Dissertations / Theses on the topic 'Dental policy'

Oral diseases including dental caries and periodontal disease are among the most prevalent and costly diseases in Australia today. Around 5.4% of Australia’s health dollar is spent on dental services totalling around $2.6 billion, 84% of which are delivered through the private sector (AIHW 2001). The other 16% is spent providing public sector services in varied and inadequate ways. While disease rates among school children have declined significantly in the past 20 years the gains made among children are not flowing on to adult dentitions and our aging population will place increasing demands on an inadequate system into the future (AHMAC 2001). Around 50% of adults do not received regular care and this has implications for widening health inequalities as the greatest burden falls on lower income groups (AIHW DSRU 2001). The National Competition Policy agenda has initiated, Australia-wide, reviews of dental legislation applying to delivery of services by dentists, dental specialists, dental therapists and hygienists and dental technicians and prosthetists. The review of the Victorian Dentists Act 1972, was completed first in 1999, followed by the other Australian states with Queensland, the ACT and the Northern Territory still developing legislation. One of the objectives of the new Victorian Act is to ‘…promote access to dental care’. This study has grown out of the need to know more about how dental therapists and hygienists might be utilised to achieve this and the legislative frameworks that could enable such roles. This study used qualitative methods to explore dental health policy making associated with strategies that may increase access to dental care using dental therapists and hygienists. The study used a multiple case study design to critically examine the dental policy development process around the Review of the Dentists Act 1972 in Victoria; to assess legislative and regulatory dental policy reforms in other states in Australia and to conduct a comparative analysis of dental health policy as it relates to dental auxiliary practice internationally. Data collection has involved (I) semi-structured interviews with key participants and stakeholders in the policy development processes in Victoria, interstate and overseas, and (ii) analysis of documentary data sources. The study has taken a grounded theory approach whereby theoretical issues that emerged from the Victorian case study were further developed and challenged in the subsequent interstate and international case studies. A component of this study has required the development of indicators in regulatory models for dental hygienists and therapists that will increase access to dental care for the community. These indicators have been used to analyse regulation reform and the likely impacts in each setting. Despite evidence of need, evidence of the effectiveness and efficiency of dental therapists and hygienists, and the National Competition Policy agenda of increasing efficiency, the legislation reviews have mostly produces only minor changes. Results show that almost all Australian states have regulated dental therapists and hygienists in more prescriptive ways than they do dentists. The study has found that dental policy making is still dominated by the views of private practice dentists under elitist models that largely protect dentist authority, autonomy and sovereignty. The influence of dentist professional dominance has meant that governments have been reluctant to make sweeping changes. The study has demonstrated alternative models of regulation for dental therapists and hygienists, which would allow wider utilisation of their skills, more effective use of public sector funding, increased access to services and a grater focus on preventive care. In the light of theses outcomes, there is a need to continue to advocate for changes that will increase the public health focus of oral health care.

Background: Regular access to dental services is a well-known factor in the oral health and development of children.1 As such, the United States federal government mandates each state to include dental services for children enrolled in Medicaid through the age of 21. Despite this mandate, the utilization rate of dental services among Medicaid enrolled children has remained remarkably low.2 In July 2005, Virginia implemented a sweeping Medicaid policy reform titled “Smiles for Children,” specifically aiming to increase Medicaid pediatric dental utilization rates. The purpose of this study aims to assess the effect of this 2005 policy reform on the utilization of dental services by children enrolled in Medicaid. Objective: The purpose of this study is to examine the impact of the 2005 Virginia Smiles for Children Medicaid policy reform on the utilization of dental services among Medicaid enrolled children. Methods: This was a retrospective cohort study of children (pre-reform n=559,820, post-reform n=690,538) enrolled in Virginia Medicaid from 2002 through 2008. Descriptive statistics and repeated measures multivariate logistic regressions were used to determine the relationship between enrollment (Pre- and Post-policy reform) and the utilization of dental services (1+ Dental Visits vs. No Dental Visits). Results: Descriptive analysis of the cohort found that 34% of pre-reform children had a dental visit while 44% of post-reform children. The logistic regression models revealed that children in the post reform period were 1.39 as likely to have had a dental visit. Stratifying for enrollment length reveals that as the length of exposure time to the post-reform policy increases, the odds of having a dental visit also increase as compared to the pre-reform period: for 31-36 months of enrollment the odds increase 1.54 times. Conclusions: Medicaid policy reform can significantly improve access to dental services for children and can therefore play an important role in promoting public health.

This cross-sectional, non-experimental study evaluates associations between cohort membership, type of dental coverage, and utilization of dental services in all patients age 47 and over who received dental care at Virginia Commonwealth University’s (VCU) School of Dentistry in 2011. Structural Lag Theory poses that society’s institutions lag behind the actuality of a healthy and capable older adult population. The two dynamisms of the Structural Lag Theory were used for this study. The Dynamism of Changing Lives is represented by Cohort differences. Cohort differences include cohort size, people living longer and retaining more of their natural teeth along with different attitudes toward dental care. This dynamism impacts the Dynamism of Structural Change, represented by the institutions of dental coverage and utilization of dental services. Cohort membership is an independent variable. The dependent variable, utilization, is defined as Financial-Total amount spent and Procedural-Routine adult dental prophylaxis. Dental coverage, a dichotomous variable, is used as an independent and dependent variable. Descriptive statistics revealed employer provided dental coverage is the most prevalent type of dental coverage. However, when considered a payment source, out of pocket funding is the primary source of payment for dental services. Using Chi-square and logistic regression, examination of Cohorts (1-Greatest Generation, 2-Silent Generation, 3-Baby Boomer Generation) revealed that Cohort 2 had more dental coverage than Cohort 1, and Cohort 3 had more dental coverage than Cohort 2. Using logistic regression, Cohort 2 showed the highest level of Procedural utilization. Evaluating Financial utilization, multiple regression models showed Cohort 1 utilized more than Cohort 2 and Cohort 2 utilized more than Cohort 3. Those with dental coverage spend more on dental services, fees for routine adult dental prophylaxis make up the majority of the total amount spent, and those with dental coverage utilize more dental services when defined as total amount spent. Because they have experienced different social, political, economic, and technological changes at different times in their life course, the receipt of dental services by new cohorts of older people differs from previous ones. Findings from this study confirm that there is a structural lag in Medicare policy and its coverage of dental services.

Thesis (M.A.) PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you.
Dental phobia, also referred to as "dental anxiety," or "odontophobia," is a significant and intense fear of visiting the dentist for oral treatments. Individuals who experience high levels of this anxious condition avoid going to the dentist. It is estimated that 9 to 15% of both children and adults in America, about 30 – 40 million individuals, experience a level of dental phobia that causes them to avoid visiting the dentist. Individuals affected with this specific form of anxiety often neglect necessary dental visits for varying periods of time, which can, obviously, lead to health concerns in the oral cavity and other parts of the human body, as well as result in mental health and image concerns. When dental phobic patients do manage to attend a dental session, the individual often experiences great levels of anxiety and stress throughout the entire experience, not only creating pain and discomfort for the patient, but also creating adverse treatment circumstances for the dental practitioners that serve to help the patient. Efforts have been made in investigating the effectiveness of various techniques and approaches that could be implemented in the dental setting to ease phobic patients, granting them a less-stressful experience and allowing the dental staff to do their jobs more efficiently in providing the patient with appropriate oral care. There are several techniques used in the dental office today to reduce anxiety such as distraction, controlled breathing techniques, attention focusing, and several sedating methods employing various types of medication, as well as different types of administration. Distraction, controlled breathing, and attention focusing require special attention and an extension of time on the end of not only the patient, but also of the dental staff. These techniques, while possibly offering a reduction in feelings of anxiety, may require multiple attempts and a greater investment of time to show substantial results. Sedation methods may consist of various medications used alone or in a combination to successfully achieve a reduction in anxiety. With the various types of medications and techniques that can be used when sedating a patient, along with the various routes of administration, such as oral, intravenous, and intranasal, sedation methods can be adapted to best suit a patient in terms of their personal preferences and level of comfort, as well as to accommodate time requirements for specific procedures. Each of the techniques and methods used in today’s dental setting should be carefully and strategically evaluated and customized for the anxious or phobic patient in mind. Some methods are favored for certain attributes, varying from ease of use, time required, and speed of onset, to the efficiency in reducing a patient’s anxious or phobic symptoms. Professionals in the field of dentistry must act as providers of the treatment options and resources of the information in regards to the methods so that patients may become aware of the current tactics used in aiding such affected people.
2031-01-01

nÃo hÃ
The aim of this study aimed to evaluate the performance of specialized dental clinics that have Ordinance Qualification Program Smiling Brazil located in the Region Cariri (CearÃ, Brazil) in 2010. We used the data recorded in the database of the Department of the SUS (DATASUS), information from SIA / SUS. After collection, the information was imported into the program TAB for Windows - TabWin - developed by DATASUS in order to allow for rapid tabs on DBF files that constitute the basic components of information systems of the SUS. An indicator called Global Compliance Goals (CGM) developed by E FIGUEREDO GÃES, 2009, was used to evaluate the performance of the services performed by CEOs. Data analysis was built a table with the number of procedures by specialty (subgroup) for each Specialty Dental Center (EOC). We calculated the average monthly procedures performed by CEO and the ratio of the average number of procedures performed monthly and the target unit of each evaluated according to the type of procedure. The efficacy of the CEO was obtained by the average of this ratio. Still, graphs were made of the number of procedures performed and advocated for the Centers. Of the seven CEOs studied, measurement of the CGM, it was found that 42.85% of the specialized obtained, poor performance, fulfilling only one of the four goals set by Ordinance 600/2006 of the Ministry of Health The only CEO who has fulfilled all goals, achieving optimal performance was the municipality of Farias Brito. In contrast, the center located in the city of Crato failed to execute the goals of the procedures in any branch of dentistry, not reaching a score (poor performance). It was found that the AB Specialty (Primary) all centers achieved the targets except the CEO Barbalha and Crato where 9% and 11%, respectively, certain procedures have not occurred. In the surgery procedure, it is emphasized that only the CEO of Farias Brito has achieved the number of attendances defined for it (1.36 times the expected number). Of those who did not reach the target the most critical situation was the CEO who left Old Mission to achieve 89% (71 cases) of the surgeries. It was concluded that the performance of specialized dental clinics of Cariri in 2010 is unsatisfactory as production proposed by the Ministry of Health.
O presente estudo visa avaliar o desempenho dos Centros de Especialidades OdontolÃgicas que possuem Portaria de HabilitaÃÃo do Programa Brasil Sorridente localizados na RegiÃo do Cariri (CearÃ, Brasil) no ano de 2010. Utilizou-se os dados registrados no banco de dados do Departamento de InformÃtica do SUS (DATASUS), informaÃÃes do SIA/SUS. ApÃs coleta, as informaÃÃes foram importadas para o programa TAB para Windows â TabWin - desenvolvido pelo DATASUS com a finalidade de permitir a realizaÃÃo de tabulaÃÃes rÃpidas sobre os arquivos DBF que se constituem nos componentes bÃsicos dos sistemas de informaÃÃes do SUS. Um indicador denominado Cumprimento Global de Metas (CGM) desenvolvido por FIGUEREDO E GÃES, 2009, foi usado para avaliar o desempenho dos serviÃos executados pelos CEOs. Para anÃlise dos dados foi construÃda uma tabela com o nÃmero de procedimentos segundo a especialidade (subgrupo) para cada Centro de Especialidade OdontolÃgico (CEO). Calculou-se a mÃdia de procedimentos mensais realizados pelos CEOs e a razÃo entre o nÃmero mÃdio de procedimentos realizados e a meta mensal de cada unidade avaliada, de acordo com o tipo de procedimento. A avaliaÃÃo da eficÃcia dos CEOs foi obtida atravÃs desta razÃo entre a mÃdia. Ainda, foram confeccionados grÃficos do nÃmero de procedimentos realizados e preconizados para os Centros. Dos 7 CEOs estudados, medido o CGM, constatou-se que 42,85% dos Centros de Especialidades obtivera, desempenho ruim, cumprindo apenas 1 das 4 metas preconizadas pela Portaria 600/2006 do MinistÃrio da SaÃde. O Ãnico CEO que cumpriu a totalidade das metas, alcanÃando desempenho Ãtimo foi o do MunicÃpio de Farias Brito. Em contrapartida, o centro localizado na cidade do Crato nÃo conseguiu executar as metas dos procedimentos de nenhuma especialidade odontolÃgica, nÃo alcanÃando pontuaÃÃo alguma (desempenho pÃssimo). Verificou-se que na Especialidade AB (AtenÃÃo BÃsica) todos os centros atingiram as metas exceto o CEO de Barbalha e do Crato em que 9% e 11%, respectivamente, dos procedimentos determinados nÃo ocorreram. Jà no procedimento CIRURGIA, ressalta-se que apenas o CEO de Farias Brito conseguiu realizar o nÃmero de atendimentos definidos para ele (1,36 vezes o nÃmero esperado). Dos que nÃo atingiram a meta a situaÃÃo mais crÃtica foi o CEO MissÃo Velha que deixou de realizar 89% (71 casos) das cirurgias. PÃde-se concluir que o desempenho dos 5 Centros de Especialidades OdontolÃgicas da regiÃo do Cariri no exercÃcio de 2010 està insatisfatÃrio quanto a produÃÃo proposta pelo MinistÃrio da SaÃde.

The rhetoric of primary health care, health promotion and health service integration is ubiquitous in health policy development in post-apartheid South Africa. However the form in which oral health promotion elements have actually been incorporated into other areas of health care in South Africa and the extent to which they have been implemented, remains unclear. The central aim of this research was to critically analyse oral health promotion elements in health policies in South Africa and determine the extent to which they have been implemented. The study set out to test the hypothesis that oral health promotion is fully integrated into South African health policy and practice.

One of the most important factors in accessing dental care is having dental insurance. For people with low incomes, Medicaid is the main source of health insurance. Medi-Cal is California’s Medicaid program. Adult dental services were mostly eliminated in Medi-Cal in 2009 due to the economic downturn and partially restored in 2014. The objective of this study is to evaluate the effect of change in Medi-Cal dental coverage, specifically the partial restoration of adult dental coverage in 2014, on dental care utilization among Medi-Cal beneficiaries. The partial restoration significantly increased the utilization rates in dental clinics from 2014 to 2017 (22% in 2017 vs. 12% in 2013) for the overall population. However, the magnitude of increase differs in different age groups and ethnic groups. More statistically significant findings show greater utilization rates among beneficiaries of 19-64 than 65-74 and 75+ years old. Also, more significant findings show lower utilization among Black than White, Hispanic or Asian beneficiaries. The partial restoration significantly reduced the dental related ER visits among Medi-Cal beneficiaries from 2015 to 2017. However, the reduction is largely seen in beneficiaries of 19-64 years old in the ethnic groups of White and Black with reductions of 20 and 15 visits per 1,000 enrollees respectively in 2017 comparing to 2013. The dental related ER visits were lower for Hispanics and Asians, and remained very low among those 65 years old and above. In addition, the partial restoration resulted in increases in participation of dental care providers in the Medi-Cal program.

Avoidable use of the Emergency Departments (EDs) constitutes a significant public health problem, which has health, economic and ethical implications. The factors that affect avoidable use of the EDs are complex and poorly understood. The goal of this dissertation was to examine the role of medical home in avoidable pediatric ED visits, assess the impact of Medicaid policy on ED visits for dental problems and assess the factors affecting follow-up dental care after a dental ED visit. Iowa Household Health Survey data was used for the first study, which included a sample of families with at least one child residing in Iowa. It was found that 68% of parents who took their child to an ED in the previous year thought the ED visit could have been avoided if primary care was available to them. Having a medical home was not found to be associated with pediatric ED visits; however, food insecurity was significantly associated. Parents of children with public insurance, those who were not referred by a healthcare provider and those who reported difficulty in getting routine care appointments were more likely to report an avoidable ED visit by their child. The second study examined a policy change in California where Medicaid eliminated its comprehensive adult dental coverage on July 1, 2009. State Emergency Department Database were obtained from Agency for Healthcare Research and Quality for California for 2006 through 2011. Interrupted time series, a quasi-experimental approach of was used to examine the impact of the policy change on rate of dental ED visits by Medicaid enrolled adults. Segmented linear regression revealed that policy change led to an immediate significant increase in the rate of dental ED visits. The policy had a differential impact on various subgroups based on age, race-ethnicity and residential location. The annual costs associated with dental ED visits made by Medicaid adults also increase 68%. Survival analytic approach was used in the final study to examine the patterns of dental care following a dental ED visit by Medicaid enrolled adults in Iowa. Medicaid claims and enrollment data were used to identify adults with an index dental ED visit in 2011, and then each subject was followed for up to 6 months. About 52% of all adults who satisfied the study inclusion criteria, had a follow up dental visit within 6 months of the index dental ED visit. Cox regression model revealed that adults who had visited a dentist in the year prior to the ED visit had greater hazards of having an early dental follow up after the ED visit. Having repeated dental ED visits was found to have a dose-response relationship to follow-up time to dentist visit, with those having 1 repeat ED visit having 53% hazards and those with 2 or more repeat ED visits having 34% hazards of having a follow-up dentist visit, compared to those with no repeat ED visits. Collectively, the results from this dissertation provide important insights in understanding the complex problem of avoidable ED visits. Factors such as food insecurity and medical home need to be further investigated in their association with avoidable ED visits. State Medicaid policy plays an important role and limiting Medicaid adult dental coverage may lead to an increased reliance of the affected population on EDs for dental care. However, EDs do not provide any definitive dental care, and our results indicate that almost half of the adults with dental ED visit do not have a follow-up dentist visit in the next 6 months.

Dental caries, popularly known as tooth decay or cavities, is among the world's most common health problems. When caught early, it is also one of the most easily resolvable. Yet, advanced decay is a trenchant marker of social inequality and a major contributor to the maldistribution of physical pain and psychosocial suffering. Why? Access to dental care within the U.S. model of fee-for-service dental private practice follows existing lines of social stratification. Dental disparities, a term that calls attention to the relationships between maldistributed disease and maldistributed care, reflect deep ontological, moral, and political differences about responsibility for the prevention and treatment of dental disease, the quality and distribution of dental care, and even what constitutes health and well-being. What kinds of sociopolitical and moral negotiations constitute and transpire around dental disparities? How do these negotiations shape the experiences of patients and providers, and how do their experiences shape these negotiations? What can an ethnography of the dental safety net–a complex, fragile, and unpredictable network of treatment opportunities for low-income families–tell us about health governance more broadly? These are some of the questions that drive my research. In this dissertation, I explore how the sociopolitical relations of dental disparities are enacted through the dental safety net. Drawing on fifteen months of ethnographic research in clinical and community settings in central Appalachia, a region that has come to symbolize the dental crisis in the popular imagination, I show how the dental safety net exemplifies health governance in a neoliberal milieu. A fragmented system characterized by a discontinuity that starkly contrasts the model of health care generally advocated in both private and public medical systems, I argue that the dental safety net in far southwest Virginia does not merely fail to relieve the suffering of marginalized people but also can produce it. For example, the constitution of publicly-funded and charitable dental care can serve to routinize and even incentivize excess extractions among low-income adults while exempting preventive or restorative care. In addition to its effects on underserved patients, the dental safety net is a site through the fraught and contradictory relationships of dental providers and the sociopolitical stakes of the pursuit of oral health equity can be understood. For example, the flexible teamwork arrangements prized in private practice, when posited for the dental safety net, are often interpreted by dentists as risks of pluralization and threats to professional hierarchy that must be contained through legislative means. Borrowing from the crude classificatory scheme used to screen teeth quickly, I show how the dental safety net is decayed, as it bears the wear of overuse beyond maintenance; missing, or better described as an absence than a presence; and filled, like a cavitated tooth or a canaled dental root, with manufactured solutions of variable standards and longevity.

Background. An online research network was set up among 11 dentists and 2 researchers in Montreal to test the feasibility of data collection over one year. Objectives. We evaluated the pilot participants' experiences and their perspectives regarding its potential utility. Methods. One-on-one qualitative interviews with 4 researchers, 4 dentists, and 3 policy makers. Interviews were recorded on audiotape and transcribed for coding and interpretation. Results. Although feasibility of data collection was evident in the pilot results; qualitative data revealed the limitations of the pilot, the unmet expectations, and the lack of impact of research findings. In terms of potential utility; the participants expressed interest in research, online communication and continuing education. Qualitative analysis revealed differences in perspectives and shared interests among the participants. Conclusion. An online research network can reduce the gap between research and practice. However, to attract participants, it must consider the needs and expectations of those involved.

Thesis (PhD)--Stellenbosch University, 1998.
Some digitised pages may appear illegible due to the condition of the original microfiche copy
ENGLISH ABSTRACT: see item for full text.
AFRIKAANSE OPSOMMING: sien item vir volteks.

Dentists have traditionally been the sole gatekeepers to the delivery of primary care dental services. Direct Access, a measure that allows Dental Care Professionals to see patients without a referral from a Dentist, is a fundamental change to this long-standing principle. This thesis systematically explores the attitudes of stakeholders across the micro, meso and macro levels of dentistry towards Direct Access in two distinct health care systems, the Netherlands and the UK.Direct Access was introduced in the Netherlands in 2006 and subsequently introduced in the UK in 2013. This study uses a qualitative approach to explore the attitudes towards the introduction of Direct Access in both of these states. It presents the results of semi-structured interviews with 74 participants (individually or as part of a group) including Students, Dental Care Professionals and Dentists at the micro-level, representatives of Professional Associations, Insurers and Dental Schools at the meso-level and Policy Makers at the macro-level. The results of this study show a significant range of attitudes towards Direct Access, but reveal a degree of consensus within individual stakeholder groups towards the reform’s introduction and impact. Dental Care Professionals interpret the introduction of Direct Access as recognition of their capabilities and expect it to primarily benefit patients through access to care and expertise. Dentists were more likely to view the introduction of Direct Access in terms of competition or professional persecution, with the impacts considered from a professional or financial viewpoint. Policy Makers saw potential for Direct Access to realign dental workforces and services to contemporary care needs. Attitudes at the meso level demonstrated the greatest variety and were more influenced by the idiosyncrasies of their respective health care system. In comparing the attitudes towards Direct Access in the Netherlands and the UK there were several differences, such as in the support of the Direct Access by Principal Dentists, however many of these can be explained by differences in healthcare funding and the time difference between the two reforms. Despite these differences stakeholders in both states felt that while Direct Access had the potential to create significant impacts on a range of issues (including professional competition, patient access to care, the reduction of care costs to patients and the state, the redistribution of dental tasks and the remodelling of the dental workforce) it was unlikely to do so in either the Netherlands or the UK. Flaws in the Direct Access regulations, legal obstructions to crucial procedures and imbalances in street-level professional power were perceived to obstruct Direct Access. Rather than revolutionising dental services Direct Access has been implemented selectively in the interest of dental practices.

Philosophiae Doctor - PhD
This study has shown conclusively that the oral health policy processes has not achieved the desired goals in both South Africa and Nigeria, and that greater advocacy for oral health is required in both countries.

Orientadores: Stela Márcia Pereira, Gláucia Maria Bovi Ambrosano
Dissertação (mestrado profissional) - Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba
Made available in DSpace on 2018-08-23T01:39:29Z (GMT). No. of bitstreams: 1 Menezes_LauradeFreitas_M.pdf: 1056891 bytes, checksum: 7814a88405461b90fc450386cd1c516b (MD5) Previous issue date: 2013
Resumo: Este estudo seccional investigou o impacto dos Centros de Especialidades Odontológicas (CEOs) nos indicadores de procedimentos da atenção secundária no Estado de São Paulo, bem como sua relação com variáveis econômicas. A amostra contou com os 645 municípios do estado, divididos segundo a presença e ausência dos CEOs, no ano de 2009. As variáveis dependentes analisadas foram os procedimentos de endodontia, periodontia e cirurgia oral menor e as variáveis independentes selecionadas foram cobertura dos Centros de Especialidades, renda per capita e PIB per capita. A análise estatística dos dados foi feita através de teste Qui-quadrado e regressão logística múltipla, ajustada para a co-variável porte municipal. Como resultado, observou-se que os municípios que têm CEO apresentaram um maior número de procedimentos quando comparados aos que não o possuem (p<0,0001). A presença do CEO (p=0,0001; OR:49,06); (p<0,0001; OR:9,59); (p<0,0001; OR:26,39) foi considerada determinante para o maior número de procedimentos clínicos de Endodontia, Periodontia e Cirurgia Oral Menor, respectivamente. Pode-se concluir que os Centros de Especialidades Odontológicas impactaram, de forma substancial, o acesso aos serviços de atenção secundária no estado de São Paulo, independente do porte municipal
Abstract: This cross-sectional study investigated the impact of Specialized Dental Clinics (SDC) on indicators of secondary care procedures in the state of São Paulo, as well as its relation to economic variables. The sample consisted of the 645 municipalities in the state, with and without SDC in 2009. The dependent variables analyzed were endodontics, periodontics and minor oral surgery procedures and independent variables selected were specialized coverage, per capita income and per capita GDP. The statistical analysis was performed using chi-square test and multiple logistic regression, adjusted for covariate municipal size. Results showed that counties with SDC presented greater number of procedures when compared with those who do not have (p <0.0001). The presence of the SDC (p = 0.0001, OR = 49.06) (p <0.0001, OR: 9.59), (p <0.0001, OR: 26.39) was considered decisive for the largest number of clinical procedures of Endodontics, Periodontics and Minor Oral Surgery, respectively. In conclusion, Specialized Dental Clinics impacted access to secondary care services in the state of São Paulo, regardless of municipal size
Mestrado
Odontologia em Saude Coletiva
Mestra em Odontologia em Saúde Coletiva

Submitted by Maria Creuza Silva (mariakreuza@yahoo.com.br) on 2014-10-01T17:24:16Z No. of bitstreams: 1 DISS MP DAYSE MATOS. 2008.pdf: 715909 bytes, checksum: 2c4700d1e92ea57f87f18e5890d9ca5c (MD5)
Approved for entry into archive by Maria Creuza Silva (mariakreuza@yahoo.com.br) on 2014-10-02T16:39:28Z (GMT) No. of bitstreams: 1 DISS MP DAYSE MATOS. 2008.pdf: 715909 bytes, checksum: 2c4700d1e92ea57f87f18e5890d9ca5c (MD5)
Made available in DSpace on 2014-10-02T16:39:28Z (GMT). No. of bitstreams: 1 DISS MP DAYSE MATOS. 2008.pdf: 715909 bytes, checksum: 2c4700d1e92ea57f87f18e5890d9ca5c (MD5)
Problemática: o Ministério da Saúde, através da Política Nacional de Saúde Bucal (PNSB), vem disseminando ações que apontam para a reorganização da atenção à saúde bucal em todos os níveis de atenção. Neste sentido, um município de médio porte da Bahia tem buscado organizar os serviços odontológicos através da implementação de protocolos assistenciais e ampliação da atenção especializada. Objetivo: Este estudo avaliou o componente da integralidade na assistência à saúde bucal, no âmbito da atenção básica e de média complexidade nesse município. Metodologia: Foi um estudo de caso, descritivo, onde foram realizadas entrevistas com informantes-chave em cinco equipes de atenção primária e usuários de três delas, além da análise documental que possibilitou a construção do modelo lógico da intervenção. Resultados: Os resultados demonstraram que houve certa apropriação dos executores com relação à integralidade no Protocolo Municipal, especialmente no que se refere à continuidade do cuidado. Houve diferenças entre as equipes entrevistadas na utilização do protocolo, o que evidencia a importância da supervisão e acompanhamento de seus processos de trabalho. Conclusão: Como recomendações, sugere-se a ampliação da oferta de serviços e organização de um sistema de marcação permanente de consultas odontológicas, com triagem diária de casos novos com maiores danos e riscos, via acolhimento, articulado com ações educativas na Unidade Básica de Saúde, implantação do tratamento endodôntico multirradicular no serviço público especializado, ampliação da oferta de prótese, cirurgia e ortodontia, além da redefinição das cotas de especialidades para unidades básicas, segundo perfil epidemiológico.

Objetivo: Estudos demonstram progressos na promoção da equidade em certos níveis da provisão de serviços no SUS. O objetivo deste trabalho foi verificar a aplicação deste princípio constitucional na provisão de serviços públicos odontológicos no Estado do Paraná, partindo do conceito de equidade vertical descrito na legislação brasileira. Método: Este estudo ecológico analisou indicadores de alocação de recursos, oferta e utilização dos serviços odontológicos para municípios do Paraná, 2003. Os dados foram obtidos através de relatórios administrativos, referências bibliográficas, e bancos oficiais disponibilizados na Internet. Utilizando estatísticas não paramétricas, através do programa SPSS 8.0 1997, analisou-se a associação entre indicadores de serviços odontológicos e de condição socioeconômica. Resultados: Identificou-se tendência redistributiva dos recursos federais transferidos aos municípios para Atenção Básica, intensificada a partir do lançamento do Programa Saúde da Família. Observou-se ainda tendência pró-equidade na oferta e utilização dos serviços odontológicos em Atenção Básica. Porém, quando um indicador de capacidade de resposta do sistema de saúde foi considerado, duas situações ocorreram: para municípios com sistemas de saúde melhor avaliados, a provisão de serviços odontológicos associou-se positivamente com os indicadores socioeconômicos; para os demais verificou-se associação negativa. O PSF apresentou características mais equânimes do que outras políticas de saúde bucal. Conclusões: Foram identificados progressos quanto à equidade na provisão de serviços públicos odontológicos no Paraná, associados principalmente com a implantação do PSF com equipes de saúde bucal. Argumenta-se que estes progressos estão relacionados com a capacidade de alguns municípios com piores condições de vida desenvolverem boas respostas dos sistemas de saúde.
Objective: Studies have shown progresses on the promotion of equity in the provision of some health services in the context of SUS. This study aimed to verify if this constitutional principle has been applied to the provision of dental public services in the state of Paraná, considering the concept of vertical equity as described in the Brazilian law. Methods: This ecological study assessed resources, supply and utilization of dental services in towns of Paraná, 2003. Data were obtained from administrative reports, bibliographic references, and official databases available on web. The appraisal of association between indices assessing dental services and socioeconomic status used non parametric statistics, performed by the SPSS 8.0 1997 software. Results: A redistributive trend was identified for federal resources addressed to municipalities for primary health care. The supply and utilization of dental services in units of primary health care also presented a pro-equity trend. However, when considering an index of responsiveness of health systems, two situations were identified: for towns with better-off health systems, the provision of dental services was positively associated with socioeconomic indices; while the remaining towns presented a negative association. The Health Family Program (PSF) presented a more equitable feature than other dental health policies. Conclusions: Progresses on the promotion of equity in the provision of dental public services at Paraná were identified, mainly associated to the implementation of PSF with dental teams. They were discussed as associated with the ability of some municipalities presenting poorer life conditions developing good answers for their health systems.

A assistência ortodôntica, que de forma incipiente, já se fazia presente no SUS, foi revigorada com a criação dos Centros de Especialidades Odontológicas (CEOs) pela Política Nacional de Saúde Bucal (PNSB), lançada em 2004. No entanto, as informações acerca dos dados dessa assistência ainda permaneciam desconhecidas. Surgiram então as questões: onde se localizam os centros que englobam esse tipo de atenção? Como se desenvolve a prática ortodôntica nesses locais? Quais são os problemas presentes neste processo? Neste sentido, a descoberta de respostas a essas perguntas, constituiu-se no objeto desta tese. Investigar a localização dos CEOs e outros centros de saúde bucal de todo o país que prestam serviços ortodônticos; lançar um olhar sobre a Saúde Pública dos municípios que os sediam; observar o modus operandi dessas ações ortodônticas. Em seguida, em um exercício prospectivo, discutir os caminhos para incrementá-las tornando-as mais efetivas. Através das Coordenações Estaduais de Saúde Bucal (CESBs), foram localizados todos os serviços ortodônticos públicos do país; em seguida solicitou-se junto aos gestores e/ou gerentes dos mesmos informações relativas ao que acontece em termos de programação ortodôntica intramuros. Foram detectados 42 serviços públicos de Ortodontia presentes em 39 municípios de todo o Brasil. Os dados obtidos referentes ao atendimento ortodôntico foram analisados e mostraram problemas na ordem de recursos humanos, de financiamento, de triagem e referência além da ausência de um protocolo clínico abrangente, norteador dessas ações. Apontou-se assim na direção de se discutir nova idéias acerca dessas questões. A Ortodontia definitivamente está em pauta no SUS e, por ser uma experiência um tanto quanto incipiente, carece de alguns ajustes. Ajustes esses discutidos em um protocolo de conduta adaptável à realidade de cada município. Neste protocolo são apontados elementos indicadores de uma maior eficácia técnica e uma maior viabilidade política e financeira no processo de aproximação Ortodontia -SUS.
Orthodontic care, which has been offered by the SUS, albeit in an incipient manner, was reinvigorated with the creation of the Dental Specialty Centers (CEOs) by the National Oral Health Policy (PNSB), launched in 2004. However, information about data regarding this care remained unknown. This led to the following questions: Where are the centers that include this type of care located? What type of orthodontic care is offered at these locations? What are the problems related to this process? In this sense, the present thesis object was to discover answers to these questions. To investigate the location of the CEOs and other oral health centers throughout Brazil that offer orthodontic care; examine the public health of the municipalities where they are located; observe the modus operandi of these orthodontic actions. Next, in a prospective exercise, the study discussed the ways to increment them to make them more effective. Through the State Oral Health Coordinators (CESB), all public orthodontic services in Brazil were located, and the managers and/or administrators of these services were asked to provide information regarding the intramural orthodontic programming provided. Forty-two public orthodontic services were found in 39 municipalities throughout Brazil. The data obtained referring to orthodontic treatment were analyzed and demonstrated problems in the areas of human resources; financing; triage and reference, in addition to the lack of a broad clinical protocol, to guide these actions. They also pointed to the need to discuss new ideas about these issues. Orthodontics is definitively part of the agenda at the SUS, and since this is a rather incipient experience, it still needs some adjustment. These adjustments have been discussed in a protocol of conduct that can be adapted to the reality of each municipality. In this protocol, elements leading to greater technical effectiveness and increased political and financial feasibility are indicated for the process of inclusion of Orthodontics at SUS.

Esta tese tem por objeto o processo de regionalização das ações de média complexidade e da oferta de próteses dentárias no âmbito da Política Nacional de Saúde Bucal (PNSB). Foram realizadas duas pesquisas fundamentais para o entendimento desse processo: a primeira esteve voltada para o levantamento da descrição da oferta de ações especializadas e de próteses dentárias nos Planos Diretores de Regionalização (PDR) nas 27 unidades federadas do país. A segunda pesquisa verificou a cobertura por Equipes de Saúde Bucal (ESBs) na Estratégia de Saúde da Família (ESF) e a distribuição dos 844 Centros de Especialidades Odontológicas (CEOs) e dos 526 Laboratórios Regionais de Próteses Dentárias (LRPDs) implantados até setembro de 2010 nas regiões de saúde do Brasil dos 27 estados da federação. Essas pesquisas permitiram concluir que: os PDRs, na grande maioria dos estados brasileiros, não contribuíram para a organização regionalizada da distribuição de CEOs e LRPDs no Brasil. A cobertura por Equipes de Saúde Bucal é heterogênea, com predominância da Região Nordeste e dos municípios de pequeno porte, em detrimento das capitais e dos estados das regiões Sul e Sudeste. No tocante à distribuição das unidades CEO e LRPD pelas regiões de saúde, a pesquisa mostrou que os critérios normativos para a seleção dos municípios a sediarem essas unidades vêm sendo cumpridos de forma precária na maior parte do país. Além disso, a distribuição dessas unidades não apresenta coerência com os princípios da regionalização prevista pelo Pacto de Gestão do SUS.
This thesis analyzes the process of regionalization of medium complexity actions and the supply of dental prostheses in the National Oral Health Policy (PNSB). Two main surveys were made for the understanding of this process: the first was aimed at describing the offer of specialized actions and dental prostheses according to the Regionalization Master Plans (PDR) in 27 federal units of the country. The second study examined the coverage by Oral Health Teams (ESBs) in the Family Health Strategy (ESF) and the distribution of 844 Specialized Dental Centers (CEOs) of 526 Regional Laboratories of Dental Prostheses (LRPDs) deployed by September 2010 in the Brazilian health regions in 27 states. These surveys showed that: the PDRs, in the vast majority of Brazilian states, have not contributed to the organization of regionalized distribution of CEOs and LRPDs in Brazil. Coverage by ESBs is heterogeneous, mostly in the Northeastern Region and in small towns, at the expense of the capital and the Southern and Southeastern states. Regarding the distribution of CEO and LRPD units by health regions, the survey showed that the normative criteria for the selection of municipalities to settle these units have been precariously completed in most of the country. Moreover, the distribution of those units is not consistent with the regionalization principles provided by the SUS Management Pact.

The need for health in general and oral health in particular is a basic and fundamental element for a quality life. Not everyone in America has access to basic oral health services. California, in particular, has greater challenges than other areas of the country in providing basic oral health services to everyone. This paper will discuss the problems of accessing oral health care, the importance of achieving oral health care, the necessity of maintaining oral health, the factors influencing oral health care access, and the response of the dental profession to the problems of access to oral health care. These problems will be examined from the following three perspectives: (1) Statewide Perspective, (2) Locality Perspective, (3) Individual Perspective. Potential solutions for vulnerable populations in accessing oral health care will be developed using data from quantitative and qualitative methodologies.

Contexto: A cárie precoce da infância (CPI), definida como a presença de um ou mais dentes decíduos cariados, perdidos por cárie ou restaurados em crianças com menos de 6 anos de idade, é um problema de saúde pública que afeta bebês e crianças pré- escolares em todo o mundo, determinando dor, problemas nas funções da fala e mastigatória, doenças sistêmicas e reflexos psicológicos. O tratamento da CPI é caro, pode requerer anestesia geral e hospitalização e a recidiva é freqüente. Desta forma, a literatura tem recomendado fortemente: (a) estudos de coorte que contribuam para o reconhecimento dos fatores de risco para a ocorrência de CPI; (b) ensaios clínicos que avaliem a efetividade de programas na redução de cárie nos primeiros anos de vida. Objetivos: Avaliar a efetividade a longo prazo de visitas às residências para orientar mães sobre práticas alimentares saudáveis no primeiro ano de vida na ocorrência de CPI e cárie severa da infância (CSI) aos 4 anos de idade. Também foram investigadas práticas alimentares no primeiro ano de vida associadas à ocorrência de CSI nesta população. Métodos: Um ensaio randomizado (grupo intervenção=200; grupo controle=300) foi realizado com mães de crianças que nasceram no Hospital de São Leopoldo, Brasil, no setor do Sistema Único de Saúde (SUS). O grupo intervenção recebeu aconselhamento mensalmente até o 6o. mês e de dois em dois meses até completar o primeiro ano de vida, baseado nos “Dez Passos para uma Alimentação saudável”, uma política nacional para atenção primária baseada nas diretrizes da Organização Mundial da Saúde (OMS). O aconselhamento nutricional foi realizado por estudantes de graduação de nutrição e incluía promoção do aleitamento materno exclusivo, introdução gradual de alimentação complementar, intervalos razoáveis entre as refeições e evitar alimentos com alta 4 densidade de gordura e açúcar. As práticas alimentares foram coletadas aos 6 e 12 meses de idade utilizando metodologia padronizada. As perdas nos 4 anos da coorte compreenderam 160 crianças (32%); 340 foram examinadas para diagnóstico de CPI e CSI na avaliação dos 4 anos de idade. Resultados: As perdas nos 4 anos da coorte compreenderam 160 crianças (32%); 340 foram examinadas para diagnóstico de CPI e CSI na avaliação dos 4 anos de idade; 53,9% (76/141) das crianças do grupo intervenção e 69,3% (138/199) do grupo controle apresentaram CPI, com um risco 22% menor no grupo intervenção (RR 0,78; IC 95% 0,65-0,93; NNT 6,5; IC 95% 3,9-20,0); 29,1% (41/141) das crianças do grupo intervenção e 42,7% (85/199) do grupo controle apresentaram CSI. O risco de ocorrer CSI foi 32% menor para o grupo intervenção (RR 0,68; IC 95% 0,50-0,92; NNT 7,3; IC 95% 4,2-29,4). O número de dentes cariados (lesão com ou sem cavidade), perdidos e restaurados (c1+eo-d) foi menor para o grupo intervenção (3,25) em relação ao grupo controle (4,15) (teste de Mann Whitney; p=0,023). A ocorrência de CSI aos 4 anos de idade (n=126/340; 37%) esteve associada com as seguintes práticas alimentares aos 12 meses, após análise multivariada: aleitamento materno ≥7 vezes ao dia (RR 1,97; IC 95% 1,45-2,68), consumo de alimentos com alta densidade de açúcar (RR 1,43; IC 95% 1,08-1,89), uso da mamadeira para outros líquidos além do leite (RR 1,41; IC 95% 1,08- 1,86), número de refeições por dia >8 (RR 1,42; IC 95% 1,02-1,97). Também estiveram associados à ocorrência de CSI: escolaridade materna ≤8 anos (RR 1,50; IC 95% 1,03- 2,19) e número de dentes erupcionados aos 12 meses. Conclusões: O aconselhamento nutricional nas visitas às residências foi efetivo em reduzir CPI e CSI e estes achados sugerem que a orientação sobre práticas alimentares durante o primeiro ano de vida é uma medida viável para prevenir cárie na infância em comunidades de alto risco. Práticas alimentares no início da vida que representam fatores de risco para severidade de cárie nos anos subseqüentes também foram identificadas. Como estas práticas são reconhecidas como de risco para outras doenças crônicas, estes achados podem contribuir para o desenvolvimento de ações integradas para a prevenção de cárie dentária e outros desfechos de saúde geral. Políticas que promovam as condições socioeconômicas, com ênfase para o nível de escolaridade, poderão contribuir para a diminuição de cárie na infância nesta população. Registro do ensaio clínico: clinicaltrials.gov; número NCT00629629.
Context: Early childhood caries (ECC), defined as the presence of one or more decayed, missing (due to caries lesions) or filled deciduous teeth in children under 6 years of age, is a public health problem that affects infants and preschoolers throughout the world, leading to pain, chewing difficulties, speech problems, general health disorders and psychological problems. The treatment of ECC is expensive, sometimes requiring general anesthesia and hospitalization, and the condition frequently returns a few months later. The literature has strongly emphasized the need for (a) cohort studies in order to recognize the risk factors for the occurrence of childhood caries (b) prospective clinical trials to test alternative methods to prevent caries development in the first years of life. Objectives: To assess the long-term effectiveness of home visits for advising mothers about healthy feeding practices during the first year of life on the occurrence of early childhood caries (ECC) and severe early childhood caries (S-ECC) at the age of 4 years. Feeding practices in the first year of life associated with the occurrence of S-ECC in these children were also investigated. Methods: A randomized trial was carried out in mothers who gave birth within the public health system in Sao Leopoldo, Brazil (intervention group =200; controls = 300). The intervention group received the advice monthly up to 6 months and at 8, 10 and 12 months, based on the "Ten Steps for Healthy Feeding", a Brazilian national health policy for primary care, based on WHO guidelines. Advices were given by nutrition graduate students and included promotion of exclusive breastfeeding, gradual introduction of complementary foods; reasonable intervals between meals; and avoid high fat and sugar foods. Feeding practices were assessed using standardised methods at 6 and 12 months of age. Results: 160 (32%) children were lost in the four-year follow-up; 340 were examined for ECC and S-ECC occurrence at the fourth year assessment. ECC was found in 53.9% (76/141) of the children in the intervention group and 69.3% (138/199) of the controls, being 22% lower for the intervention group (RR 0.78; 95% CI 0.65-0.93; NNT 6.5; 95% CI 3.9-20.0); 29.1% (41/141) of the children in the intervention group and 42.7% (85/199) of the controls had S-ECC. The risk of S-ECC was 32% lower for the intervention group (RR 0.68; 95% CI 0.50-0.92; NNT 7.3; 95% CI 4.2-29.4). The number of decayed (white spots and cavities), missing and filled teeth (d1+mft) was lower for the intervention group (3.25) compared with the control group (4.15) (Mann Whitney U-test; p=0.023). S-ECC occurrence at four years of age (n=126/340; 37%) was significantly associated with the following feeding practices at 12 months: breastfeeding ≥ 7 times daily (RR 1.97; 95% CI 1.45-2.68), high density of sugar (RR 1.43; 95%CI 1.08-1.89), bottle use for liquids other than milk (RR 1.41; 95% CI: 1.08- 1.86), number of meals and snacks >8 (RR 1.42; 95% CI 1.02-1.97). Mother’s education ≤ 8 years (RR 1.50; 95% CI: 1.03-2.19) and number of teeth at 12 months were also associated with S-ECC. Conclusions: The home visits for dietary advice were effective in reducing ECC and S- ECC and our findings suggest that nutritional counseling during the first year of life must be considered as a feasible measure to prevent childhood caries in high-risk communities. Early feeding practices which represent risk factors for caries severity in subsequent years were also identified. Since these practices are recognized as risk factors for other chronic diseases, these findings may contribute to develop integrated interventions to prevent dental caries and general health outcomes. Future childhood caries control in this population is likely to benefit from policies that improve socioeconomic status, with special attention to level of education. Trial registration: site clinicaltrials.gov; registration number NCT00629629.

Made available in DSpace on 2015-03-05T20:04:15Z (GMT). No. of bitstreams: 0 Previous issue date: 17
Nenhuma
O objetivo do presente estudo foi verificar a efetividade de um programa de orientação nutricional durante o primeiro ano de vida na incidência de cárie precoce da infância aos 12 meses de idade. Um ensaio clínico randomizado foi conduzido com 500 crianças (200 do grupo intervenção e 300 do grupo controle). As mães do grupo intervenção receberam orientação nutricional em visitas mensais aos domicílios até a criança completar 6 meses de idade e visitas de 2 em 2 meses até a criança completar 1 ano. A orientação se baseou nos "Dez Passos para uma Alimentação Saudável" uma diretriz do Ministério da Saúde com o apoio da Organização Panamericanda de Saúde. Aos 6 e 12 meses as mães de ambos os grupos responderam questionário sobre variáveis demográficas, socioeconômicas e dietéticas. Aos 12 meses, 157 crianças do grupo intervenção e 219 do grupo controle foram examinadas por um dos autores. O número médio de superfícies cariadas (incluindo manchas brancas) e a incidência de cárie foram comparadas entre os grupos.
Objectives: To assess the effectiveness of a nutritional advice program developed during the first year of life on ECC incidence at 12 months of age. Methods: A randomized clinical trial was carried out with 500 infants (200 intervention, 300 control). The mothers of the intervention group received nutritional advice in home visits at 10 days after the birth, followed by monthly visits up to six months and bimonthly visits at 8, 10 and 12 months. The orientation was based on the "Ten Steps for Healthy Nutrition", a national policy established by the Brazilian government with the support of the Pan American Health Organization. At 6 and 12 months, mothers of both groups were interviewed with regard to demographic, socioeconomic and dietary behavior variables. At 12 months, 157 children from intervention and 219 from control group were examined by one of the authors (C.A.F). Results: The mean number of decayed surfaces (including white spot lesions) and caries incidence were compared between the groups. There

A população mundial vem envelhecendo, diante dessa premissa a Organização Mundial de Saúde (OMS), bem como, o Ministério da Saúde (MS) do Brasil, vem buscando adaptar-se a esta realidade através de políticas públicas capazes de promover o envelhecimento ativo e da atenção à saúde adaptada às necessidades da população idosa. A OMS propôs a adequação da Atenção Primária à Saúde (APS) às necessidades dos idosos. O Brasil, por sua vez, segue as orientações da OMS, dentro da linha de cuidado voltada para a saúde dos idosos, na Estratégia de Saúde da Família e dentro da Política de Atenção à Saúde da Pessoa Idosa. No entanto, ainda não há evidências quanto à avaliação da adequação destas políticas e de sua relação com a forma como os idosos percebem sua saúde geral e bucal. Desta forma, esta pesquisa teve como objetivo verificar a extensão do cuidado em saúde que é acessado por idosos moradores de dois distritos de Porto Alegre/RS, em relação ao preconizado para efetividade da Atenção Primária à Saúde, e realizar um censo das unidades de saúde de APS dos mesmos distritos a fim de estabelecer uma relação entre os dados empíricos levantados e: i) Políticas de Saúde relacionadas com a Atenção Primária à Saúde voltadas às necessidades das pessoas idosas, ii) autoavaliação de saúde geral e iii) percepção de saúde bucal. A metodologia do estudo contou com um estudo teórico realizado através de um levantamento de documentos, um estudo epidemiológico de base populacional de delineamento transversal e um censo de unidades de saúde. Os resultados deste estudo apontam para uma realidade distinta entre o que as Políticas voltadas para os idosos preconizam e o que é oferecido para os idosos. Foram observadas limitações em relação ao acesso, longitudinalidade, integralidade e qualidade do cuidado. Além disso, foi possível observar que em relação à autoavaliação de saúde os resultados mostraram associações entre a avaliação positiva da saúde e fatores psicossociais (sintomatologia depressiva), características pessoais (nº de morbidades) e ambientais (orientação do serviço para a APS). Já em relação à percepção de saúde bucal, os resultados apontaram associação com determinantes primários (satisfação com último atendimento odontológico, resiliência e renda suficiente para as necessidades da família), comportamentos em saúde (hábito tabágico) e condições de saúde bucal (número de dentes e presença de restos radiculares). A conclusão que se chegou a partir de tais resultados é que há uma necessidade premente de ampliação do acesso e qualificação do cuidado para que a Atenção Primária disponibilizada para os idosos que vivem nos distritos Lomba do Pinheiro e Partenon em Porto Alegre possa ser realmente considerada adequada às necessidades dos idosos. Além disso, é necessário que se leve em consideração o papel da Atenção Primária a saúde na avaliação da sua própria saúde e na percepção de saúde bucal por parte de idosos.
The world population is aging. In response to those trends the World Health Organization (WHO), as well as the Brazilian Ministry of Health (MH), are aiming at tackling such matters through public policies that promote active aging through health care adapted to the needs of the elderly population. The WHO has proposed an Age-friendly Primary Health Care (PHC) that lies in accordance with the needs of the elderly. In Brazil, the WHO guidelines are followed within older people care provision, in the Family Health Strategy, and within the National Health Policy for the Elderly Person. However, there is still no evidence concerning the assessment of adequacy of these policies and its association with how older people perceive their general and oral health. Thus, this study aimed to verify the extension towards primary health care provided by health services accessed by older persons living in two sanitary districts of Porto Alegre/RS in relation with the recommendation in terms of effectiveness of primary health care. In addition, a census of the primary health care services of the two sanitary districts was carried out forming, along with the epidemiological survey, the basis of the empirical data that allowed establish a relationship with: i) Health Policies related to Primary Health Care and targeting on the needs of older persons, ii) self-rated health and iii) self-perceived oral health. The methodology included: theoretical study made by a documental research, a cross-sectional population-based epidemiological study and a health PHC services census. The results of this study show a distinct reality between what policies targeting older persons recommend and what is actually provided, limitations in terms of access, longitudinally, comprehensiveness and quality of care were observed. Furthermore, it was observed that positive self-rated health was associated with psychosocial factors (depressive symptomatology), personal characteristics (number of morbidities) and environmental characteristics (orientation towards PHC Attributes). Self-perceived oral health was associated with primary determinants of health (satisfaction with prior dental appointment, resilience and income that was enough to meet family needs), 17 health behaviors (smoking habit) and oral health status (number of teeth and of root remnants). Concluding, there is an urgent need to increase access and to qualify care so that Primary Health Care services made available for older people, at least for those who live in the Lomba do Pinheiro and Partenon sanitary districts of Porto Alegre/RS, reach its goals of providing adequate and resolutive care that is adequate to the needs of the elderly. Furthermore, it is necessary to take into account the role of Primary Health Care on the rate of health and perception of oral health by the elderly. Still, advances in relation to equity and quality of care in respect to primary health care professionals continued education attainment were observed.

Botswana has been experiencing high rates of recidivism and prison overcrowding, but the causes of these problems have not been explored. Thus, this qualitative study was conducted to investigate whether the denial of legal representation to criminal defendants tried in the customary courts is one of the causes of high rates of recidivism, prison overcrowding, or both. The main research question addressed a possible relationship between these factors and the denial of legal representation, and the study was guided by the punctuated equilibrium theory and the policy feedback theory. Data were collected through semi structured interviews with 10 released first offender prison inmates, 10 released recidivist prison inmates, and 10 professional participants from disciplines in the criminal justice system in addition to reviewing statistics and scholarly research. Data were analyzed through detailed description, categorical aggregation, direct interpretation, which led to naturalistic generalizations and patterns. The results indicated that the denial of legal representation to criminal defendants tried by customary courts appeared to contribute to both recidivism and prison overcrowding, which may undermine public safety and security. The implications of the study for positive social change include informing policy-makers of the need to reform the policy on legal representation to ensure that criminal defendants tried in the customary courts receive fair trials. The additional implications for positive social change include impacting rates of recidivism and prison overcrowding and enhancing community safety and security.

A case study of the conservative and allegedly climate denying think tank American Enterprise Institute and its usage of climate policy delaying discourse. By applying William Lamb et al.'s model of the discourse climate delay, this essay seeks to describe and analyse if and how American Enterpise Institute uses climate delaying discourse. The study is based on published texts from the American Enterprise Institute and the analysis is performed in two steps. Firstly, by conducting an argumentation analysis using the Toulmin model on the material to discern the main arguments of the texts. Secondly, by applying Lamb et al.'s model on the arguments to discern if any of the climate policy delaying discourses are used. This study finds that almost all of Lamb et al.'s described discourses are used by the think tank and that they are used in several different ways and with different implications. This study can expand the understanding of how climate denial focused on climate policy manifests and how climate delaying discourse is used. Moreover, the results of this study further proves what previous research has indicated: That climate denialists are changing tactics and are focusing on how to affect climate policy for their own benefit.

This dissertation analyzes the case of organized climate change denial in the United States as a manifestation of the power of the policy planning and opinion shaping networks in the US. It uses a variety of power structure research techniques to put together a topographical study of a fossil fuels network sitting at the core of a wider conservative network which sits at the core of the policy planning and opinion shaping processes. The connections between the core fossil fuels network and wider conservative policy network are examined at length. Using climate change denial as the case allows for the study of how a distinct industry— fossil fuels—can organize a faction which can help set the ideological agenda of the wider corporate and conservative networks. A power elite theoretical approach outlined by Domhoff is used, and the conclusions that may be drawn from this case study support the usefulness of that approach. I also find that the case at hand illustrates how Domhoff’s model may be extended and augmented in light of the strategic and tactical innovations employed by those in the climate change denial faction. Although elites have often tried—with varying levels of success—to employ at least a veneer of populist support in formulating policy, climate change denial employs a new level of sophistication in then fossil fuels’ faction’s long-term strategic planning and investment. This faction’s ability to wrest ideological control of much of the tea party movement and bring that party's policy aims into lie with its own allowed for the addition of a powerful populist element to the climate change denial tactical repertoire. Similarly, new secrecy techniques go far beyond those used by elites in the past, reflecting a new set of needs on the part of the individuals and groups involved in the policy network and necessitating the augmentation of the existing network with specialized entities.

Federal disaster declarations are authorized by the president under the provisions of the Robert T. Stafford Disaster Relief and Emergency Assistance Act of 1988. Prior studies have found varying levels of political influence associated with the declaration process. Factors including electoral votes, reelection years, congressional committee appointments, geographic location, and party favoritism have been implicated in claims of inequity associated with the distribution of federal disaster assistance. Compounding these concerns is evidence of recurring problems associated with disparities in the long-term recovery from disasters based on social and economic factors. This dissertation is a response to the call for further research into the political dynamics of disaster declarations. Multivariate hierarchical analytical techniques and key stakeholder interviews were utilized to systematically investigate perceived inequities in the implementation of federal disaster policy and the consequences of those inequities with respect to health-related recovery in communities that had differential access to federal resources. The research findings counter broad claims of political motive in the distribution of federal resources after disasters. However, the observation of a disproportionate post disaster stress-related disease burden in portions of the study area is indicative of a procedural inequity that must be addressed. The recently enacted Sandy Recovery Improvement Act of 2013 calls for a review of eligibility criteria for disaster declarations. The findings of this research are intended to contribute to the review process and assist in the reformulation of public policy in order to address the unique needs of previously unconsidered at-risk populations.

Les attaques cybernétiques causent une perte importante non seulement pour les utilisateurs finaux, mais aussi pour les fournisseurs de services Internet (FAI). Récemment, les clients des FAI ont été la cible numéro un de cyber-attaques telles que les attaques par déni de service distribué (DDoS). Ces attaques sont favorisées par la disponibilité généralisée outils pour lancer les attaques. Il y a donc un besoin crucial de contrer ces attaques par des mécanismes de défense efficaces. Les chercheurs ont consacré d’énormes efforts à la protection du réseau contre les cyber-attaques. Les méthodes de défense contiennent d’abord un processus de détection, complété par l’atténuation. Le manque d’automatisation dans tout le cycle de détection à l’atténuation augmente les dégâts causés par les cyber-attaques. Cela provoque des configurations manuelles de périphériques l’administrateur pour atténuer les attaques affectent la disponibilité du réseau. Par conséquent, il est nécessaire de compléter la boucle de sécurité avec un mécanisme efficace pour automatiser l’atténuation. Dans cette thèse, nous proposons un cadre d’atténuation autonome pour atténuer les attaques réseau qui visent les ressources du réseau, comme par les attaques exemple DDoS. Notre cadre fournit une atténuation collaborative entre le FAI et ses clients. Nous utilisons la technologie SDN (Software-Defined Networking) pour déployer le cadre d’atténuation. Le but de notre cadre peut se résumer comme suit : d’abord, les clients détectent les attaques et partagent les informations sur les menaces avec son fournisseur de services Internet pour effectuer l’atténuation à la demande. Nous développons davantage le système pour améliorer l’aspect gestion du cadre au niveau l’ISP. Ce système effectue l’extraction d’alertes, l’adaptation et les configurations d’appareils. Nous développons un langage de politique pour définir la politique de haut niveau qui se traduit par des règles OpenFlow. Enfin, nous montrons l’applicabilité du cadre par la simulation ainsi que la validation des tests. Nous avons évalué différentes métriques QoS et QoE (qualité de l’expérience utilisateur) dans les réseaux SDN. L’application du cadre démontre son efficacité non seulement en atténuant les attaques pour la victime, mais aussi en réduisant les dommages causés au trafic autres clients du FAI
Cyber attacks cause significant loss not only to end-users, but also Internet Service Providers (ISP). Recently, customers of the ISP have been the number one target of the cyber attacks such as Distributed Denial of Service attacks (DDoS). These attacks are encouraged by the widespread availability of tools to launch the attacks. So, there is a crucial need to counter these attacks (DDoS, botnet attacks, etc.) by effective defense mechanisms. Researchers have devoted huge efforts on protecting the network from cyber attacks. Defense methodologies first contains a detection process, completed by mitigation. Lack of automation in the whole cycle of detection to mitigation increase the damage caused by cyber attacks. It requires manual configurations of devices by the administrator to mitigate the attacks which cause the network downtime. Therefore, it is necessary to close the security loop with an efficient mechanism to automate the mitigation process. In this thesis, we propose an autonomic mitigation framework to mitigate attacks that target the network resources. Our framework provides a collaborative mitigation strategy between the ISP and its customers. The implementation relies on Software-Defined Networking (SDN) technology to deploy the mitigation framework. The contribution of our framework can be summarized as follows: first the customers detect the attacks and share the threat information with its ISP to perform the on-demand mitigation. We further develop the system to improve the management aspect of the framework at the ISP side. This system performs the alert extraction, adaptation and device configurations. We develop a policy language to define the high level policy which is translated into OpenFlow rules. Finally, we show the applicability of the framework through simulation as well as testbed validation. We evaluate different QoS and QoE (quality of user experience) metrics in SDN networks. The application of the framework demonstrates its effectiveness in not only mitigating attacks for the victim, but also reducing the damage caused to traffic of other customers of the ISP

This thesis examines the discursive interaction between the police officer and the suspected paedophile in the investigative interview. A review of the literature revealed that paedophiles talk about their offences in terms of conventional relationships, personal bonds and emotions whilst being discrete about the sexual aspects of their activities. In the investigative interview, police officers must establish accountability, avoid emotional talk and encourage paedophiles to discuss their criminal activities in terms of direct, agentic detail. Given these two distinct approaches to the description of unlawful sexual contact, there is the potential for difficulties to arise in the elicitation of information in the investigative interview. This thesis explores how police officers and paedophiles negotiate an account of `what really happened' whilst managing conflicting descriptions of the offence. This thesis also evaluates the relative effectiveness of interviewing strategies used by the police for maximising admission in suspected paedophiles. Eleven interviews conducted at Leicestershire Police Constabulary were transcribed using the Jefferson system of notation. The offenders were male and aged between 34-54 years. The victims were male (n=5) and female (n=6) and aged between 5-13 years. Content analysis confirmed that police officers and paedophiles do describe sexual acts between adults and children differently. A `physical' repertoire of explicit sexual terms was used more frequently by the police officers, while the suspects exhibited a preference for an `emotiörial' repertoire of relationship talk and euphemisms (x2 = 125.518; df = 1; p