but not all of the mortality differences between the two regions could be explained by variations in risk factors. Similar patterns were found between Germany and France. CONCLUSION: Characteristic mortality and behavioural differentials between the German- and the French-speaking parts of Switzerland could also be found between Germany and France. However, some of the international variations in mortality were not in line with the Swiss regional comparison nor with differences in risk factors. These could relate to peculiarities in assignment of cause of death. With its cultural diversity, Switzerland offers the opportunity to examine cultural determinants of mortality without bias due to different statistical systems or national health policies.

THE MULTIPLE LOCATION TIME WEIGHTED INDEX: USING PATIENT ACTIVITY SPACES TO CALCULATE PRIMARY CARE SERVICE AREAS

Geographic health planning analyses, such as service area calculations, are hampered by a lack of patient-specific geographic data. Using the limited patient address information in patient management systems, planners analyze patient origin based on home address. But activity space research done sparingly in public health and extensively in non-health related arenas uses multiple addresses per person when analyzing accessibility. Also, health care access research has shown that there are many non-geographic factors that influence choice of provider. Most planning methods, however, overlook non-geographic factors influencing choice of provider, and the limited data mean the analyses can only be related to home address. This research attempted to determine to what extent geography plays a part in patient choice of provider and to determine if activity space data can be used to calculate service areas for primary care providers. During Spring 2008, a convenience sample of 384 patients of a locally-funded Community Health Center in Houston, Texas, completed a survey that asked about what factors are important when he or she selects a health care provider. A subset of this group (336) also completed an activity space log that captured location and time data on the places where the patient regularly goes. Survey results indicate that for this patient population, geography plays a role in their choice of health care provider, but it is not the most important reason for choosing a provider. Other factors for choosing a health care provider such as the provider offering “free or low cost visits”, meeting “all of the patient’s health care needs”, and seeing “the patient quickly” were all ranked higher than geographic reasons. Analysis of the patient activity locations shows that activity spaces can be used to create service areas for a single primary care provider. Weighted activity-space-based service areas have the potential to include more patients in the service area since more than one location per patient is used. Further analysis of the logs shows that a reduced set of locations by time and type could be used for this methodology, facilitating ongoing data collection for activity-space-based planning efforts.