Tesi sul tema "Public health code"

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Bachelors
Health and Public Affairs
Legal Studies

The purpose of this policy analysis is to critically review the Welfare and Institutions Code§ 369.5, which regulates the authorization of psychotropic medication to treat mental disorders among California's dependent children. While these medications have been proven effective forms of treatment, there is a growing concern about their life threatening side effects.

Research has concluded that children exposed to chronic child abuse and neglect often present with behaviors indicative of trauma. The Diagnostic and Statistical Manual of Mental Disorders 5th Edition has included criteria for Post-Traumatic Stress Disorder (P.T.S.D.) in children. However, the Welfare and Institutions Code§ 369.5 does not mandate psychiatrists and pediatricians to first rule out trauma prior to diagnosing foster children with one or more behavior, mood, or psychotic disorders.

Results support amending child welfare legislation and policies to reflect a shift toward trauma-focused services, thereby reducing the reliance on potentially dangerous pharmaceutical drugs.

The majority of building code development and implementation practices are normally connected with the progress of construction community changing awareness, needs and perspectives, advanced technology in construction and new level of knowledge. Unproven practices and the technology of building code development and implementation in case of insufficient and outdated codes, the use of unproven advanced codes of other countries, or the infringement of the existing codes, in most cases, could lead to a large number of shortcomings of minimum requirements of public health, safety and general welfare, and poor quality of buildings. Every aspect of a building code development and implementation practice could be influenced by insufficiencies and infringements in building codes/regulations that could cause buildings failures. Generally, the success of a building code development and implementation practice is directly connected with the involved insufficiencies and infringements in the framework of building code (legal, Administrative, technical, & social), i.e. faults of building code development and implementation should be successfully resolved in order to come to an end of a building project assuring code's objectives (public health, safety and general welfare). One of the early research problems of building code development and implementation practice was conducted by Productivity Commission (2004) where the research organized and categorized the causes of shortcomings of BC according to four main functions of building code, including legal, administrative, technical, and social functions. Productivity Commission Research had been the starting point of research problems of building codes in Kuwait. For the past 20 years, many researchers have high numbers of categories, components and rankings to explain different types of insufficiencies and infringements in building codes/regulations. However, these categories and rankings produce inconsistent and overlapping cause and impact factors. In addition, researchers and practitioners at this point tend to focus on the technical and administrative sides related to the issues of building codes development and implementation, and neglecting the importance of legal and social sides. Legal issues like finding a law to prepare and enforce building codes, cover of insurance companies, building materials testing system, weak regulations related issues, building specifications, and clarity of regulation texts; as well as social issues like community awareness, issuing and enforcing legal court rules, deterrent punishments for violators, violations or cheatings in related issues, all of these were deemed not that critical by most reviewers. The research is specifically concerned with the insufficiencies and infringements in building codes/regulations which cause shortcomings of minimum requirements of public health, safety and general welfare, and how related cause and impact factors are selected and organized. Existing research highlights the need for further researches of how to relate between research and building regulations that are at present. There is evidence that construction industries around the world have little experience in this area (CIB TG37, 2001). The proposal within this research is to address this aspect of the debate by seeking to clarify the role of the four functions of building code; legal, administrative, technical, and social function as a frame of reference that stakeholder parties (building officials, design and construction professionals) might agree with and which should act as the basis for the selection and formation of occurrences of cause factors, and their iv impact on public health, safety and general welfare. The focus on the four functions of building code as a fault (cause) frame of reference potentially leads to a common, practical view of the (multi) dimensionality setting of fault (cause) within which cause factors may be identified and which, we believe, could be grounded across a wide range of practices specifically in this research of building code development and implementation. The research surveyed and examined the opinions of building officials, design and construction professionals. We assess which fault (cause) factors are most likely to occur in building and construction projects; evaluate fault (cause) impact by assessing which fault (cause) factors that building officials, design and construction professionals specifically think are likely to arise in the possibility of shortcomings of minimum requirements of public health, safety and general welfare. The data obtained were processed, analyzed and ranked. By using the EXCEL and SPSS for factor analysis, all the fault (cause) factors were reduced and groups into clusters and components for further correlation analysis. The analysis was able to prove an opinion on fault (cause) likelihood, the impact of the fault (cause) on the objectives of building code. The analysis indicates that it is possible to identify grouping of insufficiencies and infringements in building codes/regulations that is correspondent to the different parts of the framework of building code (legal, Administrative, technical, & social) these suggest three identified groups when viewing cause from the likelihood occurrence and four identified groups and their impact for each building code objective. The evidence related to the impact of building code objectives, view of cause, and provides a stronger view of which components of cause were important compared with cause likelihood. The research accounts for the difference by suggesting that a more selection and formation of cause and impact, offered by viewing cause within the context of a framework of building code, and viewing impact within the context of building code objectives (public health, safety and general welfare) allows those involved in building code development and implementation to have an understandable view of the relationships within cause factors, and between cause and impact factors. It also allows the various cause components and the associated emergent clusters to be more readily identified. The contribution of the research relates to the assessment of cause within a construction that is defined in the context of a fairly broad accepted view of the framework of building code (legal, Administrative, technical, & social). The fault (cause) likelihood construction is based on the building code framework proposed in this research and could facilitates a focus on roles and responsibilities, and allows the coordination and integration of activities for regular development and implementation with the building code goals. This contribution would better enable building officials and code writers to identify and manage faults (causes) as they emerge with BC aspects/parts and more closely reflect building and construction activities and processes and facilitate the fault (cause) administration exercise.

У роботі здійснено дослідження процесу реформування та адміністрування у галузі охорони здоров’я України. Вивчено методичні підходи до оцінювання ефективності реформування медичної галузі. Визначено поточні проблеми та перспективи реформування сфери охорони здоров'я в Україні. Акцентовано увагу на ключових засадах, які мають сприяти реформуванню галузі охорони здоров'я . Проаналізовано нормативно-законодавчу базу системи охорони здоров’я, та визначено необхідність створення єдиного нормативно – правового документу « Медичного кодексу України» та систему фінансування медичної галузі. Розглянуто діяльність в процесі реформування Державної Установи «Сумський обласний лабораторний центр МОЗ України» та його значення в створенні Центру громадського здоров’я в Сумській області , відповідно до міжнародних стандартів.
В работе проведено исследование процесса реформирования и администрирования в области здравоохранения Украины. Изучены методические подходы к оценке эффективности реформирования медицинской отрасли. Определены текущие проблемы и перспективы реформирования сферы здравоохранения в Украине. Акцентировано внимание на ключевых принципах, которые должны способствовать реформированию отрасли здравоохранения. Проанализированы нормативно-законодательная база системы здравоохранения, и определена необходимость создания единого нормативно - правового документа «Медицинского кодекса Украины» а так же система финансирования медицинской отрасли. Рассмотрена деятельность в процессе реформирования Государственного Учреждения «Сумской областной лабораторный центр МЗ Украины» и его значение в создании Центра общественного здоровья в Сумской области, в соответствии с международными стандартами.
The paper examines the process of reforming and administering health care in Ukraine. Methodical approaches to evaluating the effectiveness of medical industry reform have been studied. The current problems and prospects of healthcare reform in Ukraine are identified. Emphasis is placed on key principles that should contribute to the reform of the healthcare sector. The regulatory and legislative framework of the health care system is analyzed and the necessity of creating a single regulatory and legal document of the “Medical Code of Ukraine” and the system of financing the medical sector are determined. The activity in the process of reforming the State Institution “Sumy Oblast Laboratory Center of the Ministry of Health of Ukraine” and its importance in the creation of the Public Health Center in Sumy Oblast in accordance with international standards are considered.

Food service businesses in the United States have experienced millions of dollars in losses caused by foodborne illness outbreaks, which can lead to bankruptcy and business closures. More than 68% of all foodborne illness outbreaks occur in food service establishments. The purpose of this descriptive case study was to explore the strategies leaders of food service establishments use to implement food safety regulations. Force field analysis was the conceptual framework for this study. The population for the study consisted of 3 leaders of food service establishments located in the southeastern region of the United States. Data were collected using semistructured interviews and a review of the business policies and procedures that support compliance with critical food safety regulations. The methodological triangulation approach was used to assist in correlating the interview responses with company policies and procedures during the data analysis process. Yin's 5-step data analysis approach resulted in 3 themes: (a) organizational performance analysis for improvements in food safety, (b) strategies applied to improve food safety, and (c) stability of new strategies for food safety. The key strategies identified included adhering to the guidelines of food code and regulation, conducting employee training and awareness building, and working closely with food safety inspectors. The implications for positive social change include the potential to add knowledge to businesses, employees, and communities on the use of effective food safety strategies to minimize foodborne illnesses. Such results may lead to the improvement of service performance and long-term growth and sustainability of food service establishments.

O cuidado em liberdade de pessoas cumprindo medida de segurança no contexto de um CAPS III, tema do presente trabalho, inscreve-se num ponto de tensão entre as concepções da Reforma Psiquiátrica brasileira e as questões pertinentes às pessoas em conflito com a lei. O tema não tem acúmulo de conhecimentos, conforme evidenciado pela pesquisa bibliográfica. Este estudo demonstra como um sujeito cumprindo medida de segurança é acompanhado num serviço comunitário de saúde mental e sustenta a argumentação do direito ao cuidado em liberdade. Os objetivos são: conhecer como um CAPS III da Cidade de São Paulo se organiza para cuidar de uma pessoa cumprindo medida de segurança e quais os efeitos do cuidado para a vida dessa pessoa. Trata-se de uma pesquisa qualitativa que utiliza o Estudo de Caso como procedimento metodológico para a apreensão e compreensão dos dados empíricos. O marco teórico que norteia este estudo é a desinstitucionalização como estratégia de produção de direitos. São 13 (treze) os sujeitos do estudo entrevistados utilizando-se a entrevista semi-estruturada. O material empírico submetido à análise temática resultou nas categorias empíricas: 1) Narrativa da história de vida do Emanuel; 2) Processos de Trabalho em Saúde Mental; 3) Dispositivo para o cuidado em liberdade: o CAPS; 4) A Necessária Formação do Trabalhador da Saúde Mental. Resultados: na análise temática dos discursos foram identificados o objeto complexo do cuidado e suas necessidades, os agentes dos distintos processos de trabalho, os instrumentos e as finalidades destes processos de trabalho, ou o objeto transformado, isto é, um sujeito atravessado, tocado e interferido pelo cuidado. O CAPS é o lócus onde os processos de trabalho se organizam para dar conta das necessidades do objeto de cuidado, utilizando como instrumentos de intervenção: escuta, afeto, grupos, pintura, atendimentos individuais, equipe de referência, conhecimentos técnicos, projeto terapêutico singular e o projeto de geração de trabalho e renda na perspectiva da Economia Solidária. Aspectos positivos e negativos do processo de trabalho aparecem nos discursos, que revelam como os sujeitos entendem o CAPS, a constituição do projeto institucional do serviço, como o avaliam, a ações intersetoriais que o caso demandou e as questões da interface com a Justiça. Identificou-se nos discursos dos agentes dos processos de trabalho a necessidade de formação para a prática cotidiana do cuidado e preocupação com a questão da violência: como intervir e como prevenir. As informações específicas das pessoas em conflito com a lei também são abordadas no discurso dos entrevistados que evidenciam grande lacuna nesta área. Depreende-se dos discursos que a construção do Projeto Terapêutico Singular neste serviço pauta-se na construção de estratégias que visam responder às necessidades das pessoas, conforme as diretrizes das políticas públicas de saúde mental e da Reforma Psiquiátrica brasileira. As pessoas em conflito com a lei apresentam uma necessidade que é específica, particular, de agenciamento de possibilidade de defesa. Outros sujeitos podem demandar outras necessidades e os serviços, para serem efetivos, têm que atender todo mundo: têm que saber agenciar recursos para quem chega.
The care of people after a pleading insanity is made in freedom and can be done in a Mental Health Center (CAPS III), that is the theme of this master, and its a tension point at the conceptions of the brazilian Psychiatric Reform and people who have conflicts with the law. Theres no enough and significant accumulation of knowledge about this theme as the bibliography shows. This study can be used to make understandable as a person after the plea of insanity is followed in a treatment system in a community service of mental health. The goals: to know how a Mental Health Center of the city of São Paulo is organized to take care of people after a plea of insanity and what are the effects for this person. Its a qualitative study that uses the Study of Case as methodological procedure for the apprehension and understanding of the empirical data. The theoretical reference that guides this study was the deinstitutionalization as strategy for the production of rights. The 13 (thirteen) people of the study were interviewed, using a interview semi-structured. The empirical material after thematic analyzes showed: 1) Narrative of Emanuels life story; 2) work processes in mental health 3) A service for the treatment in freedom: the CAPS; 4) The necessary graduation of the worker in Mental Health. Results: In the Thematic Analyzes of the speech were identified: the complex object of care and its needs, the agents of the distinct processes of work, the instruments and its purposes of work processes: a person crossed, touched and interfered for the care. The CAPS is the setting where the work processes are organized to give support of the needs of this work object, and it uses instruments for intervention: as the listening, affection, groups, painting, individual consults, reference team, technic knowledge, Individual Therapeutic Projects and a project to generate employment and income in view of the Solidarity Economy. Positive and negatives aspects of the work process are also found in the speeches, what also shows that the people understand the CAPS, and the law of the institutional design of the service, such as assessing, the intersectoral actions demanded that are issues of interface with the justice. Were found in the speeches of the CAPS employees the need of studying to the daily practices of care and the concern with the violence matter: how the make an intervention and prevention. The specific information of people in debit with law are given also in the speeches of people that reveal a big gap in this area. People in conflict with the law have a need that is specific, particular, the possibility of defense. Other people can demand other needs and the services, for been effective, have to attend everybody: they need to be able to give resources for those arriving.

This project study addressed the problem of a decline in retention of students at a local allied health college. The need for allied health professionals is projected to exceed the availability by 2020, so it is important to identify strategies to help allied health students succeed. The purpose of this case study was to explore perceptions of students and faculty about motivating factors and learning strategies that foster successful progression in allied health programs. Ryan and Deci's self-determination theory, focused on the relationship between motivation and success, served as the framework for the study. Research questions addressed intrinsic and extrinsic factors that students and faculty identified as significant in motivating successful completion of core courses. Data collection included information from the college effective plan from the research site and face-to-face audio-recorded interviews with 10 allied health students and 5 faculty. Students were 18 years or older and enrolled in at least 1 core course in an allied health program; faculty taught at least 1 core course with at least 1 year of experience with allied health students. Interview data were analyzed through open coding to identify themes related to motivating student success in core courses. Significant motivating factors included improved quality of life (intrinsic) and a supportive learning environment (extrinsic). Motivating strategies for student success were active involvement in the learning process and hands-on learning. Findings from the study guided development of a 3-day learning community designed to support student success in core allied health courses. Positive social change may be impacted by motivating allied health students to succeed in order to meet the health care needs of clients.

The objective of this study was to determine the patterns of regulatory noncompliance, as identified by the U.S. Food and Drug Administration (FDA), and their effects on meta-analyses. In order to achieve these objective, three studies were undertaken: analysis of citations issued by FDA Investigators at the conclusion of an inspection; analysis of regulatory actions taken by the FDA towards clinical researchers based on the observations cited by FDA Investigators; and sensitivity analysis of meta-analyses based on the Agency’s determination of research misconduct, primarily the falsification of data. FDA Investigator citations were analyzed using Chi-Square analysis based on geographic location of the inspection, type of inspection, and type of violation. Temporal changes in the number of inspections and the violations cited were analyzed using bivariate Poisson regression models. Bonferroni correction was employed for temporal changes across the time period analyzed. Regulatory actions taken by the agency were analyzed via Chi-Square or Fisher’s exact test based on changes identified in previous publications, temporal changes, and differences between regulatory action types. Sensitivity analysis of meta-analyses identified through a systematic review were assessed both qualitatively and quantitatively for the effects of including publications of apixaban trials with significant FDA regulatory action, i.e. the comparison of odds ratio point estimate, upper and lower 95% confidence interval, both before and after consideration of falsified data. Under the FDA’s Bioresearch Monitoring program from 2007-2015, the number of inspections increased, but the rate of citation issuance per inspection decreased. One third of the violations were related to adherence to investigational procedures followed by informed consent violations and violations involving study records. During this same time period, 194 clinical researchers received a regulatory action based on FDA’s review of inspection results. Since 2007, rates of significant deviations had decreased. Lack of researcher supervision and submission of false information were cited more frequently for disqualification proceedings. A systematic review found 99 statistical analyses from 22 different meta-analyses available for sensitivity analyses. Nearly one-third resulted in a change in the conclusions reported in the originally published statistical analyses. In approximately the last decade, the number of violations cited during inspections under the Bioresearch Monitoring program has decreased; however, significant improvements can continue to be made regarding adherence to study procedures, the consenting of human subjects, and creation of adequate and accurate study documentation. Disqualification of clinical researchers is more likely to occur when researchers fail to supervise a clinical trial or false information is submitted to the FDA. Falsified data can make its way into the exploding field of meta-analyses, a study method that provides a concise and compelling method for the dissemination of medical intervention knowledge; however, this method can be highly unstable and can provide biased results. A robust sensitivity analysis that considers data quality from available sources can help ensure calculations of the best estimates.

Calcined coke is a high quality carbon material produced by calcining green petroleum coke. Calcining is the process of heating green petroleum coke in a kiln to remove excess moisture, extract all remaining hydrocarbons, and modify the crystalline structure of the coke into a denser, electrically conductive product. The final product, calcined coke, is primarily used to make carbon anodes for the aluminum industry and recarburizing agent for industries such as the steel industry. If not appropriately controlled, the calcining process could lead to excess production of particulate emissions from either handling or storing of raw coke, or from the stack emissions during the production of calcined coke. Though calcined coke has shown low hazard potential in human populations due to low volatile content, there remains some public health concern regarding the emissions from these facilities. This study is designed to evaluate the emissions of petroleum coke calcining facility and assess the public health concern from the processes engaged in the handling and storage of green coke as well as from the calcining process. The ambient air levels were measured from a calcining facility and compared with the standards promulgated by USEPA. The results showed that pollutant contribution from the facility, measured by monitoring carbon fraction of the emissions, was de-minimis. The current research also studied whether the exposure levels and health risks specified in various epidemiological studies correlate with the standards promulgated by USEPA to protect public health from petrochemical emissions.

Le droit des dispositifs médicaux est un droit qui depuis les années quatre-vingt-dix est encadré par le droit de l’Union européenne. En particulier, la directive générale adoptée en 1993 sur les dispositifs médicaux, maintes fois modifiée par la suite, constitue encore à l’heure actuelle le fondement de cette législation. Ce texte était censé harmoniser les législations nationales relatives aux dispositifs médicaux et garantir des normes de sécurité élevées afin d'inspirer une confiance au grand public. Il permet l'utilisation de ces produits dans tous les pays de l'Union européenne en posant un certain nombre de conditions (et d’évaluations), qui relèvent aussi d’un impératif d’ouverture au marché européen, d’autant que les dispositifs médicaux, contrairement aux médicaments, ne font pas l’objet d’une autorisation de mise sur ce marché. Elle a aussi pour particularité, comme toute directive européenne d’être appliquée et mise en œuvre dans les États membres au terme d’un processus législatif particulier qui est celui de l’Union européenne, faisant intervenir de multiples acteurs, à des degrés divers ˸ États membres, Institutions et professionnel de santé et industriel. L’ensemble de ce processus et ses incidences dans les États, en particulier en France, n’ont cependant pas suffit pour éviter certaines dérives, et interroge au regard du respect de la démocratie sanitaire
The law on medical devices is a law which since the 1990s has been framed by European Union law. In particular, the general directive adopted in 1993 on medical devices, which has been amended many times since then, still forms the basis of this legislation today. This text was intended to harmonise national legislation on medical devices and to ensure high safety standards in order to inspire confidenceamong the general public. It allows the use of these products in all EU countries by imposing a number of conditions (and assessments), which are also necessary to open up the European market, especially as medical devices, unlike medicines, are not subject to a marketing authorisation.It also has the particularity, like any European directive, that it is applied and implemented in the Member States at the end of a specific legislative process, which is that of the European Union, involving multiple actors, to varying degrees˸ Member States, institutions and health and industrial professionals. However, the whole process and its impact in the Member States, particularly in France, have not been sufficient to prevent certain abuses, and raises the following questions with regard to respect for health democracy

Previous studies have indicated that the promoters of the human filarial parasite Brugia malayi are unusual in that they do not exhibit the CAAT or TATAA sequences usually found in the core domains of promoters of most eukaryotic organisms. Analysis of the promoters of the ribosomal proteins showed that the region flanking the splice leader (SL) addition site plays an important role in transcription and may function as the core promoter domain in B. malayi. To test the hypothesis that the SL addition domain is the most important essential region of the ribosomal protein promoters, the SL addition site of the BmRPL13 gene was replaced with the SL addition domains from other ribosomal protein genes from B. malayi. The promoter activity of the replacement constructs were tested using a transient transfection dual luciferase assay. Promoter activity with RPL13 replacement constructs was correlated with that seen in the wild type promoters, suggesting that roughly 80% of the variations seen in promoter activity among ribosomal protein promoters is due to variation in the SL core promoter domain.

The development of new medical treatments for patients is limited by the challenges of recruiting clinical-research participants. In the United States, the Food and Drug Administration regulates the multidimensional approval process for new drugs, biologics, and medical devices to ensure consumer safety. The regulatory approval processes includes complex clinical trials that necessitate either healthy volunteers or patients who are willing to participate. The low enrollment rates of volunteers and patients willing to participate in clinical trials are resulting in significant delays in bringing new treatments to the market and substantially increasing development costs, for which consumers ultimately pay. The available research indicates that young adults and adolescents represent two of the lowest participating groups in clinical trials. Even though they are the next generation of consumers and patients, little to no research has examined the adolescent and young adult populations and their knowledge and perceptions of clinical research or their willingness to participate in clinical trials. Understanding these populations' perspectives and knowledge of the drug-development process and providing education regarding on this issue may have a profound, positive trickle-down effect on medicine, their personal well-being, and the well-being of the general public.

This study used a simple experimental design consisting of an intervention group and a control group. The intervention was a 10-minute educational video on participation in clinical research. Adolescents and young adults ( n = 527) were randomly distributed into the two groups. The knowledge, perceptions, and willingness to participate in clinical research were measured in both groups utilizing a 31-question survey instrument. The findings from this study may be used by educators, health care providers, patient advocacy groups, payers, and the pharmaceutical research and development industry to determine the best methods for educating adolescents and young adults on clinical research and trial participation.

The study concluded with a discussion of the importance of the role of leadership in social change and the process of igniting and sustaining such change. This process includes how, historically, public and private interests have come together to positively influence important public-health initiatives and, in turn, social change that holistically benefited all of society. Moving forward, leadership for social change could potentially deliver new and improved medical treatments in a timelier manner.

Auditing in health care has been recommended by many national organisations to improve patient safety and quality of care, despite inconclusive evidence to support its effectiveness. In South Africa, the National Core Standards for health establishments in South Africa (NCS) was published in 2011. The NCS recognises that staff are vital to ensuring that the health system delivers quality health care and therefore require protection against the risk of injury, infection and other occupational hazards, consistent with the South African Occupational Health and Safety act of 1993. The aim of this study was to determine: (a) the compliance of public sector primary healthcare (PHC) facilities with the NCS for occupational health and safety (OHS) and infection prevention and control (IPC), (b) the impact of the audits three years after baseline audits, at follow up self-assessment audits and (c) the reliability of self-assessment audits when compared to external audit results. This dissertation is divided in three parts. Part A is the study protocol which received ethics approval in March 2015. Part B is a structured literature review covering standards for health care, the impact and effectiveness of accreditation/certification/auditing in health care, interrater reliability and factors associated with OHS/IPC compliance. Previous studies have failed to address whether evaluating occupational health and safety or infection prevention and control standards using accreditation/certification in a primary healthcare, low and middle income setting is effective or reliable. Part C is the journal ready manuscript presenting the results of the study in the form of a manuscript for an article for a named peer reviewed journal. This was a cross-sectional study of NCS OHS/IPC audit data, with a longitudinal component, of a sample of public sector PHC facilities in the Western Cape province of South Africa between 2011 and 2015. Baseline PHC facility compliance with OHS/IPC measures was low. There was no significant improvement in compliance after three years. Poor inter-rater reliability indicates a large degree of measurement error. Practical implications of these results are the need to improve reliability of assessments and a process to convert low compliance scores into implemented improvement actions.

Includes bibliographical references.
In South Africa assisted reproductive techniques (ART) are poorly covered by health insurances or government funding thereby often inflicting out-of-pocket payment (OPP) on patients. This can create treatment barriers or high financial burdens for households, with unknown consequences of the latter. This is the first study from South and sub-saharan Africa which explores the impact of ART-related OPP on households. The study was undertaken at Groote Schuur Hospital, Cape Town, where ART is subsidized but patients have to contribute to the cost of treatment. Eighty six consecutive IVF/ICS/ cycles were prospectively analysed through patient interviews. Data included socio-demographic, economic, and infertility information, emotional and financial stress among participants, as well as coping and financial strategies adopted by households. In keeping with international recommendations, catastrophic expenditure was defined as a direct cost of all ART cycles in the last 12 months equal to or exceeding 40% of the annual non-food households expenditure.

Post and core-systems are common techniques in oral rehabilitation of teeth with inadequate structure which do not allow using of the traditional restorations. Many factors can affect the treatments’ success and survival rate. The aim of the present study was to evaluate the use and experience of post and core systems in public and private Swedish dental care. The hypothesis was that prefabricated post in composite material is the most common post and core-system used in Swedish dentistry today. Complication rates are higher for teeth with post and core and crown restorations compared with teeth restored with only crowns but without post/core. Furthermore, the risk of catastrophic failure is more frequent for teeth restored with post and core than without. A survey was conducted by sending 500 questionnaires to dentists in public and private dental care in five different cities of Sweden. Results were compiled by 297 returned surveys and showed that the most used technique was individually cast post and core and the most used material was metal alloy post and core. Conclusion: Individually cast post and core was found to be the most used technique both in public and private dental care in Sweden. Fiber reinforced composite was considered as the material with highest complication rates while metal alloy post and core was the material with lowest complication rates. Root fracture was the most common complication reported. The ferrule effect was considered as the most important factor affecting the survival rate of treatment with post and core.

BACKGROUND Public Health Nurses (PHNs) in the Province of Eastern Finland are facing a new situation when the families attending maternal and child health (MCH) services represent increasingly diverting cultural backgrounds. Cultural competency is a part of PHNs’ qualification demands in Finland, however little is known on the phenomenon in the study area at the moment. AIM This study aims to describe how cultural competence is understood and constructed among PHNs and PHN students working and training in the MCH clinics in the Province of Eastern Finland. METHODS Qualitative design was employed. Data were collected in five semi-structured individual interviews and two focus group discussions conducted in Finnish by author. Data were audio-recorder, transcribed and analysed through qualitative content analysis (QCA). Translation to English took place during the QCA process. The total number of participants was 15. FINDINGS The participants perceived culture as a multi-dimensional phenomenon, and that specific skills are needed when meeting clients from different cultures. Cultural competence in this sample refers to a four-staged process which is highly affected by social processes and interaction between the PHNs, students, clients and other stakeholders in MCH care and community. CONCLUSION This study can serve as an explanatory material to fill the knowledge-gap between the previously published theoretical studies on cultural competence and the grass-root level MCH work. The findings represent perceptions and experiences of highly educated, native Finnish sample working in a relatively rural province, and thus their transferability should be viewed with criticism.

The purpose of this work is to present the development and validation of a novel method for reconstructing time-dependent, or 4D, cone-beam CT (4DCBCT) images. 4DCBCT can have a variety of applications in the radiotherapy of moving targets, such as lung tumors, including treatment planning, dose verification, and real time treatment adaptation. However, in its current incarnation it suffers from poor reconstruction quality and limited temporal resolution that may restrict its efficacy. Our algorithm remedies these issues by deforming a previously acquired high quality reference fan-beam CT (FBCT) to match the projection data in the 4DCBCT data-set, essentially creating a 3D animation of the moving patient anatomy. This approach combines the high image quality of the FBCT with the fine temporal resolution of the raw 4DCBCT projection data-set. Deformation of the reference CT is accomplished via a patient specific motion model. The motion model is constrained spatially using eigenvectors generated by a principal component analysis (PCA) of patient motion data, and is regularized in time using parametric functions of a patient breathing surrogate recorded simultaneously with 4DCBCT acquisition. The parametric motion model is constrained using forward iterative projection matching (FIPM), a scheme which iteratively alters model parameters until digitally reconstructed radiographs (DRRs) cast through the deforming CT optimally match the projections in the raw 4DCBCT data-set. We term our method FIPM-PCA 4DCBCT. In developing our algorithm we proceed through three stages of development. In the first, we establish the mathematical groundwork for the algorithm and perform proof of concept testing on simulated data. In the second, we tune the algorithm for real world use; specifically we improve our DRR algorithm to achieve maximal realism by incorporating physical principles of image formation combined with empirical measurements of system properties. In the third stage we test our algorithm on actual patient data and evaluate its performance against gold standard and ground truth data-sets. In this phase we use our method to track the motion of an implanted fiducial marker and observe agreement with our gold standard data that is typically within a millimeter.

This dissertation describes the application of two principled variance reduction strategies to increase the efficiency for two applications within medical physics. The first, called correlated Monte Carlo (CMC) applies to patient-specific, permanent-seed brachytherapy (PSB) dose calculations. The second, called adjoint-biased forward Monte Carlo (ABFMC), is used to compute cone-beam computed tomography (CBCT) scatter projections. CMC was applied for two PSB cases: a clinical post-implant prostate, and a breast with a simulated lumpectomy cavity. CMC computes the dose difference between the highly correlated dose computing homogeneous and heterogeneous geometries. The particle transport in the heterogeneous geometry assumed a purely homogeneous environment, and altered particle weights accounted for bias. Average gains of 37 to 60 are reported from using CMC, relative to un-correlated Monte Carlo (UMC) calculations, for the prostate and breast CTV’s, respectively. To further increase the efficiency up to 1500 fold above UMC, an approximation called interpolated correlated Monte Carlo (ICMC) was applied. ICMC computes using CMC on a low-resolution (LR) spatial grid followed by interpolation to a high-resolution (HR) voxel grid followed. The interpolated, HR is then summed with a HR, pre-computed, homogeneous dose map. ICMC computes an approximate, but accurate, HR heterogeneous dose distribution from LR MC calculations achieving an average 2% standard deviation within the prostate and breast CTV’s in 1.1 sec and 0.39 sec, respectively. Accuracy for 80% of the voxels using ICMC is within 3% for anatomically realistic geometries. Second, for CBCT scatter projections, ABFMC was implemented via weight windowing using a solution to the adjoint Boltzmann transport equation computed either via the discrete ordinates method (DOM), or a MC implemented forward-adjoint importance generator (FAIG). ABFMC, implemented via DOM or FAIG, was tested for a single elliptical water cylinder using a primary point source (PPS) and a phase-space source (PSS). The best gains were found by using the PSS yielding average efficiency gains of 250 relative to non-weight windowed MC utilizing the PPS. Furthermore, computing 360 projections on a 40 by 30 pixel grid requires only 48 min on a single CPU core allowing clinical use via parallel processing techniques.

Posttraumatic stress disorder (PTSD) symptoms and substance use have been associated with increased suicide ideation, but have rarely been examined within a larger theoretical context of suicide risk. The interpersonal theory of suicide posits that feeling disconnected from others (i.e., thwarted belongingness) and feeling like a burden on others (i.e., perceived burdensomeness) are associated with increased suicide ideation. We hypothesized that perceived burdensomeness and thwarted belongingness would mediate the relation between PTSD symptoms and suicide ideation, and that using substances to cope would moderate these relations. Participants were 254 college students reporting exposure to potentially traumatic experiences. Findings from a moderated mediation analysis indicated that perceived burdensomeness, but not thwarted belongingness, mediated the relation between PTSD symptoms and suicide ideation, and using substances to cope moderated this relation. Therapeutic interventions aimed at reducing suicide ideation might benefit from decreasing perceived burdensomeness and the use of substances to cope.

Interstitial and intracavitary brachytherapy plays an essential role in management of several malignancies. However, the achievable accuracy of brachytherapy treatment for prostate and cervical cancer is limited due to the lack of intraoperative planning and adaptive replanning. A major problem in implementing TRUS-based intraoperative planning is an inability of TRUS to accurately localize individual seed poses (positions and orientations) relative to the prostate volume during or after the implantation. For the locally advanced cervical cancer patient, manual drawing of the source positions on orthogonal films can not localize the full 3D intracavitary brachytherapy (ICB) applicator geometry. A new iterative forward projection matching (IFPM) algorithm can explicitly localize each individual seed/applicator by iteratively matching computed projections of the post-implant patient with the measured projections. This thesis describes adaptation and implementation of a novel IFPM algorithm that addresses hitherto unsolved problems in localization of brachytherapy seeds and applicators. The prototype implementation of 3-parameter point-seed IFPM algorithm was experimentally validated using a set of a few cone-beam CT (CBCT) projections of both the phantom and post-implant patient’s datasets. Geometric uncertainty due to gantry angle inaccuracy was incorporated. After this, IFPM algorithm was extended to 5-parameter elongated line-seed model which automatically reconstructs individual seed orientation as well as position. The accuracy of this algorithm was tested using both the synthetic-measured projections of clinically-realistic Model-6711 125I seed arrangements and measured projections of an in-house precision-machined prostate implant phantom that allows the orientations and locations of up to 100 seeds to be set to known values. The seed reconstruction error for simulation was less than 0.6 mm/3o. For the physical phantom experiments, IFPM absolute accuracy for position, polar angle, and azimuthal angel were (0.78 ± 0.57) mm, (5.8 ± 4.8)o, and (6.8 ± 4.0)o, respectively. It avoids the need to match corresponding seeds in each projection and accommodates incomplete data, overlapping seed clusters, and highly-migrated seeds. IFPM was further generalized from 5-parameter to 6-parameter model which was needed to reconstruct 3D pose of arbitrary-shape applicators. The voxelized 3D model of the applicator was obtained from external complex combinatorial geometric modeling. It is then integrated into the forward projection matching method for computing the 2D projections of the 3D ICB applicators, iteratively. The applicator reconstruction error for simulation was about 0.5 mm/2o. The residual 2D registration error (positional difference) between computed and actual measured applicator images was less than 1 mm for the intrauterine tandem and about 1.5 mm for the bilateral colpostats in each detector plane. By localizing the applicator’s internal structure and the sources, the effect of intra and inter-applicator attenuation can be included in the resultant dose distribution and CBCT metal streaking artifact mitigation. The localization accuracy of better than 1 mm and 6o has the potential to support more accurate Monte Carlo-based or 2D TG-43 dose calculations in clinical practice. It is hoped the clinical implementation of IFPM approach to localize elongated line-seed/applicator for intraoperative brachytherapy planning may have a positive impact on the treatment of prostate and cervical cancers.

The goal of this research was to develop a greater understanding of the effectiveness of enrichment programs outside of the school setting. This study was also intended to contribute to the broader understanding of the mechanism of student school-related stress, reported by parents, as it relates to student academic performance, specifically in a population which primarily consists of students and parents who are of Asian-Indian-American descent. With rising standards and intensifying pressure on students to be academically successful, it is necessary to examine the stress students experience due to their academics, as well as its effects on their academic performance. Participants in this study included twenty 1st through 5th grade elementary students who attend weekly classes at one of three local academies where the after-school academic enrichment program is offered. Data from those students participating in both math and English was accounted for separately, resulting in 34 total student subjects which can be utilized for this study (N = 34). After performing bivariate logistic regression, the models did not reach significance (p > .05), therefore it cannot be said that an increase or decrease in dependent variable of students’ school grades can be predicted that any of the following independent variables: homework completion, length of enrollment, and academy homework scores,. The perceptions of the parents, in addition to those of the children experiencing these stressors should be studied further.

Over the past several decades rates of spine surgeries in the U.S. have increased dramatically. Spinal fusion surgery rates, in particular, have grown exponentially despite being one of the most costly, invasive, and controversial methods for treating patients suffering from back conditions. Furthermore, lumbar fusion surgeries continue to be performed at increasing rates despite a lack of scientific evidence and consensus that they are cost-effective and produce better clinical outcomes than less radical treatment of lower back pain. As a result, large amounts of healthcare dollars continue to be invested in these costly procedures which are potentially dangerous and have questionable efficacy in terms of improving patient outcomes. Importantly, there is a lack of population studies in the literature on spinal fusion surgeries from a health services research perspective. Therefore, the present research is a population based study using an administrative database and includes patients of all ages and payer types. The data used in the present study come from the Florida Agency for Health Care Administration (AHCA) and include all hospitalizations in Florida in 2010. The objective of the study is to analyze the incidence of spinal fusion surgeries in Florida hospitals for patients of all ages and payer types by demographic variables to understand who gets these surgeries and for which conditions. The first null hypothesis is that there are no statistically significant predictors of the incidence of lumbar/lumbosacral, dorsal/dorsolumbar spinal fusion surgeries in Florida hospitals. Logistic regression was used to analyze the incidence of fusion surgeries. The binary dependent variable was coded as a "1" for all patients who were a case (i.e. they received one of the five procedure codes being studied in the present research) and a "0" for all patients who were controls (meaning they did not receive any of the five fusion procedure codes). Logistic regression was used to predict the probability of an observation being a "1" given the independent variables included in the model. Additionally, hospital charges were analyzed to understand the associated hospital charges with these surgeries. The second null hypothesis is that there are no statistically significant predictors of the charges of Lumbar/Lumbosacral, Dorsal/Dorsolumbar spinal fusion surgeries in Florida Hospitals. A mixed effects model was used to test this hypothesis and the fixed effects which were included in the model were gender, age, race, principal payer, and principal procedure. A mixed effects model was chosen due to the fact that cases who had surgeries performed at the same hospital are not independent and therefore the data were clustered on hospitals. A random intercept term was used to address this fact. SAS software was used to complete all of the analyses. In 2010, there were 16,236 Lumbar/Lumbosacral, Dorsal/Dorsolumbar fusion surgery cases in Florida hospitals that were included in the case population and 21,856 individuals included in the control population for a total of 38,092 included in the study population. An understanding of who is most likely to receive a fusion surgery, at what age, and for which diagnoses, as has been done here, is extremely important. This knowledge can help researchers, policy makers, and physicians alike. Comprehensive physician practice guidelines for performing fusion surgeries still do not exist in the year 2013; therefore, in order to have the greatest impact, the efforts for creating the guidelines should be focused on those individuals who are most likely to receive fusions as shown for the first time by the data analyzed here. Given the high incidence of these surgeries in Florida alone, the need for practice guidelines cannot be overstated. The total hospital charges in Florida hospitals for the 16,236 cases were $2,095,413,584. Despite having the same principal diagnoses and a similar number of additional diagnoses, patients who received a fusion surgery resulted in approximately three times the charges as those incurred by the controls. Overall, the high incidence and charges for fusion surgeries shown in this study emphasize the importance of having a better understanding of when these surgeries are justified and for which patients. Without comprehensive practice guidelines established through evidence-based research this is difficult, if not impossible, to accomplish. The diagnoses which are most prevalent and show the most inconsistencies between cases may be a good starting point for such guidelines.

Face à l’abus d’alcool notamment chez les jeunes, les acteurs de santé recommandent de réguler le marketing des industriels. En France selon la loi Evin (1991), les publicités pour l’alcool doivent être objectives, informatives et, non attractives en termes de contenu. Cette recherche teste l’efficacité de cette régulation en comparant l’influence de publicités informatives versus plus attractives en termes de perception du produit, d’attitude envers la publicité et d’envie de consommer. Elle évalue aussi la visibilité des avertissements sanitaires alcool selon la saillance de leur format et du contexte publicitaire. Cette recherche a identifié et étudié l’appropriation des codes et de l’iconographie du luxe par les marques d’alcool comme une nouvelle forme de contenu publicitaire à travers une phase de monitoring. Grâce à une revue de la littérature, elle a formulé des propositions de recherche en termes d’implications marketing et de santé publique afin de cerner le mécanisme de persuasion potentiel relative à cette pratique marketing. Ces implications présentent le luxe comme une potentielle réponse marketing aux motivations de consommer de l’alcool chez les jeunes, sur la base de théories relatives à la construction identitaire. Elles soulignent aussi l’influence des publicités et du packaging, en particulier lorsque ces stimuli sont infusés de codes du luxe (sur la base de théorie de l’infusion de l’art et de cas des paquets de cigarettes infusés des codes du luxe). Pour tester ces propositions, une étude qualitative exploratoire (26 entretiens) a d’abord servi à cerner la nature et l’influence du contenu (publicités plus informatives versus luxe) en termes de réponses cognitives, affectives, d’intentions comportementales et de perceptions des avertissements sanitaires. Les résultats de ces entretiens ont servi à construire la phase expérimentale de la recherche en termes d’opérationnalisation des concepts de contenu publicitaire et d’avertissement sanitaire, de formulation des hypothèses de recherche, de sélection et design des stimuli et de méthodologie (combinaison de méthodes verbales et non-verbales). Sur la base d’un design inter-sujets, nous avons lancé deux études expérimentales (étude eye-tracking = 174 jeunes ; étude en ligne = 696 jeunes) testant 12 stimuli publicitaires [3 (marques d’alcool) x 2 (styles de contenu publicitaire: PO versus luxe) x 2 (formats d’avertissement: format actuel versus plus saillant)]. Les résultats soulignent l’intérêt de réguler le contenu des publicités d’alcool (cf. Loi Evin). Celui-ci influence l’attitude à l’égard de la publicité, la perception du produit et le désir de consommer. Les publicités plus informatives sont perçues comme moins attractives, alors que les publicités luxe génèrent et renforcent des perceptions positives à l’égard du produit, des bénéfices de consommation et les envies de consommer et de boire. Quant à l’avertissement actuel, il est jugé inefficace en termes de visibilité, de crédibilité et de risques perçus. Toutefois un format plus saillant permet d’augmenter le degré d’attention qu’on y porte ainsi que sa visibilité perçue. Cela est important car l’efficacité d’un avertissement repose en partie sur ses deux critères. Aucun effet d’interaction significatif des variables manipulées n’est à signaler dans cette étude
This critical social marketing research tackles the effectiveness of advertising regulation that is a health measure recommended to reduce alcohol consumption. It studies how alcohol advertising content restrictions (e.g., the French Evin law mandates ads since 1991 to convey only factual information and objective qualities of alcohol products and thus be product-oriented: PO ads) versus non-regulated advertising affect youth individuals’ perceptions of alcohol products, attitude towards the ad, desire to consume and noticeability of health warning displayed in ads (depending on format prominence). This research identified and investigated the luxury codes and iconography appropriation by alcohol brands as a new type of advertising content, through a monitoring phase. To understand the potential persuasion mechanism at stake, this study relied on assumptions in terms of persuasion and public health based on a literature review. It helped to explain luxury symbolism as a potential response to youth drinking motives on the basis of self-growth theories and suggest possible effect on consumers’ responses to alcohol advertising especially when infused with luxury perceptions (e.g., art infusion theory and tobacco packs infused with luxury codes). To test those assumptions, we implemented an exploratory qualitative study and two experimental studies. Using (26) in-depth interviews, the qualitative phase helped understand the nature and influence of advertising content (luxury versus PO) on cognitive, affective responses, behavioral intentions and warnings’ noticeability. The findings helped operationalize advertising content and warnings’ noticeability concepts, develop hypotheses, fine-tune stimuli selection and modification, and finally select methods and (verbal and non-verbal) measurements for the testing phase. Based on a between-subject design, the experimentation (eye-tracking study = 174 individuals; online study = 696 individuals) tested on samples of young people a total of 12 advertising stimuli [3 (brands) x 2 (content: luxury versus PO) x 2 (warning format: LP versus MP)]. Our results showed the relevancy of alcohol advertising content restrictions such as the French Evin law (1991). They indicated that advertising content does influence attitude towards the ad, alcohol products’ perceptions and desire to consume. While PO ads reduce the alcohol advertising attractiveness, luxury ads enhanced the participants’ positive product perceptions, perceived alcohol consumption benefits and intention to purchase and drink. They also reported the ineffectiveness of health warnings in terms of noticeability, perceived credibility and risks. Findings suggest that modifying the current warning format prominence can help increase its attentional processing and perceived noticeability, which is a first step in improving generally warnings’ effectiveness. However our results revealed no significant interaction effect of both manipulated factors in this study

Schizophrenia has long been considered a chronic mental illness predestined to irreversible progressive deterioration. However, in recent decades scientific evidence has shown that recovery in people with schizophrenia is possible and should therefore be a priority in their treatment. In that sense, the recovery model has gained strength and transformed the view of mental illness. This approach moves the therapeutic goal from symptomatic remission to the recovery of satisfactory and proper functioning. In view of this, an integrated and interdisciplinary care system is needed where professionals from different fields who treat people diagnosed with the condition work together to address not only their symptoms, but also the difficulties they present in their daily functioning, their personal characteristics and the environmental factors that affect them. This change in the therapeutic approach highlights the need for a tool that can assess the full spectrum of difficulties in functioning that a person may have and all the contextual variables involved and that facilitates the coordination and joint work between all the professions involved in the recovery process. The International Classification of Functioning, Disability and Health (ICF) covers all these requirements. Since it has more than 1400 categories, ICF Core Sets (ICF-CSs) linked to certain health states have been developed. The ICF-CSs consist of a list of the most relevant ICF categories for the description of the functioning and disability of people living with a given health condition. In the case of schizophrenia, two versions of ICF-CSs have been developed: the brief and the comprehensive. In order to apply the ICF-CSs in clinical practice, they must be validated through different sources of evidence. In this context, the present thesis aims to evaluate the content validity of the ICF-CSs for schizophrenia from the perspective of experts in the treatment of this population, as well as to identify the potential repercussions of this health condition in the functioning of people diagnosed with this disorder. To achieve this, six three-round Delphi studies were conducted with expert panels from different professional backgrounds which have shown a significant role in the treatment of people with schizophrenia (i.e., psychiatry, psychology, nursing, occupational therapy, social work and physiotherapy). Each of these studies identifies functioning difficulties from the perspective of one of these professional areas and analyzes whether the identified aspects are represented in the ICF-CSs for schizophrenia. Once the results of the six Delphi studies were obtained, all the data were integrated to conclude the expert perspective and to evaluate the content validity of the ICF-CSs globally. In total, 790 experts (352 psychiatrists, 175 psychologists, 101 nurses, 92 occupational therapists, 57 social workers and 13 physiotherapists) from 85 different countries covering the 6 demographic WHO regions (i.e., Africa, Americas, South-east Asia, Europe, Eastern Mediterranean and Western Pacific) participated in the first round of the different Delphi studies. Globally, 113 ICF categories and 31 Personal factors reached consensus (75% or more of the experts of a profession considered them relevant) by at least one professional perspective. Of these, 90 ICF categories and 28 personal factors reached expert consensus (they reached consensus from four or more professional perspectives). One hundred percent of the categories in the brief version of the ICF-CS for schizophrenia reached consensus from all professional perspectives considered. Regarding the comprehensive version, 89.7% of its categories (87 categories) reached expert consensus. Overall, the present thesis provides important support for the worldwide content validity of the ICF-CSs for schizophrenia from the expert perspective. The results highlight the relevance, in the evaluation and treatment of people with schizophrenia, of assessing functioning by considering the body functions, participation in activities, environmental aspects and personal factors that experts have identified. All this suggests that the ICF and these ICF-CSs provide an effective framework from which to evaluate and describe functioning in people with schizophrenia and therefore may be a useful tool in the comprehensive treatment of this population.
L’esquizofrènia ha estat considerada al llarg de la història com una malaltia mental crònica predestinada a un deteriorament progressiu irreversible. En les últimes dècades, però, l’evidència científica ha demostrat que la recuperació en les persones amb esquizofrènia és possible i ha de ser, per tant, un objectiu prioritari en el seu tractament. En aquest sentit, el model de la recuperació ha pres força i ha transformat la visió de la malaltia psiquiàtrica. Aquest enfocament mou l’objectiu terapèutic de la remissió simptomàtica a la recuperació d’un funcionament satisfactori i adequat. Davant d’això, es fa necessari un sistema d'atenció integral e interdisciplinari on els professionals dels diferents àmbits que tracten a la persona diagnosticada treballin conjuntament per abordar no només els seus símptomes, sinó també les dificultats que presenta en el seu funcionament diari, les seves característiques personals i els factors ambientals que l’afecten. Aquest canvi en l’abordatge terapèutic fa evident la necessitat de disposar d’una eina que permeti valorar tot l’espectre de dificultats en el funcionament que pot presentar una persona, totes les variables contextuals implicades i que faciliti la coordinació i treball conjunt entre totes les professions partícips del procés de recuperació. A tots aquests requeriments s’ajusta la Classificació Internacional del Funcionament, de la Discapacitat i de la Salut (CIF). Atès que aquesta consta de més de 1400 categories, s'han desenvolupat els Conjunts Bàsics de la CIF (CB- CIF) vinculats a determinats estats de salut. Els CB-CIF consisteixen en una llista de les categories més rellevants de la CIF per a la descripció del funcionament i la discapacitat de les persones que viuen amb una condició de salut determinada. En el cas de l’esquizofrènia, s’han desenvolupat dues versions de CB-CIF: l’abreujada i la completa. Per tal que els CB-CIF puguin ser aplicats a la pràctica clínica, cal que siguin validats a través de diferents fonts d'evidència. En aquest context, la present tesi pretén dur a terme la validació de contingut dels CB-CIF per a l’esquizofrènia des de la perspectiva del col·lectiu expert en el tractament d’aquesta població, així com identificar les repercussions potencials d’aquesta condició de salut en el funcionament de les persones diagnosticades d’aquest trastorn. Per assolir aquest objectiu es van dur a terme sis estudis Delphi de 3 rondes a grups d’experts de diferents àmbits professionals que han demostrat tenir un paper rellevant en el tractament de persones amb esquizofrènia (i.e., psiquiatria, psicologia, infermeria, teràpia ocupacional, treball social i fisioteràpia). Cada un d’aquests estudis identifica les dificultats en el funcionament des de la perspectiva d'una d’aquestes àrees professionals i analitza si els aspectes identificats estan representats als CB-CIF per a l’esquizofrènia. Un cop obtinguts els resultats dels sis estudis Delphi, es va realitzar la integració de totes les dades per concloure la perspectiva del col·lectiu expert i avaluar globalment la validesa de contingut dels CB-CIF. En total, 790 experts (352 psiquiatres, 175 psicòlegs i psicòlogues, 101 infermers i infermeres, 92 terapeutes ocupacionals, 57 treballadors i treballadores socials i 13 fisioterapeutes) provinents de 85 països diferents i que abastaven les 6 regions demogràfiques de la OMS (i.e., Àfrica, Amèriques, Àsia Sud-oriental, Europa, Mediterrani Oriental i Pacífic Occidental) van participar en la primera ronda dels diferents estudis Delphi realitzats. Es van identificar 113 categories de la CIF i 31 Factors personals que van arribar a consens (el 75% o més dels experts d’una professió la va considerar rellevant) per part d’almenys una perspectiva professional. D’aquestes, 90 categories de la CIF i 28 Factors personals van arribar a consens expert (van arribar a consens des de 4 perspectives professionals o més). El 100% de les categories de la versió abreujada del CB-CIF per a l’esquizofrènia van arribar a consens des de totes les perspectives professionals considerades. Considerant la versió completa, el 89,7% de les seves categories (87 categories) van arribar a consens expert. En conjunt, la present tesi proporciona un suport important a la validesa de contingut a nivell mundial dels CB-CIF per a l’esquizofrènia des de la perspectiva experta. Els resultats destaquen la rellevància, en l’avaluació i tractament de les persones amb esquizofrènia, de valorar el funcionament considerant les funcions corporals, la participació en activitats, els aspectes ambientals i els factors personals que els experts han identificat. Tot això suggereix que la CIF i aquests CB-CIF proporcionen un marc efectiu des del qual valorar i descriure el funcionament en persones amb esquizofrènia i poden ser una eina útil en el tractament integral d’aquesta població.

Andelen barn och ungdomar som befinner sig ett socialt utanförskap halkar efter alltmer i samhället. Att befinna sig ett socialt utanförskap kan medföra en rad negativa konsekvenser för såväl den enskilde individen som för samhället. Det finns ett stort behov av att belysa framgångsrika exempel på sociala innovationer, inriktade på unga i socialt utsatta områden, som kan förbättra deras välfärd och framtidsutsikter. Syftet med examensarbetet var att beskriva verksamheten ”Nattfotboll” utifrån programteori och undersöka dess förutsättningar för att skalas upp utifrån teorier om spridning av interventioner. Studien genomfördes med en kvalitativ studiedesign bestående av en fokusgruppsintervju med initiativtagare och projektledare, semistrukturerade intervjuer med 10 ledare och 21 ungdomar samt tre strukturerade observationer i samband med idrottsaktiviteter i Sandviken och i Örebro. Resultatet visade att konceptet Nattfotboll kännetecknades av flera viktiga kärnkomponenter och nyckelidéer. De komponenter som tillskrevs mycket stor betydelse för utfallet var de unga, utvalda ledare som drev idrottsverksamheten, men även den lokala projektledaren. Verksamheten visade sig främja ett relationsbygge mellan ungdomarna och ledarna som var betydelsefullt: ungdomarna fick tillgång till unga förebilder, medan de unga ledarna kunde växa som individer. Verksamheten erbjuder en träffpunkt som bidrar till att ungdomar breddar sitt kontaktnät, blir mer fysiskt aktiva och erbjuds en väg in i föreningslivet, då många av ledarna själva är idrottsaktiva. Studien visar att Nattfotbollskonceptet innehåller de fem kategorier som är nödvändiga för en framgångsrik uppskalning; Kärnkomponenter & Nyckelidéer, Upplägg, Kommunikation, Resultatmätning & Feedback samt Ledarskap. Ytterligare forskning skulle kunna bidra till att fördjupa förståelsen för vad interventionen har för betydelse för ledarna som individer.
A great number of children and adolescents who are in a social exclusion is lagging behind in society. A social exclusion can lead to a number of negative consequences for both the individual and the community. There is a great need to highlight successful examples of social innovations aimed at young people in socially vulnerable areas that can improve their well-being and prospects. The aim of the thesis was to describe the innovation Night Football on the basis of program theory and also examine its conditions for scaling up on the basis of diffusion theory and a framework for spread. The study was conducted with a qualitative study design consisting of a focus group interview with initiators and project managers, semi-structured interviews with 10 leaders and 21 young participants, as well as three structured observations in connection with sports activities in Sandviken and Örebro. The result showed that the Night Football concept was characterized by several key core components and key ideas. The components attributed to the outcome were the young, chosen leaders who run the sport activities, but also the local project manager. The innovation turned out to promote important relationships between the young people and the leaders: young people gained access to young role models, while young leaders could grow as individuals. The innovation offers a meeting point that helps young people broaden their network of contacts, becomes more physically active and they are also offered a way into sports associations, as many of the leaders themselves are connected to sport clubs. The study shows that the Night Football concept contains the five categories necessary for a successful upscale; Core components & Key ideas, Structure, Communication, Performance Measurement & Feedback, and Leadership. Further research could help to deepen the understanding of the innovations impact on the leaders as individuals.

Syfte och frågeställningar

Studiens syfte var att undersöka om utförandet av en isometrisk bålstabiliseringsövning/coreövning kunde påverka upplevelsen av smärta i nacke, axlar och skuldror hos kvinnor med kronisk/långvarig idiopatisk smärta. Studiens frågeställningar var: Hur påverkar utförandet av övningen ”plankan” upplevelsen av smärta i nacke, axlar och skuldror hos deltagarna? Förändras den maximala uthålligheten i övningen mellan deltagarnas första och sista träningstillfälle? Kan interventionen fullföljas av deltagarna?

Metod

Fyra kvinnliga deltagare som alla hade kronisk/långvarig smärta i nacke, axlar eller skuldror utförde övningen ”plankan” som hemträningsövning under fyra veckors tid. Mängden träning dokumenterades i en träningsdagbok som deltagarna kontinuerligt fyllde i under träningsperioden. Före samt inom en vecka efter träningsperioden ifylldes en enkät med frågor om upplevd intensitet, frekvens och lokalisation av smärta. Dessutom mättes maximal uthållighet i övningen ”plankan”.

Resultat

Efter träningsperioden uppskattade alla deltagare med smärta i nacken en förbättring med 1-3 skalsteg i en sammanslagning av alla frågor rörande smärta i nacke. Detta innebar att förändringen mellan deltagarnas svar i före- och efterenkäten, där skalan 0-10 användes, slogs samman till ett värde. Smärta i axlarna skattades som markant förbättrad av två deltagare samt som något försämrad respektive inte förändrad av två deltagare. Endast en deltagare uppskattade sig ha smärta i skuldrorna och ingen skillnad i uppskattningen sågs mellan före- och efterenkäten. Maximal uthållighet i övningen mellan första och sista träningstillfället ökade statistiskt signifikant för alla deltagare mätt i både procent och sekunder.

Slutsats

Resultatet i studien tyder på att övningen kan genomföras av individer med långvarig idiopatisk smärta i nacke, axlar och skuldror utan att ökad upplevd smärta eller andra obehag uppstår samt att den maximala uthålligheten i övningen ökar genom att övningen utförs. Hur många gånger övningen måste utföras för att ge resultat på uthållighet är oklart. Trots att flera deltagare upplevde minskad smärta efter träningsperioden så kan inga slutsatser tas då deltagarantalet var litet och resultatet för interventionsgruppen inte jämförts med en kontrollgrupp. Stora variationer i utförandet av hemträningen förekom bland deltagarna och flera faktorer utöver träningsövningen kan ha påverkat förändringen i smärtupplevelse.

Thesis (M.S.)--University of Wisconsin--Madison, 1996.
Typescript. eContent provider-neutral record in process. Description based on print version record. Includes bibliographical references (leaves 75-79).

碩士
國立陽明大學
護理學系暨研究所
97
To adapt the adjustment and expansion of the health care delivery, public health nurses’ roles and function have changed accordingly. To improve the quality of public health nursing services and to assure the roles and responsibilities of public health nurses in professional practice are important. In this study, we aimed to examine public health nurse’s core competencies and to explore their associated factors. We employed a cross-sectional survey to collect data using a translated instrument which proposed by the Council on Linkage (COL). All of 299 public health nurses working for the Community Health Stations in Taipei County were invited to participate in this study by a mailing method. Among them, 225 completed the questionnaire (response rate was 75.25%). The main findings of this study included: (1) Overall, a moderate level of core competency was revealed by this study (the mean score was 2.42 out of a possible score of 4; SD = 0.59). (2) Among eight dimensions of competency, following three dimensions had higher score: Cultural competency skills (Mean ± SD =2.63 ± 0.73); Community dimensions of practice skills (Mean ± SD = 2.61 ± 0.68); and Communication skills (Mean ± SD =2.61 ± 0.64). The following three dimensions had lower scores: Financial planning and management Skills (Mean ± SD = 2.14 ± 0.70); Leadership and systems thinking Skills (Mean ± SD = 2.32 ± 0.69); and Policy development/Program planning skills (Mean ± SD = 2.35 ± 0.68). (3) Bivariate analyses showed competency score was statistically associated with level of education (F = 5.380，p = 0.001), job position (F = 5.576，p = 0.004 ), and the experience of continuing education in the past year (t = 3.038，p = 0.035). Public health nurses who possess a graduate degree, held the position as head nurse and having attended the continuing education in the past year have a higher competency score. (4) A stepwise multiple linear regression analysis on global core competency indicating four variables (education, the experience of continuing education in the past year, types of health centers, and job position) could be singled out as significant factors and accounted for 11.5% of the variance. The study results showed the room for improvement in the core competencies among public health nurses in Taipei County. Based on our findings, we suggest health administrators should purposely strength public health nurses’ core competencies to provide high quality of care and to achieve the goals of nurse practitioner certification.

碩士
亞洲大學
長期照護研究所
96
To study the core competence and relative factors of the public health nurses (PHN) at health station in Chiayi County of Taiwan, we collected data by the questionnaire survey modified from ‘the core competencies for public health professional standards’ of the Quad Council of Public Health Nursing Organization. We got nurses’ basic information and self-reported responses in eight PHN domains which included analysis and assessment, policy development and program planning, communication, cultural competency, community administration, basic public health sciences, financial planning and management, leadership and system thinking. One hundred and twenty four copies of questionnaires were sent and all (100%) were collected back. Among them, 122 copies (98.4%) of questionnaires are valid and the Cronbach’s α is 0.94. The results reveal that average age of PHN is 38.65 years old (SD =8.85) and there are 55.8% PHN with the college background, and 58.19% PHN with their highest diploma of nursing more than 10 years, and the average public health experience is 11.10 years (SD =8.48). The average score of holistic core competence is 3.20 (SD =0.54). PHN get highest scores in communication of the self-assessment core competence, which follows by the community administration. They get lower scores in policy development/program planning, and leadership/systems thinking. By logistic regression analysis, the result shows positive correlation between core competences of PHN and their professional hierarchy, and negative correlation between core competences and population of local zones. It reveals that PHN with 10-20 years public health experience get higher scores of self-assessed core competence. PHN with Registered Professional Nurse licenses and older than 41 y/o get higher scores of self-assessed core competence. It also reveals that PHN management more than 5000 population of local zones and for on the job training over 5 times in half a year get higher scores of self-assessed core competence. Based on the research results, we advise the authority to reinforce the PHN on-the-job training programs of administration capacity, to set up the department for training PHN in medical schools, and to advocate the promotion of PHN refered to their public health professional abilities and competence.

Interpreters play a pivotal role in facilitating communication between healthcare professionals and their patients when there is a lack of a common language which inhibits direct communication. This thesis examines the roles and practices of interpreters in healthcare settings in tertiary teaching hospitals with a high proportion of patients from culturally and linguistically diverse backgrounds in Melbourne, Australia. On the surface, the process of interpreter-mediated communication may seem straightforward, and the interpreter’s role is characteristically presented as being that of a neutral ‘language conduit’, seamlessly transferring meaning between two languages. However, this research explores the argument that conceptualising and understanding the role in this way is too simplistic, and devalues a range of contributions expected and made by interpreters in facilitating patient--health professional communication in Australian hospitals. The study was designed to investigate qualitatively the expectations and experiences of each group of participants in interpreter-mediated health communication concerning the role/s of the interpreter and factors that impact these role/s. To provide a complementary lens, the qualitative investigation of interpreters’ practices includes analysis of recordings of actual interpreted health encounters. Thirty-one individuals across three groups of participants (i.e. health professionals, patients and interpreters), across two large hospitals participated in semi- structured in-depth interviews. For the contrasting perspective, three interpreter-mediated outpatient healthcare interactions (in Dari, Arabic and Italian) were recorded and analysed enabling examination of similarities and differences between reported experiences and interpreter practice. The overall findings highlighted the interpreters’ awareness of the code of ethics and code of conduct that AUSIT (Australian Institute of Interpreters and Translators) promotes as professional standards. Interpreters seek to adhere to the neutral language conduit role as best they can. However, factors impacted the effectiveness of interpreters in relation to this role in the hospital interpreting setting, in particular, patients’ limited educational level and understanding of health terminology, dialect and gender compatibility between patient and interpreter, and institutional constraints, such as time and scheduling of consultations. On average interpreters engaged solely in direct message transfer in about 60% of their interpretations. However, they demonstrated a willingness and ability to move beyond their direct language conduit role when required, to facilitate more meaningful and expeditious HP- -patient exchange. Three core non-conduit roles (conversational facilitator, cultural facilitator, and experience facilitator) were also identified. Each of these roles is discussed in detail. Most importantly, whilst interpreters adopted these three non-conduit roles on an ‘as needs basis’, they felt in control and able to manage their professional boundaries when challenged. To conclude, recommendations about enhancing communication and training for health professionals, interpreters and patients were presented.

碩士
南台科技大學
人力資源管理研究所
101
The study investigated public health nursing staffs’ background and core competencies in 37 District Health Centers of Tainan City. Nursing staffs’ marriage, age, education background, professional license, job position, type of Health Center, and core competencies were statistically analyzed to survey their background and 8 core competencies, including analytic/assessment skills, policy development/program planning skills, communication skills, cultural competency skills, community dimensions of practice skills, basic public health sciences skills, financial planning and management skills, and leadership and systems thinking skills. It is revealed that, among the 8 core competencies, public health nursing staffs considered their community dimensions of practice skills are the best. The followings are cultural competency skills, analytic/assessment skills, communication skills, basic public health sciences skills, leadership and systems thinking skills, and financial planning and management skills. Policy development/program planning skills was considered the weakest. Therefore, it is suggested that health authorities can provide training programs and courses to promote public health nursing staffs’ core competencies according to their current demands and abilities.

Thesis (Ph.D.)--York University, 2008. Graduate Programme in Business Administration.
Typescript. Includes bibliographical references (leaves 264-285). Also available on the Internet. MODE OF ACCESS via web browser by entering the following URL: http://gateway.proquest.com/openurl?url_ver=Z39.88-2004&res_dat=xri:pqdiss&rft_val_fmt=info:ofi/fmt:kev:mtx:dissertation&rft_dat=xri:pqdiss:NR39004

Neighborhood design has a significant impact on environmental and human health and is largely regulated by the codes developed by various professional organizations. While the sustainability movement as a whole has embraced the mutually beneficial goals of improving environmental and human health, the work of professionals in the environmental and public health fields has remained largely segregated over the past century. The purpose of my thesis is to compare the approach of each field in fostering sustainable neighborhoods through the development and implementation of codes and to quantify both the existing degree of collaboration and the latent potential for further collaboration within these codes. For comparison, I selected LEED for Neighborhood Development and the Healthy Development Measurement Tool to be representative of neighborhood codes generated by the environmental and public health movements, respectively, because they are the most fully developed and widely implemented evaluation systems presently available in each field. In order to investigate how the codes generated in each field compare in their approach, structure, and organization, I first performed a comparative analysis between them. I then performed a content analysis on both codes to quantify the overlap in goals between them. My hypothesis was that each field would exhibit a bias towards goals which explicitly support their own field, but that a significant portion of their goals would simultaneously support the other field. This hypothesis proved to be correct, but most interesting was the significant percentage of shared goals that were left unexpressed. Ultimately, 94% of recommended actions in LEED-ND were related to human health, though it was only explicitly referenced in 25% of the code. Similarly, 74% of recommended actions in the HDMT were related to environmental health, though it was only explicitly mentioned in 33% of the code. My thesis demonstrates that, while both fields already recognize that a small portion of their goals are shared, it is actually likely that nearly all of their goals are shared. By actively acknowledging these shared goals, both fields can potentially benefit from the greater amount of support, resources, and expertise that would become available to them through collaboration.
text

This study highlights the utility of partner typologies for examining young women's STD/HIV risk perception and sexual risk-taking behavior. Study data from quantitative sources identify general trends in perception and behavior among young women but reveal little about the influence of partner characteristics. Qualitative data analysis produces nine 'super categories' to examine the influence of partner characteristics on the outcomes of interest. These categories reveal the influence of relationship expectations, emotional commitment, and 'trust' on STD/HIV risk perception and risk-taking behavior; more detail than provided by conventional categories such as 'regular' and 'occasional' partners. Study results indicate opportunities for intervention and suggest that future research should examine partner categories used in major quantitative surveys to determine their ability to reveal differences in self-protective behavior with different partners. Such information can enhance public health efforts and make STD/HIV prevention programs for young women more target-specific and, ultimately, more effective
acase@tulane.edu

Au Québec, les négociations collectives dans les secteurs public et parapublic ainsi que dans les services publics sont assujetties aux règles du Code du travail (L.R.Q. C.-27). Certains secteurs dispensant des services dits essentiels, comme le transport en commun et le secteur de la santé et des services sociaux, ont à respecter des règles particulières, différentes de celles des autres secteurs assujettis au régime général édicté par le Code. Ces règles particulières constituent ce qu’on appelle le régime des services essentiels. Les négociations dans les services essentiels comportent des particularités importantes – considérations politiques et absence de substituts des services publics pour la population – qui les distinguent de façon notable des négociations qui se déroulent sous l’égide du modèle général de négociation collective édicté au Code et applicable dans les autres secteurs (Bergeron et Paquet, 2006). Quels sont les effets du régime des services essentiels sur la négociation collective dans le secteur du transport en commun et de la santé et des services sociaux? Dans le cadre de cette recherche, nous avons examiné les effets du régime des services essentiels (les règles du Code du travail et les décisions du Conseil des services essentiels) sur différents aspects de la négociation collective : 1) la mobilisation, 2) le rapport de force, 3) les moyens de pression, 4) le déroulement des négociations, 5) l’arrêt de travail, 6) les résultats de la négociation collective et 7) le climat de travail. Afin d’étudier ces négociations atypiques dans notre système de relations industrielles, nous avons réalisé deux études de cas (secteur du transport en commun et secteur de la santé et des services sociaux). Les résultats indiquent bien que le régime des services essentiels influence le processus de négociation collective dans ces secteurs. Par contre, la comparaison des deux secteurs montre que les règles additionnelles auxquelles est assujetti le secteur de la santé et des services sociaux n’apparaissent pas affecter de façon déterminante le processus de négociation collective.
In Québec, collective bargaining in the public sector is to follow the rules established by the Labour Code (L.R.Q. C.-27). Certain sectors, providing essential services such as the public transit sector and the health and social services sector have additional rules. Those rules are referred to as the essential services legislation. Negotiations occurring within this structure have noticeable differences - the exclusion of political considerations, on the one hand, and the lack of a replacement for public services for the public, on the other hand – that distinguishes them from the more common framework of collective bargaining established by the Labor Code for other sectors of activity (Bergeron et Paquet, 2006). We ask the question: what are the impacts of the essentials services legislation on collective bargaining? For this research project, we have analysed the impact of the essential services legislation (rules by the Labor Code and decisions rendered by the Essential services board) on different aspects of collective bargaining: 1) mobilization, 2) power bargaining, 3) pressure tactics, 4) flow of negotiation, 5) work stoppage, 6) results of collective bargaining and 7) work climat. We carried out two case studies in order to study the atypical negotiations in our industrial relations system. The first study was in the public transit sector and the second in the health and social services sector. The results demonstrate that the essential services legislation influences collective bargaining. But the additional constraints in the social services sector do not seem to influence, on a larger scale, the collective bargaining for that sector of activity.

Aim: To explore the causes of minority stress in trans individuals in Sweden, and how these individuals cope with such minority stress. Background: Trans individuals have markedly poor mental health compared to the general population. Meyer’s Minority Stress Model has been shown to apply to trans individuals. However, causes of minority stress and methods of coping for trans individuals have not been investigated in Sweden. Previously, social support has been highlighted as a key coping mechanism of minority stress. This thesis explores the causes of minority stress on trans individuals and how they cope with this stress. Methods: A qualitative study utilising semi-structured interviews with 18 trans individuals from across Sweden. A deductive approach was applied in analysis of the data, in order to explore the causes of minority stress, as detailed by the Minority Stress Model. Results: The main causes of minority stress were found to be the medical investigation, discrimination and internalised stigma. The trans community was a source of social support, facilitating coping with minority stress. Other facilitative coping mechanisms used by participants were the support of family. Discrimination and internalised stigma led to avoidant coping mechanisms, such as avoidance of social environments. Conclusion: This study reinforces previous findings that discrimination and internalised stigma cause minority stress for trans individuals. The structure of the medical investigation in Sweden should be reviewed, to reduce the stress it causes. The visibility of the trans community should be improved to increase the use of the community as a source of social support and facilitative coping.

Philosophiae Doctor - PhD
In order to manage public dental services, information is required about what work is being performed by the staff at the various clinics. Tally sheets have been used in the past to record treatment procedures but this is not an effective method of recording the amount of work done by staff at public dental clinics. But tally sheets are inaccurate, open to abuse, and fail to provide the necessary information for managers. Nor is it of any real value for providing feedback to staff on their performance. This inhibits a core aspect of job satisfaction for the staff, which is feedback. The staff just persevere, continue doing the same thing and feel frustrated. This contributes to poor work performance. Instead of using a tally sheet, 4 digit treatment codes are used for all treatment procedures (as used in the private sector for billing purposes) and additional codes were developed for services such as brushing programmes for which billing codes do not exist. These are recorded for each patient, together with a code for the patient category. A relative value unit (RVU) has been developed for each treatment code that has been weighted according to policy guidelines and the amount of time and effort required to provide the service. This was done for clinical treatment procedures as well as for community-based preventive activities. A computer program has been developed that captures the treatment codes which are saved in a number of databases that are linked to Excel pivot tables. The data can therefore be easily manipulated by the user to obtain the required information in the form of counts of procedures, monetary cost of the same clinical services in the private sector (useful with the proposed advent of National Health Insurance) and also in the form of relative value units. iii This is available for the current reporting period as well as for previous periods, allowing a detailed analysis of services rendered and staff performance over a period of time to show trends. Use is also made of an Objectives Matrix where the performance of each staff member can be measured according to seven objectives (Key Performance Areas) (five in the case of oral hygienists) to produce an overall Performance Index – which is a score out of ten. This enables performance appraisal to be carried out much easier than by comparing performance based on a number of diverse treatments provided. The data for all the public dental clinics in the Western Cape Province has been analysed for the period 1994 to 2012 using this system, and it has been shown that the system is sensitive enough to highlight problem areas as well as provide a balanced overall view of the service, as measured by a number of variables. The system is “low tech” in that it runs on a “stand alone” personal computer, but it could easily be applied to an integrated, networked information system provided the latter contained the treatment codes, and certain other patient, staff and clinic identifiers. It is therefore suitable for developing countries, such as South Africa, that may later develop a comprehensive Health Information System based on an electronic medical record. The emphasis is not on the information technology, it is focussed on the concepts behind the processing of the data into meaningful information for managing public dental services.

L’health literacy(HL) può essere definita come “l’insieme delle capacità cognitive e sociali che determinano la motivazione e l’abilità degli individui di accedere, comprendere e utilizzare le informazioni, sì da promuovere e mantenere un buon livello di salute”. In letteratura, ad oggi, sono poche le evidenze provenienti dalla misurazione dell’HL a livello di popolazione generale, nonostante che tale misurazione possa essere di notevole beneficio per orientare gli interventi di sanità pubblica. Ad oggi, infatti, molte delle evidenze in merito all’HL, ai suoi predittori e alle sue associazioni con gli outcome di salute, provengono da studi condotti in contesti clinici o su gruppi specifici di popolazione. Inoltre, per le finalità di sanità pubblica, la valutazione dell’HL richiede studi paese e area specifici, in quanto l’HL e le sue relazioni rappresentano un costrutto dinamico, che può variare da paese a paese. A tal proposito, in Italia, la ricerca sull’HL appare essere ancora agli inizi. Considerando i presupposti sopradescritti, il presente studio si è posto l’obiettivo generale di misurare il livello di Health literacy (HL) in un campione di popolazione generale adulta con domicilio sanitario nell’ex-ASL di Firenze, valutarne i predittori e le associazioni con gli outcome di salute, e validare nuovi strumenti di misura della HL per il contesto italiano. Nello specifico, il nostro studio si è concentrato sui seguenti tre obiettivi primari: 1. Obiettivo 1: valutare il livello di health literacy, i suoi predittori e le sue associazioni con gli outcome di salute in un campione di popolazione generale adulta attraverso lo strumento Newest Vital Sign (NVS-IT). 2. Obiettivo 2: Esaminare se l’health literacy costituisca una delle possibili vie attraverso cui i determinanti socio-economici influiscono sulla salute 3. Obiettivo 3: sviluppare e validare la versione short (HLS-EU-Q16) e short-short (HLS-EU-Q6) dello strumento di misura dell’HL utilizzato nella survey europea (HLS-EU-Q47). Tali obiettivi sono stati indagati attraverso il seguente protocollo di studio. Lo studio è stato condotto con un disegno osservazionale trasversale. Il campione di ricerca è stato arruolato tra i soggetti assistiti da 11 Medici di Medicina Generale (MMG) che operano nel territorio della ex-ASL di Firenze. I MMG sono stati scelti con un criterio di convenienza: la possibilità di partecipare allo studio è stata diffusa a tutti i MMG da parte dell’Ordine dei Medici Chirurghi di Firenze e i primi 11 MMG che hanno formalmente aderito all’iniziativa sono stati inseriti nel progetto. Lo studio ha previsto un campione di popolazione generale, selezionato in maniera casuale dagli elenchi degli assistiti dei MMG aderenti. Le dimensioni del campione (circa 450 soggetti) sono state stimate con studi di potenza campionaria. L’unico criterio d’inclusione è stato l’età compresa tra 18 e 69 anni (fascia di età normalmente inclusa nel sistema di sorveglianza PASSI, sistema di sorveglianza che indaga molti aspetti correlati alle finalità del nostro studio). Sono stati invece esclusi dallo studio coloro che risultavano affetti da malattie terminali, demenze o malattie psichiatriche gravi. Ogni soggetto arruolato è stato intervistato telefonicamente (durata media 20 minuti circa). L’intervista ha previsto la somministrazione di domande riguardanti caratteristiche demografiche e socio-economiche, lo stato di salute percepito e altri outcome di salute, e strumenti di misura dell’HL (NVS-IT e HLS-EU-Q16). Dalla esecuzione di tale protocollo di studio, sono stati ottenuti i risultati di seguito riassunti e illustrati per singolo obiettivo specifico: 1. Obiettivo 1: valutare il livello di health literacy, i suoi predittori e le sue associazioni con gli outcome di salute in un campione di popolazione generale adulta attraverso lo strumento NVS-IT. Introduzione: Il NVS è uno strumento di facile e veloce somministrazione sviluppato originariamente per valutare le capacità di base di HL nei contesti clinici. Ad oggi, le evidenze sull’HL (misurata con il NVS-IT) provenienti da studi condotti a livello di popolazione generale sono limitate nonostante possano fornire utili informazioni per programmare gli interventi di sanità pubblica. Metodi: l’HL è stata valutata con il NVS-IT. I predittori dell’HL e le sue associazioni con gli outcome di salute sono stati valutati attraverso modelli di regressione logistica multivariata. In particolare, sono state esaminate le seguenti variabili: caratteristiche demografiche e socio-economiche; presenza di malattie croniche; utilizzo di diverse tipologie di servizi sanitari negli ultimi 12 mesi; indice di massa corporea e stato di salute auto-percepito. Risultati: in totale, 452 soggetti hanno completato l’intervista (58,8% di genere femminile), di questi l’11,5% presenta alta possibilità di HL limitata, il 24,6% una possibilità di HL limitata e il 63,9% una HL adeguata. All’analisi multivariata, un’età più elevata (OR=1,07; C.I.95% 1,05–1,09), un titolo di studio più basso (OR=4,03; C.I.95% 3,41-7,49) e minori risorse finanziarie a disposizione (OR=1,64; C.I.95% 1,17-2,63) sono risultati aumentare significativamente l’odds di alta probabilità/possibilità di HL limitata. Inoltre, per quanto riguarda gli outcome di salute, all’analisi multivariata i soggetti con alta probabilità/possibilità di HL limitata sono risultati a maggior rischio di riportare un peggior stato di salute auto-percepito (OR=2,25; C.I.95% 1,75-2,75). Conclusioni: i risultati mostrano un buon livello di HL nella popolazione, tuttavia la presenza nei gruppi più fragili della popolazione (le persone più anziane, quelle meno istruite e quelle più povere) di un maggior rischio di HL limitata evidenzia l’importanza di progettare e attuare interventi e politiche sanitarie che tengano in considerazione il livello di HL di queste popolazioni. 2. Obiettivo 2: Esaminare se l’health literacy costituisca una delle possibili vie attraverso cui i determinanti socio-economici influiscono sulla salute. Introduzione: l’influenza dei fattori socio-economici sullo stato di salute è ben documentata, tuttavia i meccanismi con cui essi agiscono non sono ancora del tutto delucidati. Recentemente l’HL è stata proposta come una delle possibili vie attraverso cui i fattori socio-economici influenzano la salute, ad oggi però solo poche ricerche hanno concretamente esplorato questa ipotesi. Metodi: molteplici analisi di mediazione secondo il metodo proposto da Tingley e collaboratori sono state condotte utilizzando: i. le variabili “titolo di studio” e “risorse finanziarie a disposizione per arrivare alla fine del mese” come variabili indipendenti, ii. la variabile “stato di salute auto-percepito” come variabile dipendente e iii. le categorie di NVS come misura di HL. Tutti i modelli sono stati aggiustati per sesso ed età. Risultati: i risultati delle analisi hanno mostrato la presenza di un’associazione positiva tra variabili socio-economiche (titolo di studio e risorse finanziarie a disposizione) e salute auto-percepita (p<0,01 per entrambe le variabili). L’HL è risultata essere un mediatore parziale dell’associazione tra titolo di studio e un peggior stato di salute auto-percepita (proporzione mediata media dall’HL= 18,5%, p=0,02). Simili risultati sono stati evidenziati nella relazione tra risorse finanziarie a disposizione e peggior stato di salute auto-percepito (proporzione mediata media dall’HL= 12,9%, p=0,01). Conclusioni: i risultati suggeriscono che l’HL possa mediare in parte l’effetto che i determinanti socio-economici esercitano sullo stato di salute. Tale risultato permette di dare maggior comprensione ai meccanismi attraverso cui le disparità socio-economiche generano differenze nello stato salute. Inoltre, questo risultato suggerisce anche una possibile opzione di contrasto a tali diseguaglianze di salute: politiche e interventi mirati a aumentare il livello di HL nella popolazione o a rendere i sistemi sanitari più fruibili alle persone con bassa HL possono permettere di intercettare a metà del percorso l’azione dei determinanti socio-economici sulla salute, riducendone gli effetti. Tuttavia, viste le scarse evidenze presenti al momento in letteratura, ulteriori studi risultano necessari per confermare i nostri risultati, e per meglio caratterizzare il ruolo dell’HL come mediatore nella relazione tra determinanti socio-economici e stato di salute. 3. Obiettivo 3: sviluppare e validare la versione short (HLS-EU-Q16) e short-short (HLS-EU-Q6) dello strumento di misura dell’HL utilizzato nella survey europea (HLS-EU-Q47). Introduzione: recentemente sono stati sviluppati l’HLS-EU-Q16 e HLS-EU-Q6, strumenti di misurazione dell’HL pensati per la popolazione generale che permettono una valutazione approfondita dell’HL e delle sue varie dimensioni. Tale strumento è stato impiegato in numerosi Paesi europei, ma ad oggi una versione validata per il contesto italiano non è disponibile. Metodi: la versione italiana dell’HLS-EU-Q16 e HLS-EU-Q6 è stata sviluppata attraverso una procedura standardizzata di traduzione (backward-forward translation) eseguita da esperti nel settore di madre lingua italiana e inglese. Come misure di affidabilità delle scale (consistenza interna) è stato calcolato il coefficiente alpha di Cronbach. Sono state eseguite analisi di correlazione (Pearson or Spearman, a seconda della distribuzione normale o meno) tra i punteggi delle singole domande dell’HLS-EU-Q16, e tra i punteggi totali delle varie scale considerate (HLS-EU-Q16, HLS-EU-Q6, G-HL Index e NVS-IT). Le associazioni con gli antecedenti e outcome di salute sono state valutate attraverso il test del Chi2 o attraverso analisi di correlazione (Pearson o Spearman). Risultati: l’alpha di Cronbach per l’HLS-EU-Q16 e per l’HLS-EU-Q6 è risultato essere rispettivamente di 0.799 e di 0.672. L’HLS-EU-Q16 e l’HLS-EU-Q6 sono risultati essere fortemente correlati tra loro (Spearman rho: 0,861; p<0,05) ma non con il NVS-IT. Per quanto concerne la distribuzione dei livelli di HL nel campione, all’HLS-EU-Q16, l’11,8% dei partecipanti è risultato avere livelli di HL inadeguati, il 55,2% una HL problematica, mentre il 33% livelli adeguati di HL. Sia l’HLS-EU-Q16 che l’HLS-EU-Q6 sono risultati significativamente associati al titolo di studio, all’aver avuto educazione specifica e/o esperienza lavorativa nel settore sanitario e allo stato di salute auto-percepito. Conclusioni: i risultati ottenuti rappresentano le prime evidenze di affidabilità e validità degli strumenti HLS-EU-Q16 e HLS-EU-Q6 per la popolazione generale italiana. Rispetto ad altri studi pubblicati, si evidenziano alcune differenze nei livelli di HL e nei suoi antecedenti e conseguenti; tali differenze possono essere verosimilmente inquadrate nell’ambito delle specificità socio-culturali del contesto italiano. Tuttavia, per confermare questi primi risultati sono necessari ulteriori studi su campioni più ampi. In conclusione, il presente studio rappresenta uno dei primi tentativi di misurare l’HL a livello della popolazione generale italiana. I risultati ottenuti forniscono evidenze utili sia per programmare gli interventi di prevenzione delle malattie e di promozione della salute a livello comunitario, sia per migliorare l’efficacia della relazione medico-paziente a livello della dimensione assistenziale. In particolare, i risultati sottolineano l’importanza di pianificare interventi di educazione e promozione della salute volti a migliorare il livello di HL nella popolazione e di progettare servizi sanitari più fruibili alle persone con un basso livello di HL. Infine, lo studio ha permesso di validare per il contesto italiano nuovi strumenti di misurazione della HL. Tali strumenti permetteranno una più approfondita valutazione della health literacy, delle sue dimensioni e relazioni a livello della popolazione generale italiana, e consentiranno il confronto con i risultati di altri Paesi Europei.

Following the Second World War, the Food and Agriculture Organization (FAO) and the World Health Organization (WHO) teamed up to construct an international Codex Alimentarius (or “food code”) in 1962. Inspired by the work of its European predecessor, the Codex Europaeus, these two UN agencies assembled teams of health professionals, government civil servants, medical and scientific experts to draft food standards. Once ratified, the standards were distributed to governments for voluntary adoption and implementation. By the mid-1990s, the World Trade Organization (WTO) identified the Codex as a key reference point for scientific food standards. The role of science within this highly political and economic organization poses interesting questions about the process of knowledge production and the scientific expertise underpinning the food standards. Standards were constructed and contested according to the Codex twin goals of: (1) protecting public health, and (2) facilitating trade. One recent criticism of Codex is that these two aims are opposed, or that one is given primacy over the other, which results in protectionism. Bearing these themes in mind, in this dissertation I examine the relationship between the scientific and the ‘social’ elements embodied by the Codex food standards since its inception after the Second World War. I argue that these attempts to reach scientific standards represent an example of coproduction– one in which the natural and social orders are produced alongside each other. What follows from this central claim is an attempt to characterize the pre-WTO years of the Codex through a case study approach. The narrative begins with a description of the predecessor regional group the Codex europaeus, and then proceeds to key areas affecting human health: 1) food additives, 2) food hygiene, and 3) pesticides residues.

Indiana University-Purdue University Indianapolis (IUPUI)
Identifying spatial and temporal patterns of disease occurrence by mapping the residential locations of affected people can provide information that informs response by public health practitioners and improves understanding in epidemiological research. A common method of locating patients at the individual level is geocoding residential addresses stored in electronic medical records (EMRs) using address matching procedures in a geographic information system (GIS). While the process of geocoding is becoming more common in public health studies, few researchers take the time to examine the effects of using different address databases on match rate and positional accuracy of the geocoded results. This research examined and compared accuracy and match rate resulting from four commonly-used geocoding databases applied to sample of 59,341 subjects residing in and around Marion County/ Indianapolis, IN. The results are intended to inform researchers on the benefits and downsides to their selection of a database to geocode patient addresses in EMRs.