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- ItemAcesso aberto (Open Access)Ações no controle do câncer de mama : identificação das práticas na atenção primária por meio da usuária na região sudeste da cidade de São Paulo(Universidade Federal de São Paulo (UNIFESP), 2017-02-24) Marques, Carla Andreia Vilanova [UNIFESP]; Gutierrez, Maria Gaby Rivero de [UNIFESP]; Figueiredo, Elisabeth Niglio de [UNIFESP]; http://lattes.cnpq.br/5873289377529519; http://lattes.cnpq.br/4595643076722509; http://lattes.cnpq.br/8106562494475157; Universidade Federal de São Paulo (UNIFESP)Objective: to analyze the early detection of breast cancer implementation and the associated factors, for primary health care (PHC) service users from southeast of São Paulo city, according to the Ministry of Health (MoH) guideline. Method: cross-sectional study approved by the Ethics and Research Committees (nº 13926013.3.1001.5505) and conducted from October to December of 2013. The cluster sample survey in two stages was performed, considering 50% of outcome frequency in the target group, 95% of the confidence level and deff of 2.9. In the first stage, 38 of the 90 PHC service has been selected in a simple random sample. In the second stage, the proportion of the target age (35-39, 40-49, 50-69) in the population from the selected PHC services, has been considered in the distribution of the 1.117 women surveyed. The user’s randomized systematic sample has been performed, taking in account the assistance routine in some selected PHC services. The research inclusion criteria for PHC services was been ≥ 3 years in the operation time, for the women, they should be between 35 to 69 years old and been attending in those selected PHC services for ≥ 3 years. The data were collected by trained interviewers, using a validated questionnaire with 83 questions regarding to socioeconomic characteristics, breast cancer risk factors and the actions for the early detection of breast cancer. There were missing data of 167 women resulting 950 in a final sample. The outcome variables analyzed were clinical breast examination (CBE) and mammography. The independent variables were sociodemographic data, risk factor and PHC services (Family Health Strategy, Traditional and Mixed). A descriptive analysis of all the variables has been performed and afterwards, the Pearson's Chi-square test and binary logistic regression were applied, assuming p≤0.05. For the analysis of compliance, the results obtained were compared to those recommended by the MoH. Results: the majority of 950 surveyed women was married, white, with 9 to 11 years of schooling, belonged to the C economic class and did not have health insurance. The preventive practice characteristic revealed a higher prevalence of achievement for women between 50-69 years old, married, white, who were not economically active, belonged to the C economic class, with a standard risk of breast cancer. The CBE frequency was 42.9% and the mammography was 58.5%, while compliance was 39.8% and 28.6%, respectively. Regarding the PHC service to the mammography, there was a higher frequency of this exam in the Traditional PHC service and lower in the FHS. There was a greater biennial coverage of this mammography in the target women with 50 to 69 years old in the Traditional PHC and lower in the Mixed PHC, the compliance of the governmental recommendation was higher in the FHS than in the Mixed and Traditional PHC. The associated factors with mammography were: age, family history of breast cancer assessment, to perform CBE and Pap Smear, to receive age guidance to start the mammography. The associated factors with the CBE were to receive age guidance to start this examination, to have mammography, to receive age guidance to start mammography and to perform a Pap Smear. Conclusion: the mammographic performance was more frequent than the CBE, however, the exams periodicity, target age group and the hereditary breast cancer risk factors has been little considered during the users assessment on PHC services, consequently the outcome show a low coverage and compliance of the government goals. The Traditional PHC offered more mammography, but, higher compliance of the recommendation has been achieved in the FHS. The adherence predictors to preventive practices were to receive age guidance of breast cancer exams and been performed gynecological exams.
- ItemSomente MetadadadosAções para o controle do câncer de mama na atenção primária à saúde na perspectiva das usuárias(Universidade Federal de São Paulo (UNIFESP), 2019-09-28) Goncalves, Valterli Conceicao Sanches [UNIFESP]; Gutierrez, Maria Gaby Rivero De [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)Introduction: Cancer is considered an important public health problem, due to its epidemiological, social and economic relevance, in both developed and developing countries. For early detection of this condition, the Ministry of Health recommends diagnostic and screening actions, making clear the need for the tripod: population warned of signs and symptoms; health professionals trained to evaluate suspected cases and health systems, and services prepared to ensure timely diagnostic confirmation, with quality and guarantee of comprehensive care throughout the care line. It is relevant to know preventive practices related to early detection and diagnosis, since this information can support the planning of effective strategies in Primary Health Care. Objective: To evaluate the implementation of opportunistic screening actions for breast cancer control, proposed by the Ministry of Health, in Primary Health Care, through information from users. Method: Cross-sectional study conducted in 18 BHUs in the municipality of Diadema, with 675 users, aged 35-69 years, from November 2014 to March 2015. It is linked to the multicenter project entitled “Actions on Breast Cancer Control: identification of practices in Primary Care” developed by the Nursing Schools of the Federal University of São Paulo (Paulista School of Nursing / UNIFESP) and the University of São Paulo - Ribeirão Preto College of Nursing (EERP-USP), which purpose is to portray the implementation of the actions recommended by the Ministry of Health for the screening of breast cancer among users of Primary Health Care. Used a validated questionnaire which was applied after approval of the UNIFESP Research Ethics Committee. The project was approved under CAAE No. 20021714.5.0000.5505. The collected data were analyzed descriptively and analytically. Results: Of the users, 50.5% declared to be white; 44.3% married; 32.2% said they were illiterate or had completed Elementary School. 61.6% belonged to social class C and 62.1% do not perform any paid activity. Most (83.8%) used exclusively Unified Health Care System services and only 16.2% had health insurance, using it for consultations and exams. As for the risk for breast cancer, 4.7% reported having family risk factor for the neoplasm and 63.1% said the health professional asked about family risk for breast cancer; 37.5% of users at high risk for breast cancer reported having undergone breast clinical examination annually; 20.9% of users aged 50 to 69 years and at population risk performed mammography. Only 8.7% of users reported having attended an educational meeting on breast cancer. Regarding the adequacy of the parameters established by the Consensus for mammography and clinical breast examination, rates of 8.9%, 10.6% and 7.7% were found for age groups 35 to 39, 40 to 49 and 50. to 60 years, respectively. Conclusion: the opportunistic screening actions for breast cancer, carried out by Primary Health Care, need to be adjusted to comply with the guidelines proposed by the Ministry of Health in all age groups studied.
- ItemAcesso aberto (Open Access)A avaliação de programas e serviços de saúde no Brasil enquanto espaço de saberes e práticas(Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, 2014-12-01) Furtado, Juarez Pereira [UNIFESP]; Vieira-da-silva, Ligia Maria; Universidade Federal de São Paulo (UNIFESP); Universidade Federal da Bahia Instituto de Saúde ColetivaThis social and historical study drew on Bourdieu's genetic sociology to analyze the establishment and development of a specialized space for the production of knowledge and practices in health evaluation in Brazil. The study analyzed the trajectories of 28 researchers and policymakers and the historical conditions that allowed establishing this space, using in-depth interviews, document analysis, and a literature review. The resulting material was analyzed according to Bourdieu's concepts of field, habitus, and capital. The results point to the constitution of a sub-space for evaluation within Public Health, resulting from interaction between actors from the administrative and scientific fields, respectively, represented by management institutions in the Brazilian Unified National Health System at its various levels and research groups affiliated with public universities. No common habitus was found between the interviewees and the inherent issues and disputes in this sub-space.
- ItemAcesso aberto (Open Access)Cluster analysis as a tool for management improvement in the SUS(Univ Sao Paulo, Fac Saude Publica, 2015-01-01) Tanaka, Oswaldo Yoshimi; Drumond Junior, Marcos; Cristo, Elier Broche; Spedo, Sandra Maria [UNIFESP]; Pinto, Nicanor Rodrigues da Silva [UNIFESP]; Universidade de São Paulo (USP); Municipal Hlth Dept Sao Paulo; Minist Hlth; Universidade Federal de São Paulo (UNIFESP)The institutionalization of health services evaluation tools is a strategic challenge for the development of the Brazilian National Health System (SUS). The aim of the study was to explore the potential of cluster analysis as a technical tool to support the SUS management. Steps for constructing clusters applied to a concrete reality are presented and discussed, by analyzing a type of health care emergency services (AMA), in Sao Paulo city. The strategy was based on using secondary data to construct homogeneous groups, which allows multivariate analysis, enhancing the interpretation of the relationship between these data. The study findings indicate that this technique has the potential to be used by institutional actors in the SUS management to evaluate and to monitor health services in big cities or health regions.
- ItemAcesso aberto (Open Access)Como o ortopedista brasileiro trata entorse lateral aguda do tornozelo?(Sociedade Brasileira de Ortopedia e Traumatologia, 2010-01-01) Belangero, Paulo Santoro [UNIFESP]; Tamaoki, Marcel Jun Sugawara [UNIFESP]; Nakama, Gilberto Yoshinobu [UNIFESP]; Shoiti, Marcus Vinicius [UNIFESP]; Gomes, Rodrigo Vick Fernandes [UNIFESP]; Belloti, Joao Carlos [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)OBJECTIVE: Acute lateral ankle sprain (ALAS) is one of the most common injuries, the treatment of which has yet to be firmly established. The purpose of this study was to determine the Brazilian Orthopaedic Surgeon's behavior in relation to diagnosis, classification, treatment and complications of the Acute Lateral Ankle Sprain. METHODS: A multiple choice questionnaire was developed which addressed the main aspects related to the treatmentof acute lateral ankle sprains (ALAS). The questionnaire was made available from June 15 to August 1, 2004, at the Official site of the Brazilian Society of Orthopedics and Traumatology. RESULTS: 444 questionnaires were included in the analysis. The results showed agreement among most of those interviewed in the following regards: 90.8% use some classification to guide treatment of the sprain; 59% classify the ankle sprain with certainty; 63.7% use the immobilization in cases of totally ruptured ligaments; 60.6% use anti-inflammatory medication in partial ligament ruptures; 75.9% reported that residual pain was the most frequent complication. There was no consensus regarding treatment of partial ALAS, as immobilization and functional treatment were chosen with the same frequency (47% each). There was no significant difference between the answers of residents and orthopedists. CONCLUSIONS: Orthopedic surgeons and orthopedic residents in Brazil have difficulty classifying ALAS and there is no consensus about the best therapeutic option for partial ALAS.
- ItemAcesso aberto (Open Access)Comparação entre formas de extração do tempo máximo fonatório em indivíduos sem queixas vocais(CEFAC Saúde e Educação, 2014-10-01) Englert, Marina; Mesquita, Loriane Gratão; Azevedo, Renata [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)PURPOSE: to check the credibility between an acoustic program, an experienced evaluator and a non-experienced evaluator measuring the Brazilian vowel /a/ in subjects with no voice complaints and to verify if there is difference between the highest value of three emissions of MPD with the average of these values. METHODS:56 adults recorded the vowel /a/ in MPD. One measurement was performed by an experienced speech pathologist and the other by a newly graduated speech pathologist, with a stop watch. A third valuator measured the MPD in an acoustic program. The difference between the average of the three emissions and the highest value of MPD obtained by each evaluator was compared. RESULTS:there was no difference between the evaluators and an acoustic program the only difference found was among considering the average of the three emissions or the highest value of MPD. CONCLUSIONS:the MPD has high reliability regardless the form of extraction and the clinical experience of the evaluator. There was a difference in the value of MPD comparing the average of three emissions with its highest value, which suggests that we should always follow the same pattern in our assessments and reassessments.
- ItemAcesso aberto (Open Access)A elaboração participativa de indicadores para a avaliação em saúde mental(Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, 2013-01-01) Furtado, Juarez Pereira [UNIFESP]; Onocko Campos, Rosana Teresa; Moreira, Maria Inês Badaró [UNIFESP]; Trapé, Thiago Lavras [UNIFESP]; Universidade Federal de São Paulo (UNIFESP); Universidade Estadual de Campinas (UNICAMP)The specialized literature frequently cites the inclusion of different interest groups in evaluative research, referred to generically as participatory evaluation. However, there is a lack of an empirical basis for discussion on ways to operate and (especially) qualify such participation. This article discusses the participatory development of mental health indicators for use in the Centers for Psychosocial Care (CAPS) in Brazil. The process included participation by 58 health workers and managers from 26 CAPS through regular meetings over a year. The meetings were intermediated by a course on mental health evaluation and workshops in subgroups, supported by facilitators throughout the year. The creation of spaces for the qualification of their participation, through the course and other collective activities, proved effective for guaranteeing participation at various levels in the process (such as definition of issues, pre-test indicators, and data analysis) as well as for stimulating ownership of the final product by the participants.
- ItemAcesso aberto (Open Access)Função muscular isocinética de acordo com o nível de atividade física em adultos entre 20 e 80 anos(Universidade Federal de São Paulo (UNIFESP), 2020-10-08) Navarro, Renato Caleiro [UNIFESP]; Dourado, Victor Zuniga [UNIFESP]; Ostolin, Thatiane Lopes Valentim Di Paschoale [UNIFESP]; http://lattes.cnpq.br/4675570734968007; http://lattes.cnpq.br/1919368500743497; http://lattes.cnpq.br/4633344297813579; Universidade Federal de São Paulo (UNIFESP)Introdução: A avaliação isocinética é o método padrão-ouro para avaliar a função muscular periférica. Sua maior vantagem está no controle da velocidade do movimento, possibilitando uma medição detalhada ao longo de toda amplitude de movimento. Os valores de normalidade para a dinamometria isocinética são escassos e restritos ao joelho. Tendo em vista que a função muscular dos membros inferiores e superiores apresentam alterações em proporções diferentes em relação à idade e sexo, é necessário avaliar os percentis de normalidade da função muscular tanto da função muscular isocinética de joelho quanto de cotovelo. Objetivos: Avaliar os percentis de normalidade da função muscular isocinética do joelho e cotovelo e elaborar equações de referência em adultos saudáveis entre 20 e 80 anos. Secundariamente, avaliar a influência do nível de atividade física na função muscular isocinética desses adultos, bem como os atributos cardiometabólicos, clínicos e fisiológicos determinantes da função muscular em adultos assintomáticos. Materiais e métodos: Foram avaliados 1334 indivíduos adultos entre 20-80 anos selecionados do estudo Epidemiológico do Movimento Humano (EPIMOV). A priori, foi realizada uma avaliação clínica, seguida da obtenção das medidas antropométricas. A composição corporal foi obtida por meio de bioimpedância elétrica e o nível de atividade física habitual foi avaliado através de acelerometria triaxial. A função muscular tanto de joelho quanto de cotovelo foi avaliada por meio de dinamometria isocinética. Por meio de modelos de regressão múltipla lineares do tipo stepwise, foram elaboradas equações de predição da função muscular isocinética de cotovelo e joelho. Os percentis de normalidade da função muscular foram descritos segundo o sexo abaixo de 20-39 anos, 40-59 anos e com 60 anos ou mais. Resultados: A amostra foi composta sobretudo por mulheres de meia-idade, com sobrepeso e alta prevalência de inatividade física. Após análise de regressão linear múltipla do tipo stepwise ajustada por variáveis demográficas e antropométricas, a atividade física modera a intensa (AFMI) e os fatores de risco para doenças cardiovasculares foram considerados preditores significativos da função muscular de joelho e cotovelo. Apesar dos modelos explicarem de 49,6 a 70,9% da variabilidade total da função muscular de joelho e cotovelo, a AFMI e os fatores de risco para doença cardiovascular pouco contribuíram para o coeficiente de determinação (R2 = 0,003 a 0,006). Sendo assim, as variáveis demográficas e antropométricas foram preditores mais importantes em comparação à AFMI e os fatores de risco cardiovasculares nos modelos construídos, explicando de 52,5-70,9% e 49-70,7% da variabilidade da função muscular de joelho e cotovelo, respectivamente. Conclusão: Apesar de se correlacionar com a função muscular tanto de joelho quanto de cotovelo, o nível de atividade física habitual pouco explica a variabilidade da função muscular, a qual é amplamente determinada por variáveis antropométricas e sociodemográficas em adultos sem doenças crônicas sintomáticas. As tabelas de percentis e as equações desenvolvidas irão contribuir para melhor capacidade interpretativa da avaliação da função muscular avaliada por meio do dinamômetro isocinético, e, consequentemente, favorecer ainda mais sua aplicabilidade clínica.
- ItemAcesso aberto (Open Access)Impact of oral health on physical and psychosocial dimensions: an analysis using structural equation modeling(Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, 2014-06-01) Silveira, Marise Fagundes; Marôco, João P.; Freire, Rafael Silveira; Martins, Andréa Maria Eleutério de Barros Lima; Marcopito, Luiz Francisco [UNIFESP]; Universidade Estadual de Montes Claros Departamento de Ciências Exatas e Tecnológicas; Instituto Superior de Psicologia Aplicada Departamento de Ciências Psicológicas; Faculdades Integradas Pitágoras de Montes Claros Departamento de Fisioterapia; Universidade Estadual de Montes Claros Departamento de Odontologia; Universidade Federal de São Paulo (UNIFESP)This study aimed to estimate the prevalence of impact of oral health conditions on physical and psychosocial dimensions among adolescents and to identify factors associated with severity of impact. The impact of oral health status was assessed by the instrument Oral Health Impact Profile (OHIP-14). The covariates were: socioeconomic status, habits and health care, use of dental services, and normative conditions of oral health. Structural equation modeling was performed, and 15.6% of adolescents reported impact in at least one dimension of the OHIP-14. The dimensions that showed the highest prevalence of impact were psychological distress (11.8%) and physical pain (6.6%). The number of teeth needing dental treatment, number of filled teeth, and CPI significantly affected severity of impact. In this adolescent population, unfavorable socioeconomic conditions were associated with reduced use of dental services, associated in turn with precarious oral health conditions and increased severity of impact.
- ItemAcesso aberto (Open Access)Implementação de ortodontia preventiva e interceptativa no município de Suzano-SP: um estudo de caso(Universidade Federal de São Paulo, 2023-04-20) Sugaya, Marisa de Freitas [UNIFESP]; Fegadolli, Claudia [UNIFESP]; Zepeda, Jorge Ernesto Sergio; http://lattes.cnpq.br/1642460907131240; http://lattes.cnpq.br/6541145627909917; https://lattes.cnpq.br/5872904083114484; Universidade Federal de São Paulo (UNIFESP)Introdução: Este é um estudo sobre a implementação de novas práticas em odontologia no Sistema Único de Saúde (SUS), em particular, sobre a iniciativa de implementação de ortodontia preventiva e interceptativa (OPI) na atenção primária à saúde (APS) no município de Suzano-São Paulo (SP). A iniciativa responde ao problema da maloclusão, condição de elevada prevalência e impacto à saúde. Objetivo: O estudo propõe analisar a implementação da ortodontia preventiva e interceptativa no município de Suzano-SP. Método: Tratou-se de um estudo de caso com métodos mistos apoiado no referencial teórico metodológico da avaliação realista, que é um tipo de avaliação baseada na teoria do programa. A principal fonte de dados foi um conjunto de entrevistas com cirurgiões-dentistas, gestores e pesquisadores envolvidos na implementação. As entrevistas foram submetidas à análise temática guiada pelas teorias iniciais do programa. A pergunta de pesquisa foi: ‘Como e por que esta intervenção funcionou neste contexto?’. A produção de hipóteses iniciais (teorias do programa) ocorreu com base na literatura, na análise documental e na experiência da pesquisadora como coordenadora da área técnica de saúde bucal durante a implementação do programa. As teorias iniciais foram testadas e refinadas por meio de triangulação com dados da entrevista e descrição do caso. Resultados: Os principais componentes da intervenção foram: compartilhamento de informações de saúde bucal; espaços coletivos; e disponibilidade de apoio e de recursos para o trabalho. Estes componentes interagiram com os fatores do contexto institucional e características dos atores locais para ativar os seguintes mecanismos de mudança: reflexão e maior compreensão sobre o problema; segurança; participação e responsabilização pela mudança; e valorização do trabalhador. Três teorias de programa explicam como esses mecanismos contribuíram sinergicamente para implementação da OPI na atenção primária em Suzano-SP. Conclusões: As teorias refinadas se reforçam mutuamente e têm elementos recorrentes, o que sugere que o conjunto de estratégias de implementação adotadas no caso descrito podem contribuir sinergicamente para implementação de intervenções semelhantes.
- ItemSomente MetadadadosThe nutritional care during the prenatal and postpartum: perceptions of managers of primary health care(Pontificia universidade catolica campinas, 2016) Laporte-Pinfildi, Anna Sylvia de Campos [UNIFESP]; Zangirolani, Lia Thieme Oikawa [UNIFESP]; Spina, Natalia [UNIFESP]; Martins, Paula Andrea [UNIFESP]; Medeiros, Maria Angélica Tavares de [UNIFESP]Objective To evaluate the perception of managers regarding the nutritional care to prenatal and postpartum in Primary Health Units in Southern, Sao Paulo, Brazil. Methods It was conducted a census of 28 Primary Health Units from the insular area, using interviews with managers. The nutritional care was assessed according to infrastructure, work process and food and nutrition surveillance. Results The insertion of dietitians was the main insufficient component of dimension structure, interfering negatively on nutritional care for 60% of managers. It was founded low compliance for the following variables of theprocess dimension: calculate the body mass index (35%), monitoring of nutritional status in body mass index/gestational week curve (46%) and conducting individualized nutritional counseling in antenatal (14%). Conclusion Prenatal and postpartum nutritional care is unsatisfactory to achieve comprehensive care. It is necessary to sensitize local manager's awareness and qualify the health teams to ensure the effectiveness of such actions in Santos, Sao Paulo.
- ItemSomente MetadadadosUma Pesquisa Avaliativa Sobre Os Núcleos De Apoio À Saúde Da Família(Universidade Federal de São Paulo (UNIFESP), 2017-08-18) Correia, Patricia Caroline Iacabo [UNIFESP]; Furtado, Juarez Pereira [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)Endowed with a new working process model, the matrix support, the Family Health Support Centers (Nasf) were formulated with the objective of increasing the resolution of Primary Health Care in Brazil. However, concomitantly with the numerical expansion of these centers, there are questions about what and how to develop their attributions. An evaluability assessment on Nasf was carried out based on a systematic literature review and the official speech expressed in documents of the Ministry of Health. The findings proved that the initiative is evaluable and that the strategic and logical analyzes are pertinent for the current stage in which the centers are found, as the main questions about them are in their own tecno-assistential model. Through a case study, the analysis of the theoretical conceptions and hypotheses that support this initiative was carried out. Nasf still faces challenges to consolidate matrix support, as there is tension between general and specific performance, obstacles to professional collaboration and difficulties at centers’ coordination. However, there was an increase in the scope of actions offered in Primary Health Care and the incorporation of new knowledge by the teams.
- ItemAcesso aberto (Open Access)Por um gesto de leitura materialista dos conceitos da Avaliação em Saúde no Brasil(Universidade Federal de São Paulo, 2024-06-24) Gasparini, Max Felipe Vianna [UNIFESP]; Furtado, Juarez Pereira [UNIFESP]; Barbosa Filho, Fábio Ramos; http://lattes.cnpq.br/4350854052243669; http://lattes.cnpq.br/6869345414404363; http://lattes.cnpq.br/5164267918387599; Universidade Federal de São Paulo (UNIFESP)A Avaliação em Saúde no Brasil, mais especificamente no âmbito da Saúde Coletiva, tem se constituído enquanto uma prática social que se busca científica a partir de formulações conceituais que operam em e a partir de discursividades específicas. Os conceitos em operação no seu discurso são constructos historicamente determinados, cujos efeitos de sentido constituem as bases que regulam aquilo que é possível e aceitável na prática dita sistemática da avaliação. Partindo de um gesto de leitura materialista e estabelecendo uma questão inicial de investigação acerca da discursividade dos conceitos da Avaliação em Saúde no Brasil, esta tese tem como objetivo contribuir para uma apreensão crítica deste subespaço da Saúde Coletiva, compreendendo o funcionamento ideológico de sua enunciação. Para tanto, direcionamos nosso gesto de leitura materialista em quatro direções: primeiro, à forma como a história da avaliação é contada por meio da sucessão de abordagens e normas, e que constituem uma compreensão não histórica de seu desenvolvimento; segundo, para um período histórico específico, definido em função de acontecimentos já mapeados e registrados que nos parecem fornecer pistas nas quais podemos seguir para compreender aspectos da discursividade da Avaliação em Saúde no Brasil, buscando analisar suas determinações; terceiro, na análise da relação da avaliação com indicadores sociais, dada a força de evidencia com a qual os indicadores se impõem como natural na produção científica da área; e quarto, abordando o conceito de qualidade de Avedis Donabedian a partir das determinações históricas que marcaram o contexto de publicação de sua obra seminal. Compreender a formação do discurso conceitual em torno da prática social da Avaliação em Saúde Coletiva no Brasil e, assim, compreender o funcionamento ideológico de sua enunciação, buscando contribuir para que a Avaliação em Saúde não seja instrumentalizada ideologicamente, constitui a mais modesta contribuição desta tese.