Características da resposta à Aids de secretarias de saúde, no contexto da Política de Incentivo do Ministério da Saúde¹

OBJETIVOS: Analisar a cobertura da Política de Incentivo do Ministério da Saúde para Programas de Aids e as características das ações de prevenção, assistência, gestão e apoio às organizações da sociedade civil induzidas nos Estados e municípios. METODOLOGIA: Os Planos de Ações e Metas de 2006, das 27 Unidades Federadas e de 427 municípios incluídos na Política de Incentivo, foram analisados segundo indicadores estabelecidos para aferir a complexidade e a sustentabilidade das ações induzidas, a inclusão de populações prioritárias e a capacidade de intervenção na epidemia. Informações sobre população e casos de aids registrados foram utilizadas para mensurar a cobertura. RESULTADOS: Os municípios incluídos representaram uma cobertura de 85,2% dos casos de aids do País. Houve uma baixa proporção de secretarias estaduais (48,2%) e municipais (32,6%) de saúde que contemplaram, concomitantemente, ações de prevenção para a população geral e as de maior prevalência da doença, assim como ações para o diagnóstico do HIV, o tratamento de pessoas infectadas e a prevenção da transmissão vertical. Em relação às populações prioritárias, 51,9% dos Estados e 31,1% dos municípios propuseram ações específicas na prevenção e na assistência. Estados (44,4%) e municípios (27,9%) com Planos abrangentes estão mais concentrados no Sudeste e em cidades de grande porte, representando a maioria dos casos de aids do País. CONCLUSÃO: A Política de Incentivo do Ministério da Saúde compreende as regiões de maior ocorrência da aids no Brasil, porém, o perfil da resposta induzida encontra-se parcialmente dissociado das características epidemiológicas da doença no País.

State-Level Pharmaceutical Assistance Programs for the Elderly: A national survey.

In order to put Pennsylvania's Pharmaceutical Assistance Contract for the Elderly (PACE) Program in a national context, a nationwide mail survey and telephone follow-up to each of the 58 State Unit Directors on Aging in the United States and its territories identified 10 programs. The results reported in this article are specific to the seven state-level pharmaceutical assistance programs which were in operation during the fiscal year 1984-85. In general, the programs varied on select program characteristics and on their efforts to address major policy issues. Data from the non-program states indicated support, legislative efforts, and a high interest in fiscal concerns. The findings reflect a lack of program uniformity and have implications for program development and implementation. Suggestions on how to identify the "optimum" or best combination of program and policy options are discussed.

Consumer Health Information for Asians (CHIA): a collaborative project.

According to the 2000 United States Census, the Asian population in Houston, Texas, has increased more than 67% in the last ten years. To supplement an already active consumer health information program, the staff of the Houston Academy of Medicine-Texas Medical Center Library worked with community partners to bring health information to predominantly Asian neighborhoods. Brochures on health topics of concern to the Asian community were translated and placed in eight informational kiosks in Asian centers such as temples and an Asian grocery store. A press conference and a ribbon cutting ceremony were held to debut the kiosks and to introduce the Consumer Health Information for Asians (CHIA) program. Project goals for the future include digitizing the translated brochures, mounting them on the Houston HealthWays Website, and developing touch-screen kiosks. The CHIA group is investigating adding health resources in other Asian languages, as well as Spanish. Funding for this project has come from outside sources rather than from the regular library budget.

Safer sex choices among African-American college women

The purpose of this dissertation was to explore and describe the factors that influence the safer sex choices of African-American college women. The pandemic of HIV and the prevalence of other sexually transmitted diseases has disproportionately affected African-American females. As young women enter college they are faced with a myriad of choices. Unprotected sexual exploration is one choice that can lead to deadly consequences. This dissertation explores, through in-depth interviews, the factors associated with the decision to practice or not practice safe sex. ^ The first study describes the factors associated with increased sexual risk taking among African-American college women. Sexual risk taking or sex without a condom was found to be more likely when issues of self or partner pleasure were raised. Participants were also likely to have sexual intercourse without a condom if they desired a long term relationship with their partner. ^ The second study examined safe sex decision making processes among a group of African-American college women. Women were found to employ both emotional and philosophical strategies to determine their safe sex behavior. These strategies range from assessing a partner's physical capabilities and appearance to length of the dating relationship. ^ The third study explores the association between knowledge and risk perception as predictors for safer sex behaviors. Knowledge of HIV/AIDS and other STDs was not found to be a determinant of safer sex behavior. Perception of personal risk was also not highly correlated with consistent safer sex behavior. ^ These studies demonstrate the need for risk-based safer sex education and intervention programs. The current climate of knowledge-based program development insures that women will continue to predicate their decision to practice safer sex on their limited perception and understanding of the risks associated with unprotected sexual behavior. Further study into the emotional and philosophical determinants of sexual behavior is necessary for the realistic design of applicable and meaningful interventions. ^

Efforts of hospital system wound care teams to reduce hospital acquired pressure ulcers

New reimbursement policies developed by the Centers for Medicare and Medicaid Services (CMS) are revolutionizing the health care landscape in America. The policies focus on clinical quality and patient outcomes. As part of the new policies, certain hospital acquired conditions have been identified by Medicare as "reasonably preventable". Beginning October 1, 2008, Medicare will no longer reimburse hospitals for these conditions developed after admission, pressure ulcers are among the most common of these conditions.^ In this practice-based culminating experience the objective was to provide a practical account of the process of program development, implementation and evaluation in a public health setting. In order to decrease the incidence of pressure ulcers, the program development team of the hospital system developed a comprehensive pressure ulcer prevention program using a "bundled" approach. The pressure ulcer prevention bundle was based on research supported by the Institute for Healthcare Improvement, and addressed key areas of clinical vulnerability for pressure ulcer development. The bundle consisted of clinical processes, policies, forms, and resources designed to proactively identify patients at risk for pressure ulcer development. Each element of the bundle was evaluated to ensure ease of integration into the workflow of nurses and clinical ancillary staff. Continued monitoring of pressure ulcer incidence rates will provide statistical validation of the impact of the prevention bundle. ^

HPV vaccine coverage in Texas counties: An application of multilevel, small area estimation

Health departments, research institutions, policy-makers, and healthcare providers are often interested in knowing the health status of their clients/constituents. Without the resources, financially or administratively, to go out into the community and conduct health assessments directly, these entities frequently rely on data from population-based surveys to supply the information they need. Unfortunately, these surveys are ill-equipped for the job due to sample size and privacy concerns. Small area estimation (SAE) techniques have excellent potential in such circumstances, but have been underutilized in public health due to lack of awareness and confidence in applying its methods. The goal of this research is to make model-based SAE accessible to a broad readership using clear, example-based learning. Specifically, we applied the principles of multilevel, unit-level SAE to describe the geographic distribution of HPV vaccine coverage among females aged 11-26 in Texas.^ Multilevel (3 level: individual, county, public health region) random-intercept logit models of HPV vaccination (receipt of ≥ 1 dose Gardasil® ) were fit to data from the 2008 Behavioral Risk Factor Surveillance System (outcome and level 1 covariates) and a number of secondary sources (group-level covariates). Sampling weights were scaled (level 1) or constructed (levels 2 & 3), and incorporated at every level. Using the regression coefficients (and standard errors) from the final models, I simulated 10,000 datasets for each regression coefficient from the normal distribution and applied them to the logit model to estimate HPV vaccine coverage in each county and respective demographic subgroup. For simplicity, I only provide coverage estimates (and 95% confidence intervals) for counties.^ County-level coverage among females aged 11-17 varied from 6.8-29.0%. For females aged 18-26, coverage varied from 1.9%-23.8%. Aggregated to the state level, these values translate to indirect state estimates of 15.5% and 11.4%, respectively; both of which fall within the confidence intervals for the direct estimates of HPV vaccine coverage in Texas (Females 11-17: 17.7%, 95% CI: 13.6, 21.9; Females 18-26: 12.0%, 95% CI: 6.2, 17.7).^ Small area estimation has great potential for informing policy, program development and evaluation, and the provision of health services. Harnessing the flexibility of multilevel, unit-level SAE to estimate HPV vaccine coverage among females aged 11-26 in Texas counties, I have provided (1) practical guidance on how to conceptualize and conduct modelbased SAE, (2) a robust framework that can be applied to other health outcomes or geographic levels of aggregation, and (3) HPV vaccine coverage data that may inform the development of health education programs, the provision of health services, the planning of additional research studies, and the creation of local health policies.^

Planning and implementation efficacy as a determinant of health risk communication outcomes: Case studies of the U.S. Public Health Service (PHS)

This study was conducted under the auspices of the Subcommittee on Risk Communication and Education of the Committee to Coordinate Environmental Health and Related Programs (CCEHRP) to determine how Public Health Service (PHS) agencies are communicating information about health risk, what factors contributed to effective communication efforts, and what specific principles, strategies, and practices best promote more effective health risk communication outcomes.^ Member agencies of the Subcommittee submitted examples of health risk communication activities or decisions they perceived to be effective and some examples of cases they thought had not been as effective as desired. Of the 10 case studies received, 7 were submitted as examples of effective health risk communication, and 3, as examples of less effective communication.^ Information contained in the 10 case studies describing the respective agencies' health risk communication strategies and practices was compared with EPA's Seven Cardinal Rules of Risk Communication, since similar rules were not found in any PHS agency. EPA's rules are: (1) Accept and involve the public as a legitimate partner. (2) Plan carefully and evaluate your efforts. (3) Listen to the public's specific concerns. (4) Be honest, frank, and open. (5) Coordinate and collaborate with other credible sources. (6) Meet the needs of the media. (7) Speak clearly and with compassion.^ On the basis of case studies analysis, the Subcommittee, in their attempts to design and implement effective health risk communication campaigns, identified a number of areas for improvement among the agencies. First, PHS agencies should consider developing a focus specific to health risk communication (i.e., office or specialty resource). Second, create a set of generally accepted practices and guidelines for effective implementation and evaluation of PHS health risk communication activities and products. Third, organize interagency initiatives aimed at increasing awareness and visibility of health risk communication issues and trends within and between PHS agencies.^ PHS agencies identified some specific implementation strategies the CCEHRP might consider pursuing to address the major recommendations. Implementation strategies common to PHS agencies emerged in the following five areas: (1) program development, (2) building partnerships, (3) developing training, (4) expanding information technologies, and (5) conducting research and evaluation. ^

Post-Permanency: An Assessment for Families’ Needs for Services and Supports

This article reports the results of a qualitative study that sought the perspectives of birth parents and adoptive parents following reunification or adoption of children from foster care. Using a participatory action design that actively involved young adults formerly in foster care and parents in the design and implementation of the study, the study focused on the consumers’ perspectives on several issues related to permanency. The article reports findings from interviews with a subset of 27 birth and adoptive families in New York City who were asked about their post-permanency experiences and from interviews with 38 child welfare professionals who were asked to respond to the parents’ perspectives. The article offers directions for child welfare practice and program development.

Predicting smokeless tobacco cessation in a blue -collar population

The use of smokeless tobacco products is undergoing an alarming resurgence in the United States. Several national surveys have reported a higher prevalence of use among those employed in blue-collar occupations. National objectives now target this group for health promotion programs which reduce the health risks associated with tobacco use.^ Drawn from a larger data set measuring health behaviors, this cross-sectional study tested the applicability of two related theories, the Theory of Reasoned Action (TRA) and the Theory of Planned Behavior (TPB), to smokeless tobacco (SLT) cessation in a blue-collar population of gas pipeline workers. In order to understand the determinants of SLT cessation, measures were obtained of demographic and normative characteristics of the population and specific constructs. Attitude toward the act of quitting (AACT) and subjective norm (SN) are constructs common to both models, perceived behavioral control (PBC) is unique to the TPB, and the number of past quit attempts is not contained in either model. In addition, a self-reported measure was taken of SLT use at two-month follow-up.^ The study population was comprised of all male SLT users who were field employees in a large gas pipeline company with gas compressor stations extending from Texas to the Canadian border. At baseline, 199 employees responded to the SLT portion of the survey, 118 completed some portion of the two-month follow-up, and 101 could be matched across time.^ As hypothesized, significant correlations were found between constructs antecedent to AACT and SN, although crossover effects occurred. Significant differences were found between SLT cessation intenders and non-intenders with regard to their personal and normative beliefs about quitting as well as their outcome expectancies and motivation to comply with others' beliefs. These differences occurred in the expected direction, with the mean intender score consistently higher than that of the non-intender.^ Contrary to hypothesis, AACT predicted intention to quit but SN did not. However, confirmatory of the TPB, PBC, operationalized as self-efficacy, independently contributed to the prediction of intention. Statistically significant relationships were not found between intention, perceived behavioral control, their interactive effects, and use behavior at two-month follow-up. The introduction of number of quit attempts into the logistic regression model resulted in insignificant findings for independent and interactive effects.^ The findings from this study are discussed in relation to their implications for program development and practice, especially within the worksite. In order to confirm and extend the findings of this investigation, recommendations for future research are also discussed. ^

Experiments in context-sensitive analysis of modular programs

Several models for context-sensitive analysis of modular programs have been proposed, each with different characteristics and representing different trade-offs. The advantage of these context-sensitive analyses is that they provide information which is potentially more accurate than that provided by context-free analyses. Such information can then be applied to validating/debugging the program and/or to specializing the program in order to obtain important performance improvements. Some very preliminary experimental results have also been reported for some of these models which provided initial evidence on their potential. However, further experimentation, which is needed in order to understand the many issues left open and to show that the proposed modes scale and are usable in the context of large, real-life modular programs, was left as future work. The aim of this paper is two-fold. On one hand we provide an empirical comparison of the different models proposed in previous work, as well as experimental data on the different choices left open in those designs. On the other hand we explore the scalability of these models by using larger modular programs as benchmarks. The results have been obtained from a realistic implementation of the models, integrated in a production-quality compiler (CiaoPP/Ciao). Our experimental results shed light on the practical implications of the different design choices and of the models themselves. We also show that contextsensitive analysis of modular programs is indeed feasible in practice, and that in certain critical cases it provides better performance results than those achievable by analyzing the whole program at once, specially in terms of memory consumption and when reanalyzing after making changes to a program, as is often the case during program development.

A new module system for prolog

It is now widely accepted that separating programs into modules is useful in program development and maintenance. While many Prolog implementations include useful module systems, we argüe that these systems can be improved in a number of ways, such as, for example, being more amenable to effective global analysis and transformation and allowing sepárate compilation or sensible creation of standalone executables. We discuss a number of issues related to the design of such an improved module system for Prolog and propose some novel solutions. Based on this, we present the choices made in the Ciao module system, which has been designed to meet a number of objectives: allowing sepárate compilation, extensibility in features and in syntax, amenability to modular global analysis and transformation, enhanced error detection, support for meta-programming and higher-order, compatibility to the extent possible with official and de-facto standards, etc.

Abstract Interpretation-based verification/certification in the ciaoPP system

CiaoPP is the abstract interpretation-based preprocessor of the Ciao multi-paradigm (Constraint) Logic Programming system. It uses modular, incremental abstract interpretation as a fundamental tool to obtain information about programs. In CiaoPP, the semantic approximations thus produced have been applied to perform high- and low-level optimizations during program compilation, including transformations such as múltiple abstract specialization, parallelization, partial evaluation, resource usage control, and program verification. More recently, novel and promising applications of such semantic approximations are being applied in the more general context of program development such as program verification. In this work, we describe our extensión of the system to incorpórate Abstraction-Carrying Code (ACC), a novel approach to mobile code safety. ACC follows the standard strategy of associating safety certificates to programs, originally proposed in Proof Carrying- Code. A distinguishing feature of ACC is that we use an abstraction (or abstract model) of the program computed by standard static analyzers as a certifícate. The validity of the abstraction on the consumer side is checked in a single-pass by a very efficient and specialized abstractinterpreter. We have implemented and benchmarked ACC within CiaoPP. The experimental results show that the checking phase is indeed faster than the proof generation phase, and that the sizes of certificates are reasonable. Moreover, the preprocessor is based on compile-time (and run-time) tools for the certification of CLP programs with resource consumption assurances.

Some techniques for automated, resource-aware distributed and mobile computing in a multi-paradigm programming system

Distributed parallel execution systems speed up applications by splitting tasks into processes whose execution is assigned to different receiving nodes in a high-bandwidth network. On the distributing side, a fundamental problem is grouping and scheduling such tasks such that each one involves sufñcient computational cost when compared to the task creation and communication costs and other such practical overheads. On the receiving side, an important issue is to have some assurance of the correctness and characteristics of the code received and also of the kind of load the particular task is going to pose, which can be specified by means of certificates. In this paper we present in a tutorial way a number of general solutions to these problems, and illustrate them through their implementation in the Ciao multi-paradigm language and program development environment. This system includes facilities for parallel and distributed execution, an assertion language for specifying complex programs properties (including safety and resource-related properties), and compile-time and run-time tools for performing automated parallelization and resource control, as well as certification of programs with resource consumption assurances and efñcient checking of such certificates.

Programming with global analysis

Global data-flow analysis of (constraint) logic programs, which is generally based on abstract interpretation [7], is reaching a comparatively high level of maturity. A natural question is whether it is time for its routine incorporation in standard compilers, something which, beyond a few experimental systems, has not happened to date. Such incorporation arguably makes good sense only if: • the range of applications of global analysis is large enough to justify the additional complication in the compiler, and • global analysis technology can deal with all the features of "practical" languages (e.g., the ISO-Prolog built-ins) and "scales up" for large programs. We present a tutorial overview of a number of concepts and techniques directly related to the issues above, with special emphasis on the first one. In particular, we concéntrate on novel uses of global analysis during program development and debugging, rather than on the more traditional application área of program optimization. The idea of using abstract interpretation for validation and diagnosis has been studied in the context of imperative programming [2] and also of logic programming. The latter work includes issues such as using approximations to reduce the burden posed on programmers by declarative debuggers [6, 3] and automatically generating and checking assertions [4, 5] (which includes the more traditional type checking of strongly typed languages, such as Gódel or Mercury [1, 8, 9]) We also review some solutions for scalability including modular analysis, incremental analysis, and widening. Finally, we discuss solutions for dealing with meta-predicates, side-effects, delay declarations, constraints, dynamic predicates, and other such features which may appear in practical languages. In the discussion we will draw both from the literature and from our experience and that of others in the development and use of the CIAO system analyzer. In order to emphasize the practical aspects of the solutions discussed, the presentation of several concepts will be illustrated by examples run on the CIAO system, which makes extensive use of global analysis and assertions.

A generic framework for context-sensitive analysis of modular programs

Context-sensitive analysis provides information which is potentially more accurate than that provided by context-free analysis. Such information can then be applied in order to validate/debug the program and/or to specialize the program obtaining important improvements. Unfortunately, context-sensitive analysis of modular programs poses important theoretical and practical problems. One solution, used in several proposals, is to resort to context-free analysis. Other proposals do address context-sensitive analysis, but are only applicable when the description domain used satisfies rather restrictive properties. In this paper, we argüe that a general framework for context-sensitive analysis of modular programs, Le., one that allows using all the domains which have proved useful in practice in the non-modular setting, is indeed feasible and very useful. Driven by our experience in the design and implementation of analysis and specialization techniques in the context of CiaoPP, the Ciao system preprocessor, in this paper we discuss a number of design goals for context-sensitive analysis of modular programs as well as the problems which arise in trying to meet these goals. We also provide a high-level description of a framework for analysis of modular programs which does substantially meet these objectives. This framework is generic in that it can be instantiated in different ways in order to adapt to different contexts. Finally, the behavior of the different instantiations w.r.t. the design goals that motivate our work is also discussed.