Dissertationen zum Thema „Health care migration“

Magister Artium - MA
There is a widely held assumption that immigrants have difficulties in accessing public health care services in South Africa. This assumption derives from the experiences of some immigrants in accessing public health care services at some public health care facilities which are all required by law and policy to provide such services. The main aim of the study was to investigate the experiences of Zimbabwean immigrants in accessing public health care services at some public clinics and hospitals in Cape Town. Foucault’s theory on power was used to unpack the experiences of Zimbabwean immigrants at these public health care centers. Zimbabwean immigrant participants were all purposively sampled for the study and medical personnel were randomly sampled. The Zimbabwean immigrants sampled had used public health care facilities in Cape Town. Semi-structured interviews were used to collect data from the Zimbabwean immigrants which were qualitatively analysed using content analysis. Questionnaires were also used to collect data from both the Zimbabwean immigrants and medical personnel and subsequently open-ended questions from the questionnaires were also analysed using content analysis and closed questions were analysed using the Micro-soft excel package of data assessment and statistically presented using pie, bar and line graphs. Themes that were recurring from the semi-structured interviews and responses from questionnaires suggested that immigrants in their experiences at public health care facilities encountered barriers that included communication problems, negative attitudes and xenophobia from medical staff, policy and practice problems and preferential treatment offered to citizens over non-citizens. Recommendations of what needs to be done to reduce barriers to health care for immigrants were made to all involved in the provision of health care. The study contributed to our understanding of barriers that immigrants encounter in accessing public health care in South Africa as well as the role of citizens in this process.

This thesis argues the necessity of new standards for Japanese language teaching in Japan, responding to diversifying social needs. The current situation for foreign workers in Japan is a pressing issue in the light of declining fertility rates and a rapidly aging population. The focus of chapter 1 is this paper particularly focuses on issues regarding acceptance of nurses and certified care workers under the scheme of Economic Partnership Agreements (EPAs) between Japan and Indonesia in 2008, as a new policy to import more foreign skilled workers into Japan. This chapter demonstrates the nation's passive attitude toward accepting foreign workers as well as the growing demand for more consistent immigration policy in terms of language. Chapter 2 discusses the validity and accountability of the current major influential assessment tool in Japan, Japanese Language Proficiency Test (JLPT). It includes a discussion of how linguistic `proficiency' is understood in the JLPT and reveals its problems, comparing JLPT with other influential measurement tools in the world such as the American Council on the Teaching Foreign Language-Oral Proficiency Interview (ACTFL-OPI) and the Common European Framework of Reference for languages (CEFR).

This thesis explores and analyses the manifold relations between migration and health, what I call the migration-health nexus, in the contemporary Nicaraguan context. The study is based on fieldwork in León and Cuatro Santos and a mixed-methods approach combining qualitative in-depth interviews and quantitative survey data. In the thesis health is “traced” within the migration process; i.e. in places of origin, during travel, at the destination and after return, including the situation and consequences for both migrants and family members to migrants (“left-behinds”). The study shows that migration-health relations in Nicaragua are connected to broader economic, social and political factors and to the country’s historical experiences of colonization, neo-colonization and structural adjustments. Contemporary Nicaraguan migrations are primarily related to the strategies of making a living and the struggle for a better life (i.e. a practice of mobile livelihoods). In the study setting health concerns were both indirectly embedded in people’s mobile livelihoods, as well as directly influencing decisions to move or to stay, and migration involved both advantages and disadvantages for health. Through migration, women could see an end to physical violence and sexual abuse. Internal migrants could improve their access to health care and medicine. Vulnerabilities related to the unpredictable nature conditions could be avoided through moving. And, through the money made from migrant work people’s everyday lives and health could be improved, in terms of better nutrition, housing, and access to education, health care and medicine. However, remittances do not necessarily lead to development, as they are used to compensate for the lacking public sector in Nicaragua. Under these circumstances, I argue that the Nicaraguan population is not guaranteed their social rights of citizenship. I also argue that the negative aspects surrounding migration must be taken into account when discussing the development potentials of migration and remittances. Both internal and international migrants in this study experienced stress while moving to a new place. International migrants had difficulties accessing health care in the destination, particularly those lacking documentation. The separation within families due to migration often caused emotional pain. Family members left behind did not rate their physical health as good as often as non-migrant families. The vulnerability, stress experiences and sufferings of migrants and left-behinds varied, however. I therefore conclude that social differences (in terms of e.g. gender, class, skin colour, and legal immigration status) are key for the enactment of the migration-health nexus, and that an interplay of individual, social and structural factors influence the outcome.

The case study of this thesis is the analysis of international health care students joined the emergency call of local authorities and performed emergency work during COVID-19 to help the Hungarian health care teams and facilities manage the pandemic. Through this case, the thesis puts an existing student interaction typology (Rose-Redwood and Rose-Redwood, 2013) to the test, and sets out to answer how the COVID-19-induced changes in their typology affected the students’ experience of being a migrant in Hungary. With semi-structured interviews and an inductive approach, the thesis identifies three recurring feelings – isolation, gratitude and responsibility – and the core argument of the thesis is that the feelings and migration experiences that the student shared were connected to the disruption of the student interaction typology. This study informs our understanding of student mobility and helps further research account for atypical situations in student mobility research.

Philosophiae Doctor - PhD (School of Public Health)
South Africa has an estimated two million documented and undocumented immigrants. In addition, Statistics South Africa (2014) notes very significant internal migration. This mobile population is affected by chronic communicable and non-communicable diseases such as TB, HIV, and diabetes, although it has a Constitutional right to health and healthcare. Their quality of healthcare and disease control also affects the general population and the burden on the health system can be increased by inadequately managed chronic conditions as well as acute health care needs. Access to healthcare and continuity of care reflect both patient agency and the health system. Community Health Workers (CHWs) play an important role in linking communities and patients to health services and vice versa. The aim of this study was to understand how agricultural migrants in the Cape Winelands District of Western Cape Province of South Africa navigated the healthcare system to access healthcare services including securing continuity of care, and in particular the role of CHWs in this process, in order to inform policy and practice.

China’s rural-urban migration has resulted in 61 million children living apart from their parent(s) in rural communities. Previous studies have failed to examine the long-term effects of parental migration on left-behind children’s nutritional health, and have not examined the gender differences (of parents and children) in those associations. This research uses a mixed-methods design that incorporates quantitative and qualitative techniques to explore links between parental migration, care-giving arrangements and left-behind children’s nutritional health in rural China. The quantitative analyses draw on a longitudinal dataset – the China Health and Nutrition Survey (CHNS) (1997, 2000, 2004, 2006, and 2009) to examine the relationships between children’s nutritional outcomes and different patterns of parental migration including being left behind in different stages of childhood, and being left behind by the father or the mother. The qualitative component consists of analyses of interviews with 32 caregivers (21 grandparents, 9 mothers, and 2 uncles/aunts), and children’s diaries (26 children aged 6-12, 21 left-behind children and 5 non-left-behind children) to explore the care-giving practices for left-behind children from the perspectives of a group of children and their caregivers in rural northern central China. Results of the quantitative analyses show negative associations between parental migration, especially maternal migration, and left-behind children’s nutritional outcomes indicated by anthropometric measures and macronutrient intakes, and this is particularly true for boys left behind during early life in rural China. The qualitative findings highlight the importance of socio-cultural factors, since there seems to be a paradox of intergenerational obligations for boys in a culture where sons are more valued than daughters. This is because parents migrate to save for their sons’ adult lives, reducing the remittances sent to support their sons who stay behind. There is less pressure to save for daughters’ adult lives and so more potential for remittances to support their nutrition. The research also recognizes the importance of grandparents as carers, and their experiences and beliefs about healthy eating for children. Grandparents, particularly on the paternal side, are expected to fulfil social obligations to care for left-behind grandchildren even without immediate financial returns. Inadequate financial support from the migrant parents of left-behind boys in rural China, in particular boys cared for by paternal grandparents, may result in greater risk of poor nutrition during the early childhood. This potentially renders such left-behind boys vulnerable to developmental delays. These findings are important for policy-makers to develop effective interventions to improve left-behind children’s nutritional well-being in rural China.

Migrant women are often omitted within the migrant discourse/research, with that in mind, the research study brings to the fore migrant women's experiences when accessing public health care services within underdeveloped communities. The study explored Zimbabwean migrant women's experiences in accessing public health care services in Makhado, a small town based in Limpopo, South Africa which has only two public health care services namely, Louis Trichardt Memorial Hospital and Louis Trichardt clinic. To conduct this study, ethical clearance was obtained in November 2018 from the Department of Sociology at the University of Cape Town. The qualitative research method was adopted in collecting the data. The study conducted in-depth interviews with five Zimbabwean migrant women who had made use of the two public health care services in Makhado. Field notes, diary entry, an impromptu focus group were used to collect the study data. The sample for the study was purposively selected. The study worked with a total of twelve participants, in-depth interviews with five Zimbabwean women, and a focus group with seven health care workers. The collected data was manually transcribed and was analyzed using the framework analysis. Main themes and sub-themes were extracted from the transcribed interview scripts. The study revealed that migrants accessing the two hospitals in Makhado faced challenges such as language barriers, discrimination, and adverse health personnel attitudes based on the patient's citizenship status. Furthermore, the challenges that nurses are faced within their workplace, which include lack of resources, absenteeism, long working hours and overcrowded public health care services within their workplace contributed towards their negative attitude in assisting patients. As a result, migrants bore the challenges faced by the nurses within the public health care services. Therefore, the migrants reverted to having other alternatives such as traditional healers, churches, connections with nurses working in the hospitals, private hospitals and over the counter medication. However, participants underscored that in order for betterment within the public health care services, the following measures ought to be implemented, these include the introduction of independent centres, an increase of mobile clinics, increased number of interpreters, better working environment for the health personnel within the public health care facilities and intensive education training of the health personnel around the awareness migrant issues when accessing public health care services. Foucault's (1980) theory on power and knowledge, played a significant role in understanding the operational systems of public health care services. It also assisted in understanding how public health care services function, to exclude and control migrant patients, through the introduction of fees and required documentation to access public health care services.

This research examined the health care related issues of the American seniors retiring in Mexico. Data for this study were collected through in-person questionnaire surveys and case studies. Findings of this study indicate that US seniors retiring in Mexico are predominantly non-Hispanic whites, married, and more likely to be college graduates. This study challenges the general perception that US seniors move to foreign countries is "amenity-led." The case studies clearly show that many US seniors move there because they are afraid that with reduced income and increased health care needs they would not be able to maintain the same lifestyle after retirement in the US. Climate and the slower pace of life are two other big attractions for seniors' to move to Mexico. A major finding of this study is age, gender, education, use of Medicare for medical care coverage, and chronic medical condition are significant predictors of US seniors' health behavior and health outcomes in Mexico. The policy implications of the findings have been discussed.

BACKGROUND: Millions of people have fled from their countries, due to war or conflict, in order to find a safer environment for themselves and their children. One common destination is Europe, which people can reach only through the sea from the Turkish coast to the Greek coast after walking hundreds of kilometers through the mountains. This long journey has a significant impact on refugee children’s health and that is primarily observed in the Greek islands were they can seek for emergency health care. The aim of this study is to investigate the reasons that the refugee children seek for emergency help in the hospital of Lesbos, Greece.   METHODS: Primary data collection from the medical records of the Pediatric department of the hospital of Lesbos. Statistical analysis of the data with R commander 3.2.1.The results will be presented in diagrams and tables, showing the most common symptoms/clinical findings, diagnoses, origin, gender, hospitalization or not of the refugee children and the relation of the symptoms and diagnoses in accordance with the seasonality, age, gender and origin calculated with Chi² and Chi² Fischer test.   RESULTS: Respiratory tract infections and gastro-intestinal tract infections are the first two most common diagnoses by far. Almost half of the refugee children that were submitted in the Hospital of Lesbos needed hospitalization and further treatment. More than half of the refugee children that sought after emergency help in the hospital of Lesbos were Syrians and boys. Mental health was also a big issue.   CONCLUSION: The journey that the refugee children are undertaking in order to reach the Greek islands and the prolonged living in refugee camps and detention centers is affecting their mental and physical health, with respiratory tract infections and gastro-intestinal tract infections being the major diagnoses.

Research demonstrates that perspectives of health and illness vary by social and cultural context. This has implications for the ways in which people experience and respond to health and illness and becomes particularly important when people face major social and cultural change through migration. This is explored in this study through the relationship between health and place. The location for the study is a Chinese community centre, in which the centre members are first generation migrants from Hong Kong, China and Vietnam, aged 50 and over, who have spent the larger part of their lives living in the UK. The study uses the concept of therapeutic landscapes as an analytical lens through which to explore understandings of health and illness, issues of identity and belonging, and practices of wellbeing as they are enacted outside of formal healthcare settings. As an ethnographic study, the primary means of data collection has been through participant observation. This included regular attendance at the community centre to participate in activities and events over a period of ten months from August 2013 to May 2014. Twenty one formal interviews were also conducted with members of the community centre, the majority in English, and several in Cantonese. The migration stories of the participants in the study are explored as gendered experiences; that is, that the men and women experienced, and spoke about, migration differently. For the women in particular, their experiences of migration were recalled as a time of profound loneliness and isolation. Understandings of health and illness among the centre members are also explored. A shared understanding of health as a holistic and collective concept was expressed. In particular, they spoke about maintaining a positive attitude in the face of difficulties, about their own health in terms of family and social relationships, and the importance of being together and being active. The choices that they make around the use of Chinese and/or biomedicine are also explored within the context of this understanding. The experiences of migration and the understandings of health and illness are further explored through a consideration of the everyday practices, and associated materialities, that constitute the day-to-day life of the centre. These are explored as ways of re-connecting with the past and maintaining a sense of identity, but also as ways of negotiating both continuity and change at the same time. The role of the community centre in the lives of its members, and the ways in which they interact with one another in this particular place, is approached through the concept of therapeutic landscapes. The day-to-day activities, and the ways in which the centre members participate in these are presented as everyday practices of care; as the enactment of a particular understanding of health and wellbeing that helps to create a sense of identity and belonging at the community centre, which in turn contributes to the health and wellbeing of the centre members.

During the latest decade Somali-born women with experiences of long-lasting war followed by migration have increasingly encountered Swedish maternity care, where antenatal care midwives are assigned to ask questions about exposure to violence. The overall aim in this thesis was to gain deeper understanding of Somali-born women’s wellbeing and needs during the parallel transitions of migration to Sweden and childbearing, focusing on maternity healthcare encounters and violence. Data were obtained from medical records (paper I), qualitative interviews with Somali-born women (II, III) and Swedish antenatal care midwives (IV). Descriptive statistics and thematic analysis were used. Compared to pregnancies of Swedish-born women, Somali-born women’s pregnancies demonstrated later booking and less visits to antenatal care, more maternal morbidity but less psychiatric treatment, less medical pain relief during delivery and more emergency caesarean sections and small-for-gestational-age infants (I). Political violence with broken societal structures before migration contributed to up-rootedness, limited healthcare and absent state-based support to women subjected to violence, which reinforced reliance on social networks, own endurance and faith in Somalia (II). After migration, sources of wellbeing were a pragmatic “moving-on” approach including faith and motherhood, combined with social coherence. Lawful rights for women were appreciated but could concurrently risk creating power tensions in partner relationships. Generally, the Somali-born women associated the midwife more with providing medical care than with overall wellbeing or concerns about violence, but new societal resources were parallel incorporated with known resources (III). Midwives strived for woman-centered approaches beyond ethnicity and culture in care encounters, with language, social gaps and divergent views on violence as potential barriers in violence inquiry. Somali-born women’s strength and contentment were highlighted, and ongoing violence seldom encountered according to the midwives experiences (IV). Pragmatism including “moving on” combined with support from family and social networks, indicate capability to cope with violence and migration-related stress. However, this must be balanced against potential unspoken needs at individual level in care encounters.With trustful relationships, optimized interaction and networking with local Somali communities and across professions, the antenatal midwife can have a “bridging-function” in balancing between dual societies and contribute to healthy transitions in the new society.

Syfte: Det övergripande syftet med denna licentiatavhandling är att beskriva resultat från en kartläggning av hälsosituationen hos nyanlända flyktingar som genomgår SFI studier samt att belysa den självskattade hälsorelaterade livskvalitet som arabisktalande deltagare i en specifik hälsofrämjande gruppaktivitet (Hälsoskola) beskriver före, efter samt vid en sexmånaders uppföljning av aktiviteten. Design, metod, urval: Urvalet deltagare i delstudie I var nyanlända arabisktalande flyktingar bosatta i Fosie stadsdel i Malmö och som deltog i SFI utbildning. Undersökningsgruppen bestod av sammanlagt 67 personer, 52 procent män och 48 procent kvinnor. Datainsamlingen genomfördes med hjälp av frågeformulär innehållande frågor om familj och anhöriga, nätverk och service, svenskundervisning och delaktighet, introduktion och hjälpbehov samt om sömn och återhämtning. I delstudie II bestod urvalet av arabisktalande nyanlända flyktingar som genomgick en sju veckors Hälsoskola som en del i sin introduktionsplanering. Dataunderlag bestod av kvalitativa data inhämtat vid deltagande observationer och muntliga grupputvärderingar med 65 kursdeltagare. Därutöver besvarades ett frågeformulär för självskattning av hälsorelaterad livskvalitet samt om sömn och återhämtning. Frågeformuläret besvarades vid kursstart, kursavslutning samt sex månader efter kursens slut. Respondenter i denna del var 39 kursdeltagare som besvarat samtliga tre frågeformulärsomgångar. Därutöver innehåller avhandlingen en artikel vars syfte är att beskriva kursen/metoden Hälsoskola, dess bakgrund och teoretiska kopplingar samt den samverkansprocess som utvecklats mellan professionella aktörer och brukare. Resultat: I delstudie I rapporterade respondenterna hög förekomst av sömn- och trötthetsbesvär. Sextioåtta procent av respondenterna hade sömnproblem motsvarande hälften av veckans dagar. Något färre 43 % rapporterade regelbundna besvär med sömnighet, till exempel att man nickade till under dagen. Fyrtioen procent (män 36 %, kvinnor 50 %) uppfyllde kraven för klinisk insomni baserat på att respondenterna hade både sömnbesvär och trötthetsbesvär under minst hälften av veckans dagar. Därutöver upplevde drygt 80 % av samtliga stor oro över sin familj eller andra anhöriga i hemlandet. Många kände sig isolerade och ensamma, hade svårt att få kontakter med föreningsliv, få tillgång till platser för kulturella aktiviteter, för religionsutövning och för sportaktivitet. Många upplevde också svårighet att få tillgång till hälso- och sjukvård samt tandvård. I utbildningssituationen upplevde drygt hälften stora svårigheter att förstå vad läraren sade och 68 % hade svårt att hinna med i tempot på lektioner. Drygt 64 % rapporterade koncentrationssvårigheter, de hade problem att förstå hemuppgifter liksom att kunna göra hemuppgifter i lugn miljö. För många respondenter rådde oklarhet om introduktionsplanen och cirka hälften av dem hade velat få mera hjälp av sin introduktionshandläggare med läkar- och sjukvårdskontakter samt med sin bostadssituation. I den kvalitativa delen av delstudie II vars syfte var att belysa de viktigaste frågorna från deltagarnas synvinkel, utkristalliserade sig fyra kategorier: 1) Fördjupningsfrågor beträffande innehåll i kursen/Hälsoskolan. 2) Kommentarer angående form och struktur på kursen/Hälsoskolan. 3) Vilka av kursdeltagarnas ”behovsområden” som kursen/Hälsoskolan täcker in och vilka områden som saknas? 4) Vad kursdeltagarna önskar få framfört till administratörer, beslutsfattare och politiker. I den kvantitativa uppföljningsstudien framkom att deltagarna upplevde en hög grad av sömn och koncentrationsproblematik vid kursstart. Denna problematik var betydligt mindre vid kursens avslutning och förändringen kvarstod vid uppföljning sex månader senare. Det framkom även att sömnproblematik var relaterad till de fem variablerna av hälsorelaterad livskvalitet;( rörlighet, aktivitet, egenvård, smärta och oro/depression) och till upplevelsen av det allmänna hälsotillståndet. Angående variablerna smärta och oro/depression kvarstod en signifikant förändring både vid uppföljning ett och vid uppföljning två sex månader efter kursavslut. Både män och kvinnor bedömde sitt allmänna hälsotillstånd som signifikant bättre vid båda uppföljningarna jämfört med vid kursstart, men förändringen var störst beträffande kvinnorna. Konklusion: De sammantagna resultaten visar att det finns en hög fysisk och psykisk ohälsoproblematik i den undersökta populationen med avseende på deras självskattade hälsa. Denna problematik har ett nära samband med sömn och koncentrationsproblem och får även konsekvenser för de nyanländas dagliga aktiviteter och etablering i det nya samhället. Det framkommer ett stort behov av hjälp från hälso- och sjukvården men också en brist på tillit till detsamma, bland annat beroende på svårtillgänglighet och brist på professionella tolkar. Å andra sidan visar resultaten i denna licentiatavhandling att mottagningssystemet med noga överlagda insatser kan åstadkomma betydande positiva förändringar för gruppen nyanlända flyktingar. Den självupplevda hälsorelaterade livskvaliteten för deltagare i kursen Hälsoskola visade på signifikanta förändringar inom de undersökta aspekterna för gruppen som helhet vid kursslut och vid senare uppföljning. De reella faktiska kunskaperna inom egenvård och om det svenska hälso- och sjukvårdssystemet hade ökat betydligt vid kursavslut. Nämnda effekter kan även få positiva följdverkningar för nästa generation och andra personer i kursdeltagarnas nära omgivning.
Aim: The overall aim of this thesis is to describe the results of a survey of the health situation of newly-arrived refugees attending a course in Swedish for Immigrants (SFI) (study I) and elucidate the self-rated health-related quality of life that Arabic-speaking participants in a spe-cific health-promoting group activity (Health School) report before, immediately after and at a six-month follow-up of that activity (study II). Design, method, sample: The sample in study I comprised newly-arrived Arabic-speaking refugees living in the Malmö district of Fosie who were attending a SFI course. A total of 67 persons participated, 52 per cent men, 48 per cent women. Data were collected with the aid of a questionnaire with both open-ended and closed alternative responses about family and relatives, networks and services, Swedish language lessons and participation, introduction and needs, sleep and recovery. In study II the sample comprised newly-arrived Arabic-speaking refu-gees who attended a seven-week Health School as a part of their intro-ductory planning. The study was based on qualitative data obtained by participatory observation and oral group evaluations with 65 course participants. In addition, we used a questionnaire with closed response alternatives for self-rating health-related quality of life, including sleep and recovery. The questionnaire was administered at the beginning and end of the group activity as well as six months after the end. This sam-ple comprised 39 participants in the group activity who responded to the questionnaire on all three occasions. Furthermore, the thesis contains an article describing the Health School group activity/method, its background and theoretical links, as well as the collaborative process that developed between professionals and re-cipients. Results: The respondents in study I reported a high frequency of sleep- and fatigue-related complaints. Sleep disturbances on the equivalent of every other day were reported by 68 per cent and somewhat fewer, 43 per cent, reported regular problems with drowsiness, for instance drop-ping off during the day. Criteria for clinical insomnia were met by 41 per cent (36 per cent of the men, 50 per cent of the women), based on the combination of sleep disturbance and complaints of fatigue at least every other day. In addition, over 80 per cent of the sample experienced great anxiety about their family or other relatives in their home country. Many felt isolated and lonely, found it hard to get in touch with associations, have access to places for cultural activities, practicing religion and participating in sports. Many also experienced difficulties in gaining access to health care and dental care. In the educational situation (SFI), more than half had great difficulty in understanding what the teacher said and 68 per cent found it hard to keep up with the pace of the lessons. More than 64 per cent reported difficulties with concentration, problems with understanding homework and being able to do homework in a calm environment. Many respondents were uncertain about the introductory plan and roughly half had wanted their introductory officer to be more helpful in contacts with health care, including doctors, and housing matters. The qualitative part of study II, which aimed to elucidate the most im-portant issues according to the participants, gave rise to four categories: 1) More in-depth issues concerning the content of the group activi-ty/Health School, 2) Comments on the form and structure of the group activity/Health School, 3) Which of the participants’ “needs” were cov-ered by and which were missing, and 4) What the participants wanted to convey to administrators, decision-makers and politicians. The quantitative follow-up study showed that when the group activity started, the participants experienced a high degree of problems with sleep and concentration. Such problems were considerably less frequent at the end of the activity and this change persisted six months later. Moreover, the sleep disturbances were related both to the five variables of the health-related quality of life (mobility, activity, self-care, pain and anxiety/depression) and to the perception of general health. The variables pain and anxiety/depression showed significant improvements at the end of the activity as well as six months later. Men as well as women rated their general health as significantly improved at both follow-ups compared with baseline; the change was greatest for women. Conclusions: Taken together, the results show that in terms of self-rated health, the studied population has a high degree of problems with physical and mental ill-health. These problems are closely related to problems with sleep and concentration, besides having consequences for the newly-arrived persons’ daily activities and for settling in the host country. A great need of assistance from health care emerges, as well as a lack of trust in this, partly due to difficulty of access and a lack of professional interpreters. At the same time, the findings in this thesis show that the reception sys-tem with evidence-based inputs can achieve considerable positive changes for newly-arrived refugees. The self-rated health-related quality of life for participants in the group activity/Health School showed that for the group as a whole, the studied aspects had improved significantly both by the end of the activity and at the six-month follow-up. Proper actual knowledge about self-care and the Swedish health care system had increased significantly by the end of the activity. These effects can also have positive consequences for the next generation and others close to the participant. The group activity needs to be tested with other language groups of newly-arrived in order to warrant general conclusions.

The aim of this study is to gain an understanding of how experiences of sexual-health counseling and sex education are described by young Somali women in Sweden. Further the study aims at finding the best practices when it comes to offering sexual-health counseling in a multiethnic setting; in respect of, what should be communicated, where, how and by whom sex education and counseling should be given.Previous studies indicate that young immigrant women have less access to sexual health-care services. Discussing sexual matters is traditionally taboo among Somalis and a girl who gets pregnant before marriage runs the risk of being excluded from the Somali community. Therefore issues on sexual health are of utmost importance for the well-being of this group.Data were conducted through focus-group discussions and interviews with twelve young Somali women in Sweden. The women’s experiences showed that access to sexual health care services is limited by traditional values demanding chastity and modesty in women. School is perceived as the best place for discussing sexual-health matters. However most participants considered the sex education they received in school to be poor. Participants reported that sex and related attitudes, sexual consequences (from a medical as well as a social perspective) and female circumcision are issues that need to be addressed. The youngest women also expressed a need to understand and address the conflicting sexual norms adolescents have to deal with in a more religious and culturally diverse setting.

Dissertação de Mestrado em Sociedade, Risco e Saúde
O presente estudo teve como objectivo aprofundar conhecimento sobre algumas das dificuldades sentidas por mulheres brasileiras residentes na região de Lisboa, no tocante ao acesso a cuidados de saúde. De dentre essas dificuldades e com base em conversas informais avulsas e anterior ao estudo, procurou identificar-se a existência (ou não) de representações (por parte das inquiridas) de experiencia de discriminação no acesso a cuidados de saúde em estruturas de saúde pública. A pesquisa foi sustentada numa abordagem qualitativa e foram utilizados como principais instrumentos de recolha de dados as entrevistas semiestruturadas, para que as participantes pudessem relatar as suas práticas e os seus entendimentos referentes à migração e saúde, assim como algumas das dificuldades mais sentidas. Utilizou-se também a técnica da análise de conteúdo para melhor compreender estes relatos. Apesar do pequeno número de entrevistas, a análise dos dados sugere que as maiores dificuldades sentidas por estas mulheres, mais do que ligadas a situações de discriminação, dizem respeito à forte burocracia e à negligência.
The present study aimed to deepen knowledge about some of the difficulties experienced by Brazilian women living in the city of Lisbon, regarding access to health care. Among these difficulties and based on individual informal conversations and prior to the study about the existence (or not) of representations (on the part of respondents) of experience of discrimination in access to health care in public health structure. The research was supported by a qualitative approach and semi-structured interviews were used as the main data collection instruments, so that the participants could report their practices and understandings regarding migration and health, as well as some of the most felt difficulties. The content analysis technique was also used to better understand these reports. Despite the small number of interviews, the analysis of the data suggests that the greatest difficulties experienced by these women, more than linked to situations of discrimination, concern the heavy bureaucracy and neglect.
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Substance abuse and suicidal behaviour are major challenges to public health. These phenomena are mainly studied by quantitative designs. This qualitative thesis aims at gaining a deeper understanding of substance abuse and suicidal behaviour, as experienced by young men in different types of treatment. By describing, exploring and interpreting lived experiences, in this thesis I try to give a more nuanced language of both substance abuse and suicidal behaviour, also in young migrating men. I also focus on the system of services related to the prevention and follow-up of life-threatening overdoses by describing and exploring how this phenomenon is experienced by individuals and professionals in Oslo. By researching the lived experiences of substance abuse and suicidal behaviour, combined with researching the phenomenon of life-threatening overdoses, a deeper insight is gained and this can be an important source to both prevention and health promotion for the group in question. The first three papers are based on descriptive, explorative and interpretative studies. How meaning is constructed is the core research question. In the fourth study I describe and explore life-threatening overdoses as a contemporary phenomenon in its context. The research questions are on a descriptive level. In the first three papers, the research object is the personal narratives from in-depth interviews, which are analysed using a phenomenological hermeneutic method. The case study is composed of data collected from different sources, and analysed by triangulation. The main finding in the first paper is that substance abuse and suicidal behaviour can be understood as goal-oriented, communicative and meaning-making activities about the individuals’ balance between death as an escape from pain and the hope of a life. In the second study, metaphorical expressions about a shifting sense of self is understood as balancing being an agent or a victim. In migrating young men these phenomena are interpreted as goal-oriented, communicative and meanig-making activities about existing in a maze that is perceived as closed. The findings of the case study show that different forms of life-threatening overdoses in Oslo are experienced in a state of existential and material stress. A wish of follow-up might not be expressed by the individual. Due to structural problems, such as lack of goals, professionals do not prevent such events in a planned way, nor do they cooperate between different levels. Professionals decide what is good quality in prevention and follow-up of life-threatening overdoses
Rusavhengighet og selvmordsadferd representerer store folkehelseproblemer. Disse fenomenene er hovedsakelig studert med kvantitative design. Målet med denne kvalitative avhandlingen er å få dypere kunnskap om rusavhengighet og selvmordsadferd slik fenomenene er opplevd av yngre menn i ulike typer behandling. Gjennom å beskrive, undersøke og tolke levde opplevelser forsøker avhandlingen å få fram en mer nyansert forståelse av, og språk om, både rusavhengighet og selvmordsadferd, også hos yngre menn med migrasjonserfaring. Avhandlingen fokuserer systemnivået gjennom å beskrive og undersøke hvordan livstruende overdoser oppleves og erfares som levde erfaringer og som yrkesutfordring i Oslo. Et omverdensperspektiv, kombinert med en dypere forståelse og et rikere språk kan være viktige bidrag til forebyggende og helsefremmende tiltak. Det første, andre og tredje arbeidet i avhandlingen er beskrivende, undersøkende og tolkende studier som fokuser yngre menns levde erfaringer med rusavhengighet og selvmordsadferd. Hvordan mening konstrueres er det sentrale forskningsspørsmålet. Det fjerde arbeidet, case studien, undersøker livstruende overdoser i en nå-tidig kontekst, og forskningsspørsmålene er beskrivende. I de første tre arbeidene er forskningsobjektet personlige narrativer samlet gjennom åpne dybdeintervjuer, og som er tolket ved bruk av en fenomenologisk hermeneutisk analyse. I case studien er data fra ulike kilder analysert ved hjelp av triangulering. Hovedfunnet i den første studien er at rusavhengighet og selvmordsadferd kan forstås som måltettede, kommunikative og meningsfulle handlinger om personens balanse mellom døden som befrielse fra smerte og håpet om et bedre liv. I den andre studien kommer metaforiske beskrivelser av en skiftende opplevelse av seg selv i prosessene knyttet til både rusavhengighet og selvmordsadferd tydelig fram. Dette kan forstås som å balansere en selvopplevelse mellom aktør og offer. I den tredje studien kan rusavhengighet og selvmordsadferd hos migrerte menn forstås som målrettede, kommunikative og meningsfulle handlinger om personens opplevelse av å eksistere i en stengt labyrint. Funnene i case studien tyder på at livstruende overdoser i Oslo erfares i eksistensielt stressfulle omstendigheter. Et personlig ønske om oppfølging gis ikke alltid eksplisitt. Strukturelle problemer medfører at profesjonelle arbeider med livstruende overdoser uten overordnete mål og uten samordnet planlegging. Profesjonelle bestemmer derfor selv hva som er god kvalitet når det gjelder forebygging og oppfølging av livstruende overdoser

Ce travail de recherche s’inscrit dans le cadre de la psychosociologie, de la microsociologie et de l’anthropologie sociale. Nous envisageons l’étude des liens sociaux développés au sein du collectif des prostituées transgenre migrantes d’Amérique du Sud dans la ville de Paris. Pour ce faire, nous devrons penser l’organisation sociale dans leurs pays d’origine ainsi que leurs trajectoires de migration. La subjectivité des personnes transgenre migrantes sera étudiée à différents niveaux : individuel, groupal et communautaire. Nous nous sommes ainsi servis de plusieurs catégories d’analyse comme la classe, la migration, la race, l’ethnie, etc. Nous considérons que l’adoption d’une identité de genre qui ne coïncide pas avec le genre attribué à la naissance mène les personnes transgenre à une place de stigmatisation sociale. En France, nous étudierons le passage du milieu de la prostitution au travail associatif. Nous cherchons à comprendre comment, à partir d’une proposition biopolitique précise de la part des pouvoirs publics (VIH), les acteurs sociaux vont négocier au niveau local une existence sociale possible, en-dehors du statut de « malade ». Cela nous conduira à des réflexions sur le changement du rôle de l’État et des acteurs sociaux à partir de la subjectivité moderne et contemporaine
This research follows the principles of psychosociology, microsociology and social anthropology. It studies social bonds in communities of migrant transgender prostitutes from South America in Paris. In order to do that, we will start analyzing their social organization in their country of origins, and their migration trajectories. We will think three-level analysis for transgender migrant subjectivity : individual, groupal and community. We will also consider different categories such as class, migration, race, ethnicity, etc. We consider that assuming a gender identity different from the one assigned on birth implies for people a stigmatised social existence. In France, we are going to analyse the transition between two professional identities : from prostitution to self-help organizations. We are looking forward to understand how, following a biopolitical proposition from french government related to HIV, subjects try to negotiate in a local level, different identities beyond the « sick » labelling. This analysis will teach us the historical transitions between State and individual roles in modern and contemporary subjectivity

Mayotte département d’outre-mer français depuis 2011, fait partie de l’archipel des Comores ; elle est séparée des îles de l’État de l’Union des Comores depuis 1975. L’instauration d’un visa en 1995 et l’ordonnance n° 2002-688 du 12 juillet 2004 entréeen vigueur le 1er avril 2005 relative à l’extension de la sécurité sociale à Mayotte exclut les malades étrangers du système de santé mahorais. Ceci entraine des processus d’évacuation sanitaire par la voie d’une immigration clandestine qui provoque des naufrages et des violations des droits du patient. L’attrait de Mayotte et de la France métropolitaine pour les populations défavorisées occasionne des situations de conflits et de concurrence pour l’accès à la protection sanitaire et sociale. Les populations défavorisées de Mayotte, qui se battent pour combler leur retard par rapport à la métropole, vivent mal cette concurrence ; tandis que les populations immigrées vivant dans la clandestinité et sous la menace d’une expulsion imminente, rencontrent des difficultés pour faire valoir leur droit aux soins et au bénéfice à l’assistance du système social. Les obstacles sont nombreux et souvent considérables, dus notamment à la discrimination, à une disparité de difficultés sociales et économiques et à leurs conditions de vie généralement très difficiles. La maîtrise des flux migratoires et la lutte contre l’immigration irrégulière demeurent des priorités de la politique du gouvernement français en matière d’immigration. Laspécificité de la situation du département de Mayotte ainsi que l’importance des flux migratoires qui y sont constatés ont conduit les autorités sanitaires à gérer les flux migratoires liés aux évacuations sanitaires par la voie illégale. La France mène une politique sanitaire en continuant de soutenir l’Union des Comores dans l’amélioration de l’accessibilité et de laqualité des soins, à travers les programmes d’appui au secteur de la santé. Ces programmes auront pour finalité l’amélioration de la santé des mères et des enfants, notamment la réduction des mortalités maternelle et néonatale. La France à travers son organisme Agence française de développement (AFD) entend appuyer le ministère de la Santé dans l’élaboration et la mise en oeuvre des politiques publiques et contribuer au renforcement du cadre institutionnel et juridique du secteur. Il s’agira notamment d’appuyer l’État comorien dans la mise en place de mécanismes de régulation du service privé dans le secteur public et de réformer la pharmacie nationale. Cette recherche pointe les enjeux liés au droit de la protection sociale et au droit de la santé des étrangers sur le territoire national, aussi bien en France métropolitaine qu’à Mayotte. La diversité des droits nationaux applicables à Mayotte constitue une entrave sérieuse face aux dispositifs locaux relatifs à l'accompagnement sanitaire et social. Il est donc indispensable de chercher des solutions juridiques relatives à l’uniformisation de ce droit sanitaire et social afin d’améliorer le système de santé. Les résultats de cette recherche ont montré que les dispositifs locaux tels que le « bon rose » et le « bon AGD » ne sont pas du tout équivalents aux dispositifs nationaux (l'AME et la CMUc)
Mayotte a French overseas department since 2011, is part of the comorian archipelago from which it was separated from the State of Union of the Comoros islands since 1975. The introduction of a visa in 1995 and the order n° 2002-688 delivered on 12 july 2004 and entered into force on April 1st 2005 with regard to the extension of social security in Mayotte exclude the foreign sick from Mayotte's health system. This leads to a process of medical evacuation following an illegal immigration way that causes shipwrecks and the violation of the patient's rights. The attraction of Mayotte and Mainland France for disadvantaged populations lead to conflict situations and competition in the access to health and social protection. Mayotte's disadvantaged populations, who are struggling to catch up with the mainland, do not get along with that competition. At the same time the illegal immigrants living clandestinely and with the threat of expulsion are facing difficulties to assert their right to health care and to benefit from social system assistance. Obstacles are numerous and most of the time considerable, mainly because of discrimination, because of their judicial status, of disparity in their social and economical difficulties and because of their generaly very hard living conditions. The control of migratory flow and the fight against illegal immigrant remain the top priorities of the French government policy as far as immigration is concerned. The singularity of the situation in the department of Mayotte and the huge migratory flows that have been observed led healthcare authorities to handle migratory movements related to illegal medical evacuations. France has a healthcare policy and continues to support the Union of Comoros in the effort to improve healthcare access and quality, through support programs to health sector. These programs aim at improving the health of mothers and children, mainly in reducing maternal mortality. Through its organisation AFD, France aims at supporting health ministry in elaborating and implementing public policies and helping comorian state to put in place regulatory mechanisms of a private service within public sector and to reform the national pharmacy. This work focus on the issues related to the right to social protection and the health law for foreigners on the national territory, in mainland France and in Mayotte as well. Diversity of national laws applicable in Mayotte is a significant barrier to local devices in terms of medical and social assistance. It is necessary to seek legal solutions related to standardization of this health and social law in order to better the healthcare system. During our field research we observed that local devices such as the "pink warrant" and the "good AGD" are not at all equivalent to the national devices (AME and CMUc)

The global shortage of human resources for health and the brain drain of health care professionals exacerbate health care challenges in many small and medium sized economies, including efforts to curb the HIV/AIDS pandemic. This research investigated attitudes, perceptions, and dynamics among health care students and professionals in Thailand related to human resources for health, migration, inequitable distribution between rural and urban areas as well as between the public and private sector, and influences on migration ambitions. This included contemporary social and political parameters. Perceptions and attitudes among health care students and professionals were explored through a questionnaire survey and semi-structured interviews with health care professionals. Additional interviews with key-informants encapsulated contemporary events, dynamics, adversities, and challenges specific to the Thai context. It is argued that both the right to health care and health care professionals’ right to free movement must be protected and upheld. This research adds to the knowledge and insight into the specific health care challenges in Thailand and reflections upon the sustainability of the health care system; both in light of these health care challenges and the principles of sustainability as proposed by The World Commission on Environment and Development, the Brundtland Report (1990). It will enhance the scope from which health care, manpower expansion, and reform is pursued. Any approach to stem the exodus of health care professionals must recognise the rights of all stakeholders, including health care professionals and health care consumers, and all stakeholders must be engaged in the pursuit of sustainable health care through the principles of sustainable development and global sustainability.

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Para explorar as necessidades, o acesso e a utilização dos serviços de saúde dos emigrantes valadarenses nos EUA e em Governador Valadares, assim como a influência desta demanda na oferta de serviços de saúde na cidade mineira, o presente estudo adotou três linhas de investigação. A primeira relacionou a percepção dos emigrantes da amostra, a respeito dos profissionais e dos serviços de saúde utilizados nos EUA e em Governador Valadares. A segunda concentrou-se na percepção dos profissionais de saúde selecionados a respeito das características da demanda do emigrante, assim como da sua influência na oferta de serviços de saúde em Valadares. A última, uma pesquisa documental na Vigilância Sanitária, contabilizou as aberturas anuais de serviços de saúde da localidade. As informações recolhidas junto aos emigrantes valadarenses permitem afirmar a viabilidade do acesso e da utilização dos serviços de saúde subsidiados pelos governos federal, estaduais e municipais nos Estados de Massachusetts e em Connecticut, onde se concentram mais da metade dos valadarenses residentes nos EUA. Seja pelas restrições governamentais ao acesso aos serviços de saúde norte-americanos, pelo custo da assistência em saúde nos EUA, ou mesmo por fatores culturais, o emigrante valadarense, ao retornar ou visitar a cidade de origem, busca os profissionais e os serviços de saúde da localidade. A análise da pesquisa documental, com as informações acerca da abertura de serviços privados de saúde e das entrevistas com os profissionais da área da cidade, revelou a existência de uma relação entre a demanda do emigrante e o crescimento de abertura de serviços privados de saúde ocorrida a partir da segunda metade da década de 90.
In order to examine the needs, the access and the use of health services available to Valadares emigrants in the USA and in the city of Governador Valadares, as well as the influence this demand has on the offer of health services in that Minas town, three investigative lines were adopted in this study. The first looks into the relation between the perception the sample has of the health professionals and services used both in the USA and in Governador Valadares. The second focuses on the perception the selected health professionals have of the characteristics of the demands of emigrants, as well as their influence on health services in Governador Valadares. The last, a documental research with the Vigilância Sanitária - Department of Health and Human Services, shows how many health service facilities are opened in that location annually. The information gathered with the Valadares emigrants, allows us to state that the access and use of health services subsidized by federal, state and city governments in the states of Massachusetts and Connecticut - where over half the Valadares emigrants in the USA reside - is viable. Whether it is due to government restrictions to access American health services or the cost of health care in the USA, or even because of cultural factors, when returning to or visiting their town of origin, the Valadares emigrants seek local health services and professionals. The analysis of the documental research on the opening of private health facilities, as well as interviews with professionals from that part of town, have revealed a relationship between the emigrants´ demand and an increase in the opening of private health facilities as of the second half of the 90´s.

Magister Human Ecology - MHE
Forced migration is a serious problem worldwide and it is always associated with political, ethnic or violent conflict accompanied by intensive human rights abuses. Africa has the largest number of refugees (more than 15 million) compared to other regions. Many Africans are forced to abandon their homes and go into exile because of ethnic conflicts, civil wars and ongoing violence which in turn cause millions of refugees to be separated from their families and loved ones. The aim of this study was to explore the experiences of refugees in the Western Cape province with regard to their integration into the society. The objectives of the study were (1) to explore the experiences of refugees in the Western Cape, South Africa; (2) to explore the link between their experiences and integration into the South African society. This research employed an exploratory study design that was conducted qualitatively. Semi-structured interviews with refugees were conducted with the aim of understanding personal experiences and challenges that refugees face. The population of the study was refugees who visited two of the refugee centres in Cape Town. A purposive sampling method was used. A total of ten refugees were interviewed and a questionnaire was used to collect the demographic characteristics of the participants. Data was analyzed by thematic analysis method where the data was coded and categorized and discussed according to the aims and objectives of the study in relation to previous studies. The major themes identified were employment and financial independence, education, health, language, culture, emotional sustainability, support and xenophobia. The results of the study were made available to refugees and the centres participating in the study. The main findings were that most refugees are educated and have skills and relevant work experience yet they feel dissatisfied in their current work place because they are underutilized and not using their skills optimally. Emotional sustainability and integration is often challenged and refugees rely on spiritual faith to face their hardships. Issues of cultural differences and language gaps contribute to the lack of well being. Accessing treatment in public health care facilities was described as inadequate by refugees. Xenophobia contributes to the problems of integration. Participants felt to some extent their difficulties could be reduced if proper intervention could be made by the government in terms of support. The main recommendations resulting from the research were 1) government and non governmental institutions should work together to improve services delivery to refugees for integration purposes; 2) policy intervention is needed from the government to address the problems of refugees and 3) nongovernmental organizations should extend their services to community development to improve the interaction of refugees in adopted countries.

This thesis provides an ethnography and critical phenomenology of undocumentedness in the Swedish context. By attending to the forces and processes that circumscribe the life-worlds of undocumented persons, as well as the phenomenology and essential experiences of their condition, a complex and multi-layered illustration of what undocumentedness is and means is successively presented. Employing a dual conceptualization of the state, as a juridico-political construct as well as a practiced and embodied set of institutions, the undocumented position emerges as a legal category defined only through omission, produced and reproduced through administrative routine and practice. The health care sector provides empirical examples of state-undocumented interaction where the physical and corporeal presence of the officially absent becomes irrefutable. This research suggests that the Swedish welfare state – universalistic, comprehensive and with digitized administrative routines – becomes a particularly austere environment in which to be undocumented. Drawing on interviews with regional and local health care administrators, NGO-clinics’ representatives and health professionals, as well as extensive participatory observation and interviews with undocumented persons, I argue that the undocumented condition is characterized by simultaneous absence and presence, and a correspondingly paradoxical spatiality. I suggest that the official absence and deportability of undocumented persons deprives them of the capacity to define space and, in an Arendtian sense, appear as themselves to others. There are, however, some opportunities for embodied political protest and dissensus. The paradoxical qualities of the absent-present condition manipulate the undocumented mode of being-in-the-world and I argue that alienation and disorientation are essential experiences of the undocumented situation.

INTRODUÇÃO: A hanseníase é uma doença infecciosa crônica granulomatosa, cujo agente etiológico é uma bactéria de vida intracelular obrigatória, o Mycobacterium leprae, que tem no homem seu principal reservatório. A doença possui distribuição universal, predominando atualmente, em latitudes tropicais e tem sido enquadrada entre as enfermidades negligenciadas, atingindo desproporcionalmente populações pobres e marginalizadas. O bacilo é altamente contagioso, de baixa patogenicidade e acomete primordialmente pele e nervos, com grande potencial incapacitante. A doença grassou no Velho Mundo durante a Idade Média e praticamente desapareceu da Europa ainda no início do século XX, antes que qualquer recurso terapêutico eficaz estivesse disponível. Introduzida com os primeiros colonizadores europeus, a hanseníase é doença endêmica no Brasil e um problema de saúde pública. A hanseníase é hiperendêmica em muitos municípios, notadamente nos estados das regiões Norte e Centro-Oeste, que abrangem biomas de cerrado, pântano e floresta amazônica, em vastas áreas de baixa densidade demográfica; estas áreas vêm sofrendo enorme pressão antrópica relacionada ao incremento de atividades agropecuárias e extrativistas, gerando preocupações em relação ao impacto ambiental sobre a saúde humana, decorrente de transformações na dinâmica territorial. OBJETIVO: O propósito desta pesquisa foi conhecer o efeito ecológico de fatores sociodemográficos na delimitação de espaços endêmicos de hanseníase e gerar hipóteses sobre a relação entre a constituição do território e a exposição ambiental ao agente biológico da doença. MATERIAL E MÉTODOS: Supondo que a variação dos fatores de risco para contrair hanseníase pudesse ser maior entre grupos populacionais do que entre indivíduos, foi empreendido um estudo epidemiológico de delineamento ecológico do tipo grupo múltiplo, envolvendo 203 municípios dos estados do Mato Grosso e Mato Grosso do Sul, que estão localizados na região Centro-Oeste do Brasil. Foram constituídas variáveis sociodemográficas de exposição e a variável de efeito foi representada pela taxa de detecção média anual de hanseníase entre os anos de 2000 e 2006. Foram aproveitados dados secundários provenientes do Instituto Brasileiro de Geografia e Estatística e do Ministério da Saúde. Para compor um modelo multivariado, 14 variáveis foram analisadas por regressão linear simples e selecionadas sete variáveis com probabilidade de p < 0,2 para o coeficiente de inclinação da reta de regressão. As variáveis independentes selecionadas foram passo a passo testadas, simultaneamente e analisada a associação da variável dependente, visando o ajuste de um modelo singular da variabilidade da taxa de detecção de hanseníase. RESULTADOS: As variáveis que restaram no modelo após o processo de ajuste foram: Proporção da população moradora em domicílios com seis ou mais pessoas; Proporção da população não natural do estado; e, Cobertura populacional da estratégia de Atenção Saúde da Família. Estas variáveis juntas explicam 24,1% da variação nas taxas de detecção de hanseníase. CONCLUSÕES: Fatores sociodemográficos representam um importante domínio na epidemiologia da doença. A associação positiva do desfecho com a cobertura da estratégia de Atenção Saúde da Família indica que deve haver melhora no acesso ao diagnóstico mediante a implantação de modelos de Atenção Primária à Saúde baseados em racionalidades preventivas. Doentes poderiam ter sua contagiosidade interrompida mais precocemente, uma vez melhorada a capacidade diagnóstica dos serviços de saúde. Como recomendação para melhorar o acesso ao diagnóstico nas áreas endêmicas, a adoção da estratégia de Atenção Saúde da Família deve ser encorajada. Aglomeração domiciliar como variável ecológica foi interpretada como sendo um indicador socioeconômico indireto, mais do que propriamente relacionada às condições de contato. A qualidade da moradia, talvez seja mais importante para controle da endemia, tanto quanto possa vir acompanhada de melhorias gerais no padrão de vida. Reservatórios do M. leprae constituídos por indivíduos que eliminam bacilos cronicamente são os que perpetuam a endemia, embora possam, em tese, serem suplementados por fontes secundárias representadas por portadores transitórios. Fatores ligados à formação da fronteira agrícola e à urbanização brasileira podem ter fomentado a endemia de hanseníase, ao predisporem a renovação de susceptíveis pelas migrações, que modificam a composição populacional quanto à experiência de contato com o bacilo. Migrações poderiam romper os focos de hanseníase que estivessem saturados de indivíduos resistentes ao redistribuir espacialmente a população susceptível, levar infectantes para áreas indenes ou instalar as premissas biológicas e territoriais para tornar o contágio recorrente na população, mesmo que o contingente demográfico proveniente de imigrações não seja predominantemente mais vulnerável à doença. Tecnicização rural e constrições na esfera do trabalho têm movimentado populações que procuram refúgio nas periferias das cidades, caracterizadas por escassa infraestrutura urbana e rápido crescimento demográfico, supostamente continentes de grupos humanos dotados de diferentes perfis de resistência ao M. leprae. O circuito inferior da economia, uma resposta social à escassez de meios de vida e um traço da territorialização brasileira, tem oferecido os predicados espaciais para a persistência da endemia de hanseníase nos bolsões de pobreza urbana, ao gerar uma multiplicidade de contatos em proximidade e alimentar suas relações sociais de uma massa de recém-chegados do campo e da cidade, sua principal e mais abundante variável. Se a geografia estuda as condições de vida sobre a terra, estes resultados sugerem que a topografia médica, para além da descrição dos aspectos demográficos e socioeconômicos dos lugares de surgimento de doenças, pode contribuir em muito ao conhecimento em saúde, ao considerar analisar tais fatores enquanto potenciais condicionantes de endemias
BACKGROUND: Leprosy is a chronic granulomatous infectious disease whose causative agent is an obligate intracellular bacterium of life, Mycobacterium leprae, which has its main reservoir in man. The disease has a worldwide distribution, currently prevailing in tropical latitudes and has been framed between neglected diseases, disproportionately affecting poor and marginalized populations. The bacillus is highly contagious, and low pathogenic primarily affects the skin and nerves, with great potential crippling. The disease raged in the Old World during the Middle Ages and still practically disappeared from Europe in the early twentieth century, before any effective therapeutic resource was available. Introduced with the first European settlers, leprosy is endemic in Brazil and a public health problem. Leprosy is hyperendemic in many cities, especially in the states of North and Midwest, covering biomes savannah, swamp and rainforest, in vast areas of low population density; these areas have suffered huge human pressure related to increased activity agricultural and extractive, generating concerns about the environmental impact on human health, due to dynamic changes in territorial. OBJECTIVE: The purpose of this research was to understand the ecological effect of sociodemographic factors in the delimitation of leprosy-endemic areas and generating concerns about the relationship between the constitution of the territory and environmental exposure to the biological agent of the disease. MATERIAL AND METHODS: Assuming that the variation of the risk factors for contracting leprosy could be higher among population groups than between individuals, an epidemiological study was undertaken to design ecological type group multiple, involving 203 municipalities in the states of Mato Grosso and Mato Grosso do Sul, which are located in the Midwest region of Brazil. Sociodemographic variables were recorded for exposure and effect was variable represented by annual average detection rate of leprosy between 2000 and 2006. We utilized secondary data from the Brazilian Institute of Geography and Statistics and the Ministry of Health to compose a multivariate model, 14 variables were analyzed by linear regression and seven variables selected with probability p<0.2 for the slope coefficient of regression line. The independent variables were tested step by step, and simultaneously analyzed the association of the dependent variable in order to fit a model of the variability of the detection rate of leprosy. The variables that remained in the model after adjustment process were: \"Proportion of population living in households with six or more people,\" \"Proportion of population unnatural state,\" and \"Coverage of Population Health Care Strategy Family \". These variables together explain 24.1% of the variation in detection rates of leprosy. CONCLUSIONS: Sociodemographic factors represent an important area in the epidemiology of the disease. The positive association with the outcome of the strategic coverage of Family Health Care indicates that there must be improved access to diagnosis by implementing models of primary care-based preventive rationales. Patients could have their contagiousness interrupted earlier, once improved the diagnostic capacity of health services. As a recommendation to improve access to diagnosis in endemic areas, the adoption of the strategy of the Family Health Care should be encouraged. Household crowding as ecological variable was interpreted as an indirect socioeconomic indicator, rather than strictly related to contact conditions. The quality of housing, perhaps most important for disease control, as far as can be accompanied by general improvements in living standards. Reservoirs of M. leprae consist of individuals who are chronically eliminate bacilli that perpetuate endemic, although, in theory, be supplemented by secondary sources represented by transient carriers. Factors related to the formation of the agricultural frontier and the Brazilian urbanization may have fostered endemic leprosy, predispose to the renewal of the likely migration, which modify the composition of the population as to the experience of contact with the bacillus. Migration could break outbreaks of leprosy that were saturated with individuals resistant to spatially redistribute the population likely lead to infective areas unaffected or install the territorial and biological assumptions to make the recurring infection in the population, even though the population from immigration quota is not predominantly more vulnerable to disease. Technicisation rural and constrictions in the sphere of labor are busy people seeking refuge on the outskirts of cities, characterized by poor urban infrastructure and rapid population growth, supposedly continents groups of humans with different resistance profiles to M. leprae. The lower circuit of the economy, a social response to the scarcity of livelihood and a dash of Brazilian territorialization, has offered the spatial predicates for the persistence of endemic leprosy in pockets of urban poverty, to generate a plurality of contacts in proximity and feed their social relationships from a mass of newcomers from the countryside and the city, its main and most abundant variable. If geography studies the conditions of life on earth, these results suggest that medical topography, beyond the description of the demographic and socioeconomic aspects of the places outbreaks of diseases, can contribute greatly to health knowledge, to consider examining such factors as potential determinants of diseases

This study explores the changing nature of filial piety in contemporary society in rural China. With the economic, social and political upheavals that followed the Revolution, can 'great peace under heaven' still be found for the rural Chinese family as in the traditional Confucian proverb,"make yourself useful, look after your family, look after your country, and all is peaceful under heaven"? This study explores this question, in terms not so much of financial prosperity, but of non-tangible cultural values of filial piety, changing familial and gender roles, and economic migration. In particular, it examines how macro level changes in economic, social and demographic policies have affected family life in rural China. The primary policies examined were collectivisation, the hukou registration system, marketization, and the One-Child policy. Ethnographic interviews reveal how migration has affected rural family structures beyond the usual quantifiable economic measures. Using the village of Meijia, Sichuan province, as a paradigmatic sample of family, where members have moved to work in the cities, leaving their children behind with the grandparents, the study demonstrates how migration and modernization are reshaping familial roles, changing filial expectations, reshuffling notions of care-taking, and transforming traditional views on the value of daughters and daughters-in-law. The study concludes that the choices families make around migration, child-rearing and elder-care cannot be fully explained by either an income diversification model or a survival model, but rather through notions of filial piety. Yet the concept of filial piety itself is changing, particularly in relation to gender and perceptions about the worth of daughters and the mother/ daughter-in-law relationship. Understanding these new family dynamics will be important for both policy planners and economic analysts.

Personal care homes have become increasingly dependent on the employment of immigrant care workers. This qualitative study explored the high concentration of Filipino health care aides in personal care homes from their own perspectives, as well as that of policy stakeholders. In depth interviews were conducted with seven Filipino health care aides working in personal care homes in Winnipeg, Manitoba. Semi-structured interviews with policy stakeholders examined the policy context of the health care aide labour force. The study identified several factors that influenced the migration and employment of Filipino health care aides including: poverty and unemployment, migrant social networks, barriers in the labour market and financial incentives. The lack of regulations for health care aides sustained the flow of immigrant labour and enabled the expansion of social networks. Although their employment decisions were primarily based on financial need, health care aides valued their work and viewed themselves as critical care providers.

The subject of international migration has become an important social issue and feature of globalized labour market in health care. International migration of nurses has increasingly become a concern and the volumes are reported to be increasing particularly from the developing world where, in some countries, is a leading cause of attrition and subsequent shortage of nurses as a human resource. This has implications on the capacity of health systems to respond to the challenge of health care delivery to populations considering that nurses form the largest health workforce in most countries. In Zambia, nurse migration has equally been a concern including the absence of relevant studies with evidence to inform policy direction, planning and management of nursing human resource. The purpose of this study was to determine the extent of nurse migration, the reasons why nurses resign their employment positions and leave the country, why other nurses do not migrate and to further determine the perceived nurse migration impact on the public health care system. The study was a non-experimental descriptive survey design that used both quantitative and qualitative approaches to data collection and data analysis. A triangulation approach was used in data collection involving various methods; multistage, stratified and systematic sampling; purposive and snowball with a range of data collection instruments; semi-structured for focused interviews of nurse migrants, nurses seeking verifications and policy makers; self-administered questionnaire that enlisted data from clinical nurses and nurse educators on the perceived impact of nurse migration on the public health care system and topic guides for focus group discussions. Computer software were used to code and analyze data; SPSS version 11.0 for quantitative data and NVivo7 for qualitative data. A total of 309 clinical nurses and 23 nurse educators responded to the self administered questionnaire. Thirty three key informants participated in focus group discussions conducted in four health facilities situated in four districts. There were five directors at provincial, district and national levels and 13 nurse migrants interviewed. Data on nurses with verification of qualifications sent to countries were collected from a total of 1,142 records; 931 for RNs and 211 for ENs. The study was guided by a conceptual framework developed from two migration theories namely the World Systems Theory and the Push and Pull Theory. The World Systems Theory structured the world into three zones of Periphery (poor countries), Semi-Periphery (Transitional economies) and the Core (industrialized wealthy countries). Push factors caused people to leave the Periphery to the Semi-periphery and to the Core where the Pull factors attracted those from the Periphery and Semi-periphery. Major findings of the study showed dissatisfaction with work conditions, poor living conditions, lack of professional recognition and autonomy and lack of access to professional development as being among the push factors while the pull factors included attractive work conditions, conducive work environment and access to professional development, among others. The perceived impact included nurse shortage, excessive workload, long working hours and poor quality of patient care. Findings on issues for policy on managing nurses leaving for greener pastures were in the form of interventions that would address the push factors and formed the basis for recommendations from the study.
Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2007.

A quantitative, descriptive, explorative design was applied to study the problems that hindered the Primary Health Care (PHC) nurses in rendering quality health care in the health facilities in Limpopo province South Africa. The sample consisted of 53 PHC nurses who completed a pre-tested questionnaire which covered various aspects related to the provision of quality PHC services. The data were analysed by computer using SPSS version 15 soft ware. The findings revealed that most of the problems could be attributed to financial constraints, poor budgeting, and shortage of staff to manage large number of patients, lack of enough support from other professional staff, unreliable referral systems and communication networks. PHC nurses work under difficult conditions and often have to improvise to care for patients, but unless more funds are allocated to rural health care facilities and these problems are addressed, more nurses will work under difficult circumstances.
Health Studies
M.A. (Health Studies)

Student Number : 8910202A - MPH research report - School of Public Health - Faculty of Health Sciences
An increasing number of people are migrating to South African urban centers (GJMC, 2000). There are various reasons that can be attributed to this migration; including the hope of finding employment and better living conditions. Recent urban migrants find themselves faced with the basic problem of lack of shelter and, depending on the migrant’s situation, they may choose to live in indoor shacks within the city center, backyard shacks in the black townships or join the growing number of informal settlement dwellers (GJMC, 2000). The number of informal settlements continues to grow at an alarming rate in Johannesburg (CEROI, 2000). This poses unique health care challenges as well as presenting the health care system with unusual disease conditions associated with general lack of infrastructure and services (CEROI, 2000). It has been established that the proportion of HIV infected patients is higher in people living in informal settlements when compared to people living in private houses (SAHR, 2000). Thus, it is expected that more people will be presenting with HIV and AIDS related illnesses in an informal settlement health center as compared to well-developed residential areas. This study aimed at exploring the prescribing patterns of health care givers for patients attending a health center in an informal settlement as well as to determine the major disease patterns prevalent in the area. The study was carried out in Davidsonville and OR Tambo clinics as well as Bophelong and Hikhensile clinics in Ivory Park. The study covered regions five, one and two respectively according to Gauteng metropolitan services area classification (GJMC, 2000). The findings of the study will help the appropriate policy makers improve the Essential Drug List and inform public health officials in formulating strategies that may lead to health status improvement for people living in informal settlements.

abstract: Most studies on refugee populations tend to focus on mental health issues and communicable diseases. Yet, reproductive health remains a major aspect of refugee women's health needs. African refugee women in the United States continue to experience some difficulties in accessing reproductive health services despite having health insurance coverage. The purpose of this study was to understand the reproductive health journey of African refugee women resettled in Phoenix, Arizona. This study also explored how African refugee women's pre-migration and post-migration experiences affect their relationships with health care providers. The study was qualitative consisting of field observations at the Refugee Women's Health Clinic (RWHC) in Phoenix, verbally administered demographic questionnaires, and semi-structured one-on-one interviews with twenty African refugee women (between the ages of 18 and 55) and ten health care providers. The findings were divided into three major categories: pre-migration and post migration experiences, reproductive health experiences, and perspectives of health care providers. The themes that emerged from these categories include social isolation, living between two cultures, racial and religious discrimination, language/interpretation issues and lack of continuity of care. Postcolonial feminism, intersectionality, and human rights provided the theoretical frameworks that helped me to analyze the data that emerged from the interviews, questionnaire and fieldnotes. The findings revealed some contrasts from the refugee women's accounts and the accounts of health care providers. While refugee women spoke from their own specific social location leading to more nuanced perspectives, health care providers were more uniform in their responses leading to a rethink of the concept of cultural competency. As I argue in the dissertation and contrary to conventional wisdom, culture per se does not necessarily translate to resistance to the American health care system for many African refugee women. Rather, their utilization (or lack thereof) of health services are better conceived within a broader and complex context that recognizes intersectional factors such as gender, racialization, language, displacement, and class which have a huge impact on the reproductive health seeking patterns of refugee women.
Dissertation/Thesis
Ph.D. Gender Studies 2011

Thesis (M.A. (Nursing Science)) --University of Limpopo, 2018
Introduction and background The shortage of human resources in rural areas remains a crisis, especially in subSaharan Africa, affecting rural primary health centres. The purpose of this study was to identify and describe factors influencing the retention of health care workers in rural clinics, in order to develop strategies to improve retention in rural clinics. Methodology A quantitative research method and descriptive design was used in this study. The population was professional nurses and operational managers in rural clinics. Simple random sampling was used to select the clinics, the professional nurses and operational managers. The sample size were 210 professional nurses and operational managers. Only 170 professional nurses and operational managers participated in the study. Data were collected using a questionnaire, and all ethical principles were adhered to. The data was analysed using SPSS version 22.0. Results The study revealed that there are complex interconnecting factors that affect retention. It was further revealed that age is the core factor affecting retention (P= 0.001) with 19 (100%) of those aged < 30 years intending to leave rural practice. Furthermore, more than half of the respondents 118 (87.06%) were dissatisfied with the salary they earned. Only 1 (0.6%) of the respondents had a masters’ degree. Conclusion It is therefore concluded that both financial and non-financial incentives such as education, improving working conditions and relationship with colleagues needs to be incorporated in order to improve nurse retention. Key words: Retention, migration, rural health care workers, job satisfaction

The republic of South Africa has a “health for all” policy, regardless of nationality and residence status. However, challenges still exist for non-nationals and little is known regarding migrants’ maternal healthcare experiences. This study explores the maternal healthcare experiences of migrant Zimbabwean women living in Johannesburg, South Africa. It focuses on the lived experiences of women aged 18years and above, who engaged with the public healthcare system in Johannesburg during pregnancy and childbirth. A desk review of the literature was undertaken. The theoretical framework in this study draws from three concepts (1) the Social determinants of health framework (WHO 2010), (2) the Access to healthcare framework (McIntyre, Thiede and Brich 2009) and (3) the “three-delays (Nour 2008). Primary data was collected through the use of open-ended semi-structured interviews with a sample of 15 migrant Zimbabwean women who have been in Johannesburg for a minimum of 2 years, and have attended and given birth or are currently attending antenatal care in inner city Johannesburg. Thematic content analysis was used to analyse data since it helps to extract descriptive information concerning the experiences of Zimbabwean women in Johannesburg and to construct meaning in order to understand their perceptions and opinions about the healthcare system in the city. Although the findings indicate that documentation status is not a key issue affecting access to healthcare during pregnancy and delivery, a range of other healthcare barriers were found to dominate, including the nature of their employment, power relations, language, and discrimination(generally) among others. Language was singled out as the major challenge that runs throughout the other barriers. More interestingly the participants raised their desire of returning home or changing facilities within the Public sector or to private institutions in case of any further pregnancy. This study concludes that the bone of contention is on belongingness, deservingness and not being able to speak any local language, that runs through the public health care institutions and this impact on professionalism and discharge of duties.

This study aims to examine how the migration experience influences newcomer mothers’ young child feeding and care practices and their children’s overall health. The thesis comprises three separate manuscripts, each of which examines one of the three intermediate determinants of the nutritional status of young children (UNICEF 1990): access to healthcare, household food insecurity, and child feeding and care practices. The research was conducted in Toronto’s Jane-Finch neighbourhood, a suburban neighbourhood home to a high density of newcomers. Thirty-two participants (16 Sri Lankan Tamil and 16 Latin American) who had migrated to Canada within the past five years as refugee claimants or family sponsored immigrants participated in the study. Data collection consisted of semi-structured interviews with women from low-income households who had a child between the ages of 1 and 5 years. Spanish and Tamil speaking interviewers interviewed each participant two or three times. Data was analyzed using a mid-level approach in which broad analytical themes are determined prior to analysis and specific themes were then generated based on participants’ perspectives and are grounded in the data. The first manuscript examines newcomer mothers’ experiences accessing physicians for their children and identifies the major gaps between mothers’ expectations and their actual experiences that lead to barriers in communication and overall patient dissatisfaction. The second manuscript demonstrates that mothers’ past experiences with food insecurity affect two aspects of the construct of food insecurity: its managed aspect and its temporal nature. This finding has implications for the measurement of food insecurity in newcomer populations. The third manuscript reveals that newcomer mothers are exposed to several parallel and often conflicting systems of knowledge concerning health and nutrition for their children, and that their utilization of Canada’s Food Guide is impeded by its failure to acknowledge alternate parallel knowledge systems. These findings can be applied to the development of social and health policy aimed at improving cultural competency in healthcare and nutrition education and at ameliorating the income constraints leading to household food insecurity.

Little is known about the factors that influence people from the Caribbean to seek reproductive health services in the United States. In this paper, I focus on Indo-Caribbean women from Guyana and Trinidad who undertake reproductive journeys to New York. I ask: (1) What influences Indo-Caribbean women to begin their reproductive journeys to Richmond Hill, New York? (2) How do Indo-Caribbean women challenge gender norms during their reproductive journeys? (3) How does women’s class inform their decision making in challenging gendered norms? After conducting 30 in-depth interviews with Indo-Caribbean women from Guyana and Trinidad who seek reproductive health services in New York, I find that Indo-Caribbean women’s reproductive journeys are influenced by sexism experienced within households, communities, and doctors’ offices, lack of proper care, legal restrictions, and unaffordable treatment. Another driver is support from women networks. Social networks helped women challenge gendered norms around motherhood that are present within communities in home countries. As women receive support from their networks, they challenge gender norms varied by their class. Women from middle-income households are more likely to challenge gender norms outwardly. Obtaining reproductive health care abroad becomes a journey with multidimensional experiences of gendered negotiations and constraints.

Comment s’adaptent des organisations lorsqu’elles font face à des changements qui les dépassent? De cette question a émergé une recherche voulant comprendre comment et pourquoi des organisations de santé décident d’adapter (ou non) leurs services aux besoins et aux caractéristiques des populations migrantes accueillies sur leur territoire. Pour y répondre, cette thèse s’est intéressée à la gouvernance multiniveaux appliquée aux organisations de santé fournissant des services à des populations migrantes. Dans un contexte de régionalisation de l’immigration, la dynamique du processus migratoire est de mieux en mieux documentée, mais les capacités organisationnelles d’adaptation le sont beaucoup moins. Nous avons réalisé une étude de cas multiples à l’aide d’entrevues semi-directives auprès d’acteurs provenant de deux CSSS montéregiens (région au sud de Montréal, Québec) et des paliers locaux, régionaux et nationaux. Les résultats de cette étude ont permis (1) de mettre en évidence les différents acteurs impliqués dans ce processus d’adaptation, dont des acteurs de connectivité; (2) de cerner huit leviers d’action, divisés en trois catégories de leviers : administratif, émergent et d’habilitation. La possible imbrication de ces trois catégories de leviers facilite l’apparition de structures de connectivité, légitimant ainsi l’adaptation de l’organisation; et (3) de montrer l’ambigüité de l’adaptation à travers des facteurs d’influence qui favorisent ou entravent le processus d’adaptation à plusieurs niveaux de la gouvernance. Cette thèse est construite autour de quatre articles. Le premier, de nature conceptuelle, permet de circonscrire les concepts d’adaptation et de gouvernance multiniveaux à travers la lentille des théories de la complexité. Nous campons ainsi notre sujet dans une problématique liée à la vulnérabilité et la migration tout en appréhendant l’adaptation du système et son opérationnalisation au niveau local. Il en ressort un cadre conceptuel avec six propositions de recherches. Le second article permet quant à lui de comprendre les jeux des acteurs au sein d’une organisation de santé et à travers son Environnement. Le rôle spécifique d’acteurs de connectivité y est révélé. C’est dans un troisième article que nous nous intéressons davantage aux différents leviers d’action, analysés selon trois catégories : administrative, émergente et d’habilitation. Les acteurs peuvent les solliciter afin de d’adapter leurs pratiques au contexte particulier de la prise en charge de patients migrants. Un passage des acteurs aux structures de connectivité est alors rendu possible via un espace : la gouvernance multiniveaux. Enfin, le quatrième et dernier article s’articule autour de l’analyse des différents facteurs pouvant influencer l’adaptation d’une organisation de santé, en lien avec son Environnement. Il en ressort principalement que les facteurs identifiés sont pour beaucoup des leviers d’action (cf. article3) qui à travers le temps, et par récursivité, deviennent des facteurs d’influence. De plus, le type d’interdépendance développé par les acteurs a tendance soit à façonner un Environnement « stable », laissant reposer les besoins d’adaptation sur les acteurs opérationnels; soit à façonner un Environnement plus « accidenté », reposant davantage sur des interactions diversifiées entre les acteurs d’une gouvernance multiniveaux. De cette adéquation avec l’Environnement à façonner découle l’ambigüité de s’adapter ou non pour une organisation.
How do organizations adapt when faced with changes that exceed their current capacities? More specifically how and why do healthcare organizations choose to adapt- or not- their services to the needs and characteristics of new and established migrant populations? In this thesis, we attempt to answer these questions using a conceptual model of multilevel governance, applicable to healthcare organizations that provide primary care to migrant population. In a context of regionalized immigration, the dynamics of the migration process are well documented, however organizations abilities to adapt are less so. We conducted a multiple case study, collecting data from semi-structured interviews with providers from two healthcare organizations from Montéregie region (South shore of Montréal, Québec) as well as stakeholders from local, regional and national scale. The data collected has allowed us, (1) to identify the most significant stakeholders in adaptation process and to highlight the connectivity between them; (2) to reveal eight action levers that we divided in three categories: administrative, emerging and enabling. The possible imbrications of these three categories facilitate the creation of connectivity structures that legitimate the organization’s adaptation; and (3) to show the ambiguity of adaptation through the influence of facilitating or hindering factors at several levels of governance. This thesis is structured on four articles. The first article is conceptual: adaptation and multilevel governance are therein defined through the framework of complexity theory. We anchor our subject in the vulnerability and migration schemata, while apprehending the system’s adaptation at the local scale. The result is a conceptual framework with six research propositions. The second article elaborates on the dynamics among stakeholders within healthcare organizations, its networks and the Environment. The specific role of the connectivity between stakeholders is highlighted. In the third article, we focus on the different action levers, which are analysed in three categories: administrative, emerging and enabling. The stakeholders seek to adapt their practices to the particular context of providing timely and appropriate care to migrant patients. A transition from connectivity between actors and structures is then made possible through multilevel governance. Finally, the fourth article is an analysis of the different factors that influence a healthcare organization’s adaptation with regards to the Environment. The results show that many identified factors are firstly action levers (see article 3), and become through time and recursively of influence factors. In addition, the type of interdependence developed between the stakeholders tends to shape either “stable” Environment which transfers the responsibility of the adaptation to the operational stakeholders or “rugged” Environment based on diverse and decentralized interactions between stakeholders through multilevel of governance. From this constant adjustment with the Environment appears the ambiguity of the adaptation for a healthcare organization.

Orientação: Patrícia Magda Monteiro Pascoal ; co-orientação: Jorge Cardoso
Apesar do multiculturalismo de Portugal, poucos estudos foram realizados para entender se há diferenças relativamente à saúde sexual e reprodutiva entre os portugueses e os imigrantes. Através deste trabalho pretendemos explorar se há diferenças relativamente a certos indicadores de saúde sexual e reprodutiva entre portugueses e imigrantes residentes em Portugal. Trata-se de um estudo exploratório, transversal, descritivo, quantitativo, onde, através de uma amostragem não probabilística, reunimos 935 participantes (50.5% homens e 49.5% mulheres), entre os 18 e 72 anos, vivendo em Portugal. Utilizámos um questionário para recolher dados sociodemográficos e informação sobre indicadores de saúde sexual e reprodutiva. Os resultados demonstraram que existem algumas diferenças estatisticamente significativas entre os participantes de diferentes países no que diz respeito ao uso do preservativo, frequência de masturbação, história de dor durante a penetração vaginal, falta de desejo sexual, ejaculação atrasada ou ausência de ejaculação e prática de mutilação genital feminina ou de circuncisão. Devido às diferenças encontradas, defendemos um aumento do conhecimento cultural relativamente à sexualidade por parte dos profissionais de saúde bem como uma adaptação cultural dos programas de promoção da saúde sexual. Devem ser realizados estudos qualitativos para entender melhor as representações e comportamentos relacionados à saúde sexual de cada país.
Despite Portugal’s multiculturalism, few studies have been done to understand if there are differences in sexual and reproductive health between Portuguese people and immigrants that justify a culturally sensitive approach from health care professionals. We aim to explore if there are differences regarding sexual and reproductive health indicators among the Portuguese and immigrants living in Portugal. This is a cross-sectional descriptive exploratory quantitative study. Across the non-probabilistic sampling, we gathered 935 participants (50.5% men and 49.5% women), aged 18-72 years living in Portugal. We used a questionnaire to collect socio-demographic data as well as information about sexual and reproductive health indicators. The results showed that there are some significant differences between the participants of different countries in what concerns condom use, masturbation frequency, history of pain during vaginal penetration, lack of sexual desire, delayed ejaculation or absence of ejaculation, and practice of female genital mutilation and circumcision. Due to the differences found, we advocate an increase in the cultural specific knowledge of sexuality by health professionals. We also believe sexual health promotion programs need to be adapted to acknowledge and integrate cultural differences. However, qualitative studies must be done to better understand the significations and behaviors related to sexual health of each country.

The purpose of this study was to examine the extent to which human resources capacity of the Ministry of Health and Social Services (MoHSS), Namibia, influences health care services delivery to the Namibian population. A qualitative research model using exploratory and descriptive study designs was adopted. Data were collected through semi-structured interviews with 46 health workers from two referral hospitals and two directorates in Windhoek District. The study found that there is severe staff shortage in the MoHSS, which has resulted in high workload and poor health care. Health worker migration, new services and programmes, emerging diseases, and population growth were reported to have contributed to staff shortage and high workload in the MoHSS. Study findings suggested a need to create more posts to accommodate emerging needs, and to introduce an effective retention strategy to attract and retain health professionals with scarce skills, and those working under difficult conditions.
Public Administration & Management
M. Tech. (Public Management)

For many years Canada has quietly rationalized importing temporary “low-skilled” migrant labour through managed migration programs to appease industries desiring cheap and flexible labour while avoiding extending citizenship rights to the workers. In an era of international human rights and global competitive markets, the Canadian Seasonal Agricultural Workers Program (SAWP) is often hailed as a “model” and “win-win” solution to migration and labour dilemmas, providing employers with a healthy, just-in-time labour force and workers with various protections such as local labour standards, health care, and compensation. Tracing migrant workers’ lives between Jamaica, Mexico and Canada (with a focus on Ontario’s Niagara Region), this thesis assesses how their structural vulnerability as non-citizens effectively excludes them from many of the rights and norms otherwise expected in Canada. It analyzes how these exclusions are rationalized as permanent “exceptions” to the normal legal, social and political order, and how these infringements affect workers’ lives, rights, and health. Employing critical medical anthropology, workers’ health concerns are used as a lens through which to understand and explore the deeper “pathologies of power” and moral contradictions which underlie this system. Particular areas of focus include workers’ occupational, sexual and reproductive, and mental and emotional health, as well as an assessment of their access to health care and compensation in Canada, Mexico and Jamaica. Working amidst perilous and demanding conditions, in communities where they remain socially and politically excluded, migrant workers in practice remain largely unprotected and their entitlements hard to secure, an enduring indictment of their exclusion from Canada’s “imagined community.” Yet the dynamics of this equation may be changing in light of the recent rise in social and political movements, in which citizenship and related rights have become subject to contestation and redefinition. In analyzing the various dynamics which underlie transnational migration, limit or extend migrants’ rights, and influence the health of migrants across borders, this thesis explores crucial relationships between these themes. Further work is needed to measure these ongoing changes, and to address the myriad health concerns of migrants as they live and work across national borders.

Due to the higher migration rates, there is more cultural diffusion. The healthe care personnel will be dealing with patients from different cultures more often. This is why it is important to use an appropriate approach and give competent heathcare considering cultural backround of the patients. The goal of this thesis was to map the cultural differences in care for an underage patient and to trend the minority groups that are being cared for by nurses in the children's ward. To achieve the goal of this thesis, there were four specified questions and to achieve the result, there was a threephase trial, specifically qualitative trial supplemented with quantitative method using a questionnaire. The first phase was the pilot poll and a techniquire "snowball slamping" was used. The second phase of the trial consisted of pre-structured interviews with the nurses. The third phase consisted of pre-structured interviews with the parents. On the basis of this trial, it was concluded that the nurses are caring for Romany and Vietnamese minority groups most often. The other most patiens from Ukraine, Russia, Germany, Poland, Muslims and Jehova witnesses. The most common problems that occur during the care are: language barrier, cultural customs, communication and co-operation. Based on the data collected from interviews with nurses and parents, there are specific variations in expectency of care, such as food, daily regime, differences in behavour, communication, reliability to adhere to given rules and consequent care after the hospital stay. There are other different specifics such as rituals and traditions during child labour or at the time of death, celebration of different festivals, fasting and other spiritual needs. Traditions relating to refusal or demand of specific care were also mentioned. Results of this thesis were presented at the 13th Student conference in Pardubice and will be published in a technical journal.

A presente investigação debruça-se sobre a temática de doença renal crónica nos cidadãos evacuados de Cabo Verde ao abrigo do Protocolo de Saúde entre Portugal e os Países Africanos de Língua Oficial Portuguesa (PALOP). A presente investigação centra-se no efeito das doenças renais no estado emocional dos doentes, tendo como principal objetivo compreender o significado de ser um doente evacuado de Cabo Verde com patologia renal crónica, bem como perceber que recursos e desafios se colocam para a sua integração em Portugal. Para responder a estas questões, foi recrutada uma amostra de 15 participantes, cabo-verdianos com doença renal crónica. A metodologia utilizada foi a entrevista semiestruturada, tendo sido gravado e transcrito todo o material recolhido e posteriormente analisado com base na Análise de conteúdo utilizando o MaxQDA. Os principais resultados revelaram a ausência de suporte familiar na vida da maioria destas pessoas, bem como a dificuldade de gestão das limitações resultantes da doença (em particular, o regresso a Cabo Verde), com impactos na integração em Portugal. Ainda assim, alguns exemplos de processos de resiliência face às adversidades foram identificados.
The present study approaches the subject of chronic kidney disease among patients from Cape Verde who have been brought to Portugal under a Health protocol among Portugal and PALOP countries (Portuguese as an official language). It focuses on the emotional impact of kidney disease on these patients, aiming to explore the meaning that these patients attribute to the illness, as well as understanding the resources and challenges faced by them in their integration process in Portugal. A sample of 15 participants was obtained, all of which were from Cape Verde and were chronically ill due to kidney disease, having been brought to Portugal under the Health Protocol. A semi-structured interview was developed and all interviews where recorded and transcribed with MaxQDA, using content analysis. The main results reveal the absence of family social support for most participants, as well as the difficulty in managing the limitations brought on by the disease (in particular, regarding return to home country), with impacts on the integration processes in Portugal. Still, some examples of resilience processes in face of adversity were identified.