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  • Access to Primary Health Care by older adults from rural areas in Southern Brazil Original Articles

    Ferreira, Luiza Santos; Moreira, Laísa Rodrigues; Paludo, Simone dos Santos; Meucci, Rodrigo Dalke

    Abstract in Portuguese:

    RESUMO OBJETIVO Caracterizar o acesso e utilização de serviços de saúde considerados como referência pela população rural idosa de um município do sul do Brasil, com cobertura de 100% da área rural pela Estratégia Saúde da Família (ESF), investigando os fatores associados à escolha da Unidade Básica de Saúde da Família (UBSF) como serviço de referência. MÉTODOS Estudo transversal com amostragem sistemática dos domicílios da área rural do município de Rio Grande (RS), realizado em 2017, através de questionário padronizado, aplicado em domicílio. Foram realizadas análises descritivas referentes a perfil sociodemográfico; tipo de serviço de referência escolhido; e motivos de escolha/utilização do serviço de primeira opção e da UBSF mais próxima. Realizou-se regressão de Poisson para investigar fatores associados ao tipo de serviço de referência escolhido. RESULTADOS Participaram do estudo 1.030 idosos, dos quais 61,4% indicaram a unidade básica como serviço de primeira opção/referência. Enquanto aqueles que escolheram ser atendidos na UBSF o faziam principalmente em razão da proximidade (82,6%), os demais procuraram outros locais pela percepção de maior facilidade (34,6%) e resolutividade (52,6%). Quase ⅔ dos entrevistados buscaram atendimento na UBSF no último ano, e os motivos foram diferentes entre aqueles que consideravam a unidade como referência (doença crônica) e aqueles que procuravam outro local (procedimentos). Além disso, quanto menor a idade, renda, escolaridade e distância residência-unidade, maior a probabilidade do idoso considerar a UBSF mais próxima como serviço de referência. CONCLUSÃO A ESF tem conseguido atingir a parcela rural idosa em situação de vulnerabilidade, indo ao encontro de um sistema de saúde público equitativo. Todavia, novas avaliações para averiguar adequação e qualidade do atendimento se fazem necessárias, visto que estrutura social, fatores capacitantes (como condição econômica) e possíveis crenças sobre saúde ainda definem o padrão de escolha do serviço.

    Abstract in English:

    ABSTRACT OBJECTIVE To characterize the access and use of health services considered reference among the older rural population from a municipality in southern Brazil, whose rural area has full coverage of the Family Health Strategy (FHS), investigating factors associated with the choice of the Basic Family Health Unit (BFHU) as reference. METHODS This is a cross-sectional study conducted in 2017 with systematic sampling of rural households in the municipality of Rio Grande (RS) using a standardized in-house questionnaire. We performed descriptive analyses of sociodemographic profile, type of reference service chosen, and reasons for choosing/using the prime-choice service and the nearest BFHU. Poisson regression was used to investigate factors associated with the type of reference service chosen. RESULTS Among the 1,030 older adults who participated in the study, 61.4% considered the BFHU a prime choice/reference service mostly due to its proximity (82.6%); the others sought other places due to a greater ease (34.6%) and resoluteness (52.6%). Almost ⅔ of the respondents sought care at the BFHU during the last year, and the reasons differed among those who considered the unit as reference (chronic disease) and those who sought another place (procedures). We also found that the lower the age, income, education, and household-unit distance, the greater the likelihood of the older adult considering the nearest BFHU as reference service. CONCLUSIONS The FHS has reached the vulnerable older rural population, approaching an equitable public health system. However, further evaluations are necessary to verify the quality and adequacy of care, given that social structure, enabling factors (such as economic condition), and possible beliefs regarding health still establish the standards for choosing a service.
  • Financial impact of the change in the vulnerability profile of More Doctors Program Original Articles

    Cavalcante, Denise de Fátima Barros; Domingues, Carolina Vitti; Meloni, Diego Roberto; Almeida, Frederico Machado de; Probst, Livia Fernandes; Cavalcanti, Yuri Wanderley; Meneghim, Marcelo de Castro; Pereira, Antonio Carlos

    Abstract in Portuguese:

    RESUMO OBJETIVO Calcular o fluxo de profissionais e o impacto financeiro do Projeto Mais Médicos para o Brasil (PMMB), dentro do Programa Mais Médicos (PMM), para o Ministério da Saúde e os municípios do estado de São Paulo aderentes, no período de janeiro de 2019 a março de 2022. MÉTODOS Realizou-se estudo de impacto financeiro a partir de bases de dados secundários públicos do estado de São Paulo. O número de vagas do PMMB por município, de médicos do projeto e os perfis de vulnerabilidade foram descritos para dimensionar a perda de reposição de profissionais no período. RESULTADOS No intervalo de tempo especificado, o número de médicos do PMMB em cidades a ele aderentes passará de 2.533 para 320, e o número de municípios participantes de 373 para 86. O impacto orçamentário para os municípios que necessitarão repor médicos será de R$ 929.487.904,77 (com análise de sensibilidade variando de R$ 650.641.533,34 a R$ 1.208.334.276,20). CONCLUSÃO A mudança de metodologia da vulnerabilidade adotada para o PMMB trará sérias consequências, ou seja, desassistência da população e alto impacto financeiro para os municípios do estado de São Paulo em um cenário de limitações orçamentárias.

    Abstract in English:

    ABSTRACT OBJECTIVE To estimate the flow of professionals and the financial impact of the Programa Mais Médicos para o Brasil (PMMB – More Doctors for Brazil Program) within the More Doctors Program (MDP) for the Brazilian Ministry of Health and the participating municipalities of the state of São Paulo, from January 2019 to March 2022. METHODS A financial impact study was conducted in the state of São Paulo based on public secondary databases. The number of PMMB vacancies per municipality, of physicians and vulnerability profiles were described to measure the loss of replacement of professionals in the period. RESULTS In the specified period, the number of PMMB physicians in participating cities will decrease from 2,533 to 320, and the number of participating municipalities from 373 to 86. The municipalities that will need to replace the physicians will have a financial impact of R$ 929,487,904.77 (with sensitivity analysis, ranging from R$ 650,641,533.34 to R$ 1,208,334,276.20). CONCLUSION The change of vulnerability methodology adopted for the PMMB will represent serious consequences, that is, less population assistance and high financial impact for the municipalities of the state of São Paulo in a scenario of budget limitations.
  • Accidental falls in middle-aged women Original Articles

    Stolt, Lígia Raquel Ortiz Gomes; Kolish, Daniel Vieira; Cardoso, Maria Regina Alves; Tanaka, Clarice; Vasconcelos, Erika Flauzino Silva; Pereira, Elaine Cristina; Dellú, Máyra Cecilia; Pereira, Wendry Maria Paixão; Aldrighi, José Mendes; Schmitt, Ana Carolina Basso

    Abstract in Portuguese:

    RESUMO OBJETIVO Estimar a prevalência de quedas acidentais em mulheres e identificar possíveis associações de variáveis sociodemográficas, clínicas e de hábitos de vida com as quedas, em 2007 e 2014. MÉTODOS Foram realizados dois estudos transversais, em 2007 e 2014, dentro do Projeto de Saúde de Pindamonhangaba (PROSAPIN), com mulheres com idades variando de 35 a 75 anos. As amostras probabilísticas foram selecionadas dentre as mulheres residentes no município e participantes da Estratégia Saúde da Família. A coleta de dados incluiu: entrevista face a face, exame antropométrico e exame sanguíneo. A variável de desfecho “Sofreu queda nos últimos seis meses?” foi levantada durante a entrevista. Foram estimadas as prevalências de quedas em 2007 e 2014 por ponto e intervalo de confiança de 95% (IC95%). Modelos de regressão logística múltipla foram construídos para identificar a associação das variáveis independentes e a ocorrência de quedas para cada ano a partir da odds ratio (OR). Utilizou-se o software Stata 14.0 para análise estatística. RESULTADOS As prevalências de quedas acidentais foram: 17,6% (IC95% 14,9–20,5) em 2007 e 17,2% (IC95% 14,8–19,8) em 2014. Em 2007 os fatores associados a quedas foram: idade de 50–64 anos (OR = 1,81; IC95% 1,17–2,80), ensino médio (OR = 1,76; IC95% 1,06–2,93), hiperuricemia (OR = 3,74; IC95% 2,17–6,44), depressão (OR = 2,07; IC95% 1,31–3,27), sono ruim (OR = 1,78; IC95% 1,12–2,82) e sonolência diurna (OR = 1,86; IC95% 1,16–2,99). Em 2014 permaneceram: idade de 50–64 anos (OR = 1,64; IC95% 1,04–2,58), hiperuricemia (OR = 1,91; IC95% 1,07–3,43) e depressão (OR = 1,56; IC95% 1,02–2,38), acrescidos da síndrome metabólica (OR = 1,60; IC95% 1,03–2,47) e da dor musculoesquelética (OR = 1,81; IC95% 1,03–3,18). CONCLUSÕES As quedas ocorrem de maneira importante em mulheres a partir dos 50 anos, indicando que não são restritas a idosos e que há necessidade de iniciar medidas preventivas mais precocemente. Os dois estudos mostraram magnitudes semelhantes de ocorrência de quedas acidentais e reforçaram sua multifatorialidade. Além disso, a hiperuricemia pode ser um potencial novo fator associado a quedas.

    Abstract in English:

    ABSTRACT OBJECTIVE To estimate the prevalence of accidental falls in women and to identify possible associations of sociodemographic, clinical and lifestyle variables with falls, in 2007 and 2014. METHODS Two cross-sectional studies were performed, in 2007 and 2014, within the Projeto de Saúde de Pindamonhangaba (PROSAPIN – Pindamonhangaba Health Project), with women aged between 35 to 75 years. Probabilistic samples were selected among women living in the municipality and participating in the Health Family Strategy. Data collection included: face-to-face interview, anthropometric examination and blood test. The outcome variable “have you fallen in the last six months?” was raised during the interview. The prevalence of falls in 2007 and 2014 were estimated by score with a 95% confidence interval (95%CI). Multiple logistic regression models were constructed to identify the association of independent variables with the occurrence of falls for each year based on the odds ratio (OR). We used the Stata 14.0 software for statistical analysis. RESULTS The prevalence of accidental falls were: 17.6% (95%CI 14.9–20.5) in 2007 and 17.2% (95%CI 14.8–19.8) in 2014. In 2007, factors associated with falls were: aged 50–64 years (OR = 1.81; 95%CI 1.17–2.80), high school (OR = 1.76; 95%CI 1.06–2.93), hyperuricemia (OR = 3.74; 95%CI 2.17–6.44), depression (OR = 2.07; 95%CI 1.31–3.27), poor sleep (OR = 1.78; 95%CI 1.12–2.82) and daytime sleepiness (OR = 1.86; 95%CI 1.16–2.99). In 2014, they were: aged 50–64 years (OR = 1.64; 95%CI 1.04–2.58), hyperuricemia (OR = 1.91; 95%CI 1.07–3.43) and depression (OR = 1.56; 95%CI 1.02–2.38), plus metabolic syndrome (OR = 1.60; 95%CI 1.03–2.47) and musculoskeletal pain (OR = 1.81; 95%CI 1.03–3.18). CONCLUSIONS Falls occur significantly in women aged 50 years or over, indicating that they are not restricted to older adults and that there is a need to initiate preventive measures earlier. Both studies showed similar magnitudes of occurrence of accidental falls and reinforced their multifactorial nature. In addition, hyperuricemia may be a potential new factor associated with falls.
  • Quality of life in individuals initiating antiretroviral therapy: a cohort study Original Articles

    Pimentel, Gabriela Sales; Ceccato, Maria das Graças Braga; Costa, Juliana de Oliveira; Mendes, Jullye Campos; Bonolo, Palmira de Fátima; Silveira, Micheline Rosa

    Abstract in Portuguese:

    RESUMO OBJETIVO Avaliar longitudinalmente a alteração da qualidade de vida em pessoas que vivem com HIV iniciando a terapia antirretroviral, atendidas em três serviços públicos de referência na assistência especializada ao HIV em Belo Horizonte. MÉTODOS Estudo de coorte prospectivo, com o acompanhamento de pessoas que vivem com HIV, com 18 anos de idade ou mais, e iniciando terapia antirretroviral. Dados sociodemográficos, comportamentais, clínicos, relacionados ao tratamento farmacológico e ao serviço foram obtidos por entrevistas, complementados com informações dos prontuários clínicos e dos sistemas de informação do Programa Brasileiro de HIV/AIDS. A qualidade de vida foi avaliada utilizando o instrumento WHOQOLHIV-bref, por meio de entrevista face a face, com intervalo mínimo de seis meses entre as entrevistas. A alteração média na qualidade de vida entre as duas entrevistas foi avaliada utilizando o teste t pareado. Os fatores associados foram avaliados por meio de regressão linear múltipla. RESULTADOS A qualidade de vida global, assim como a qualidade de vida nos domínios físico, psicológico, nível de independência, ambiente e espiritual foram estatisticamente melhores em pessoas que vivem com HIV usando terapia antirretroviral no final do tempo de acompanhamento. Fatores independentemente associados ao incremento na qualidade de vida foram possuir crença religiosa e morar com outras pessoas. Enquanto ter sinais ou sintomas de ansiedade e depressão e o número de reações adversas a medicamentos reportadas foram preditores associados à piora da qualidade de vida. CONCLUSÕES Os resultados evidenciam melhora na qualidade de vida em pessoas vivendo com HIV iniciando a terapia antirretroviral ao longo do tempo. Evidenciam ainda a necessidade de se acompanhar e prover cuidados de saúde, em especial para indivíduos com sinais e sintomas de ansiedade e depressão e que relatam reações adversas a medicamentos no início do tratamento.

    Abstract in English:

    ABSTRACT OBJECTIVE To assess longitudinally the change in quality of life in people living with HIV initiating antiretroviral therapy in three public reference services specialized in HIV care in Belo Horizonte, Brazil. METHODS Prospective cohort study among people living with HIV, aged 18 years or older, and initiating antiretroviral therapy. We obtained sociodemographic, behavioral, clinical data related to pharmacological treatment and to the service by face-to-face interviews, and supplemented these data with information from clinical records and Information Systems of the Brazilian HIV/AIDS Program. We measured the quality of life using the WHOQOL-HIV bref instrument, with a minimum interval of six months between the baseline and the follow-up interviews. We used paired t-test to assess the mean change in quality of life between the two interviewsand evaluated factors associated with this outcome using multiple linear regression. RESULTS The overall quality of life, as well as the physical, psychological, level of independence, environment and spiritual quality of life domains were statistically higher in people living with HIV using antiretroviral therapy at the end of the follow-up. Factors independently associated with the increase in quality of life were having religious belief and living with other people. Having signs or symptoms of anxiety and depression and the number of adverse drug reactions reported were predictors associated with worsening quality of life. CONCLUSIONS These results show an improvement in the quality of life over time in people living with HIV on antiretroviral therapy. They also highlight the need to monitor and provide health care support, especially for individuals with signs and symptoms of anxiety and depression and that report adverse reactions to medicines at the beginning of treatment.
  • Spatial pattern of mortality from breast and cervical cancer in the city of São Paulo Original Articles

    Bermudi, Patricia Marques Moralejo; Pellini, Alessandra Cristina Guedes; Rebolledo, Elizabeth Angélica Salinas; Diniz, Carmen Simone Grilo; Aguiar, Breno Souza de; Ribeiro, Adeylson Guimarães; Failla, Marcelo Antunes; Baquero, Oswaldo Santos; Chiaravalloti-Neto, Francisco

    Abstract in Portuguese:

    RESUMO OBJETIVOS Verificar o padrão espacial da mortalidade pelos cânceres de mama e do colo do útero, em áreas da atenção primária à saúde, levando em consideração as condições socioeconômicas. MÉTODOS O estudo é ecológico, de janeiro de 2000 a dezembro de 2016. A área de estudo é o município de São Paulo, Brasil, e suas 456 áreas de abrangência das unidades básicas de saúde. As informações sobre óbitos de mulheres com 20 anos ou mais de idade foram geocodificadas segundo endereço de residência. Foram calculadas as taxas de mortalidade, padronizadas por idade, e suavizadas pelo método bayesiano empírico local, além de agrupadas em três ou dois anos para reduzir a flutuação aleatória dos dados. Além disso, foram calculados os índices de Moran global e local bivariados, para verificar a existência de aglomeração espacial das taxas de mortalidade padronizadas com um domínio de condição socioeconômica, elaborado a partir do Índice Paulista de Vulnerabilidade Social. RESULTADOS A taxa de sucesso da geocodificação foi de 98,9%. A mortalidade por câncer de mama, sem estratificação por tempo, apresentou um padrão com maiores taxas localizadas nas regiões centrais e com melhores condições socioeconômicas. Apresentou queda ao final do período e mudança de padrão espacial, com aumento da mortalidade nas regiões periféricas. Já a mortalidade por câncer do colo do útero manteve-se com as maiores taxas nas regiões periféricas e com piores condições socioeconômicas, apesar de apresentar redução ao longo do tempo. CONCLUSÃO O padrão espacial da mortalidade pelos cânceres do estudo, ao longo do tempo, sugere associação com as melhores condições socioeconômicas do município, seja como proteção (colo) ou risco (mama). Esse conhecimento pode direcionar recursos para a prevenção e a promoção da saúde nos territórios.

    Abstract in English:

    ABSTRACT OBJECTIVE To verify the spatial pattern of mortality from breast and cervical cancer in areas of primary health care, considering socioeconomic conditions. METHODS This is an ecological study, from January 2000 to December 2016. The study area is the municipality of São Paulo, Brazil, and its 456 coverage areas of primary health units. Information on deaths of women aged 20 years or over were geocoded according to residence address. We calculated mortality rates, standardized by age, and smoothed by the local empirical Bayesian method, and grouped into three or two years to reduce the random fluctuation of the data. In addition, bivariate global and local Moran indexes were calculated to verify the existence of spatial agglomeration of standardized mortality rates with a domain of socioeconomic condition, elaborated based on the Índice Paulista de Vulnerabilidade Social (IPVS – São Paulo Index of Social Vulnerability). RESULTS The success rate of geocoding was 98.9%. Mortality from breast cancer, without stratification by time, showed a pattern with higher rates located in central regions with better socioeconomic conditions. It showed a decrease at the end of the period and a change in spatial pattern, with increased mortality in peripheral regions. On the other hand, mortality from cervical cancer remained with the highest rates in peripheral regions with worse socioeconomic conditions, despite being reduced over time. CONCLUSION The spatial pattern of mortality from the studied cancers, over time, suggests association with the best socioeconomic conditions of the municipality, either as protection (cervical) or risk (breast). This knowledge may direct resources to prevent and promote health in the territories.
  • Analysis of the interrelationships between factors influencing blood pressure in adults Original Articles

    Freire, Rafael Silveira; Reis, Vivianne Margareth Chaves Pereira; Brito, Alexandre Botelho; Brito, Maria Fernanda Santos Figueiredo; Pinho, Lucinéia de; Silva, Rosângela Ramos Veloso; Silveira, Marise Fagundes

    Abstract in Portuguese:

    RESUMO OBJETIVO Investigar as inter-relações entre fatores sociodemográficos, comportamentais e clínicos associados à elevação da pressão arterial em adultos. MÉTODOS Utilizaram-se dados de um estudo transversal de base populacional. Foi desenvolvido um modelo hipotético em que condição socioeconômica, consumo de frutas e vegetais, adiposidade e pressão arterial foram tratadas como variáveis latentes, e idade, sexo, glicemia, atividade física, tabagismo, consumo de álcool e controle da hipertensão arterial (HA) foram tratadas como variáveis observadas. Utilizou-se a modelagem de equação estrutural para ajustar o modelo final. RESULTADOS Participaram do estudo 808 indivíduos, com idade média de 44,2 anos (DP = 17,8), sendo 52,7% do sexo feminino. Verificou-se que a idade exerceu efeito positivo sobre pressão arterial (β = 0,39), adiposidade (β = 0,44), glicemia (β = 0,26) e tabagismo (β = 0,30), e efeito negativo sobre atividade física (β = -0,17) e consumo de álcool (β = -0,09). O sexo masculino mostrou-se associado positivamente com a pressão arterial (β = 0,13), com o tabagismo (β = 0,28) e com o consumo de bebida alcoólica (β = 0,18). A adiposidade teve efeito positivo sobre a pressão arterial (β = 0,23) e a glicemia (β = 0,16), o consumo de álcool produziu efeito positivo sobre a adiposidade (β = 0,09), o consumo de frutas e vegetais exerceu efeito negativo sobre a pressão arterial (β = -0,11), e a condição socioeconômica teve efeito positivo sobre o consumo de frutas e vegetais (β = 0,47). O modelo estrutural foi ajustado pela variável controle médico da hipertensão, que apresentou efeito negativo sobre a pressão arterial (β = -0,10). CONCLUSÕES Os resultados sugerem que o aumento da idade se associa ao aumento da pressão arterial, adiposidade, glicemia e tabagismo, assim como com a redução da atividade física e consumo de álcool. O sexo masculino associou-se com aumento da pressão arterial e maior uso de bebida alcoólica e cigarros. A adiposidade correlaciona-se ao aumento da pressão arterial e da glicemia, enquanto maior consumo de álcool associa-se com aumento da adiposidade e maior consumo de frutas e vegetais, assim como o controle ativo da hipertensão, correlaciona-se com redução da pressão arterial. A melhor condição socioeconômica mostrou-se associada com maior consumo de frutas e vegetais.

    Abstract in English:

    ABSTRACT OBJECTIVE To investigate the interrelationships between sociodemographic, behavioral and clinical factors associated with high blood pressure in a population of Brazilian adults. METHODS Data from a cross-sectional population-based study conducted with adults were used. In the hypothetical model developed socioeconomic status, fruit and vegetable intake, adiposity and blood pressure were treated as latent variables and age, gender, glycemia, physical activity, smoking, alcohol consumption and control of arterial hypertension were considered observed variables. Confirmatory factorial analysis was used to construct the latent variables measurement models and the structural equation modeling was used to adjust the final model. RESULTS The study included 808 individuals, with mean age of 44.2 years (± 17.8), 52.7% being female. It verified that age exerted a positive direct effect on blood pressure (β = 0.39), adiposity (β = 0.44), glycemia (β = 0.26) and smoking (β = 0.30). Age had a negative direct effect on physical activity (β=-0.17) and alcohol consumption (β = -0.10). Males were positively associated with blood pressure (β = 0.13), smoking (β = 0.28; p < 0.001) and alcohol consumption (β = 0.18). Adiposity had a positive direct effect on blood pressure (β = 0.23) and glycemia (β = 0.16) and alcohol consumption produced a positive effect (β = 0.09) on adiposity. Fruit and vegetable intake had a negative direct effect on blood pressure (β = -0.11), while socioeconomic status had a positive direct effect on fruit and vegetable consumption (β = 0.47). We adjusted the structural model according to the variable medical control of arterial hypertension, which had a negative direct effect on blood pressure (β = -0.10). CONCLUSIONS Results suggest that increasing age is associated with increased blood pressure, adiposity, glycemia and smoking, as well as with reduced physical activity and alcohol consumption. Males were associated with increased blood pressure and greater use of alcohol and cigarettes. Higher adiposity indicators were correlated with increased blood pressure and glycemic levels; higher alcohol consumption was associated with increased adiposity. Higher consumption of fruits and vegetables, as well as active control of hypertension were associated with reduced blood pressure. Better socioeconomic status was associated with higher consumption of fruits and vegetables.
  • Population-based seroprevalence of SARS-CoV-2 and the herd immunity threshold in Maranhão Original Articles

    Silva, Antônio Augusto Moura da; Lima-Neto, Lídio Gonçalves; Azevedo, Conceição de Maria Pedrozo e Silva de; Costa, Léa Márcia Melo da; Bragança, Maylla Luanna Barbosa Martins; Barros Filho, Allan Kardec Duailibe; Wittlin, Bernardo Bastos; Souza, Bruno Feres de; Oliveira, Bruno Luciano Carneiro Alves de; Carvalho, Carolina Abreu de; Thomaz, Erika Barbara Abreu Fonseca; Simões-Neto, Eudes Alves; Leite Júnior, Jamesson Ferreira; Cosme, Lécia Maria Sousa Santos; Campos, Marcos Adriano Garcia; Queiroz, Rejane Christine de Sousa; Costa, Sérgio Souza; Carvalho, Vitória Abreu de; Simões, Vanda Maria Ferreira; Alves, Maria Teresa Seabra Soares de Brito e; Santos, Alcione Miranda dos

    Abstract in English:

    ABSTRACT OBJECTIVE: To estimate the seroprevalence of SARS-CoV-2 in the state of Maranhão, Brazil. METHODS: A population-based household survey was performed, from July 27, 2020 to August 8, 2020. The estimates considered clustering, stratification and non-response. Qualitative detection of IgM and IgG antibodies was performed in a fully-automated Elecsys® Anti-SARS-CoV-2 electrochemiluminescence immunoassay on the Cobas® e601 analyzer (Roche Diagnostics). RESULTS: In total, 3,156 individuals were interviewed. Seroprevalence of total antibodies against SARS-CoV-2 was 40.4% (95%CI 35.6-45.3). Population adherence to non-pharmaceutical interventions was higher at the beginning of the pandemic than in the last month. SARS-CoV-2 infection rates were significantly lower among mask wearers and among those who maintained social and physical distancing in the last month compared to their counterparts. Among the infected, 26.0% were asymptomatic. The infection fatality rate (IFR) was 0.14%, higher for men and older adults. The IFR based on excess deaths was 0.28%. The ratio of estimated infections to reported cases was 22.2. CONCLUSIONS: To the best of our knowledge, the seroprevalence of SARS-CoV-2 estimated in this population-based survey is one of the highest reported. The local herd immunity threshold may have been reached or might be reached soon.
  • Trend of preventable deaths up to the 6th day of life in the state of São Paulo – 2008 to 2017 Original Articles

    Sala, Arnaldo; Luppi, Carla Gianna

    Abstract in Portuguese:

    RESUMO OBJETIVO: Analisar a tendência da mortalidade infantil neonatal precoce no estado de São Paulo segundo evitabilidade e região de residência. MÉTODO: Estudo ecológico com dados secundários de 2008 a 2017, obtidos a partir do Sistema de Informação sobre Nascidos Vivos e do Sistema de Informação sobre Mortalidade. As causas de óbito foram classificadas segundo grupos de evitabilidade, sendo estimadas as variações percentuais anuais das taxas de óbito de cada grupo de evitabilidade, por meio do software Joinpoint . RESULTADOS: O componente neonatal precoce apresentou tendência de redução com variação percentual anual de −1,18 (IC95% −1,63 – −0,72), menos acentuado que os demais componentes etários da mortalidade infantil. Na análise segundo evitabilidade, as causas reduzíveis por atenção à mulher na gestação e as reduzíveis por cuidado ao feto e ao recém-nascido apresentaram variação percentual anual, respectivamente de −1,03 (IC95%: −1,92 – −0,13) e −2,6 (IC95%: −4,07 – −1,11). Nas causas reduzíveis por atenção à mulher no parto, não se observou tendência de redução. Ocorreram discrepâncias regionais na variação das taxas de mortalidade infantil neonatal precoce segundo evitabilidade. CONCLUSÕES: A mortalidade até o 6º dia de vida apresentou maior dificuldade de redução na comparação com os outros componentes etários. A ausência de tendência de redução nos óbitos evitáveis pelo cuidado à mulher no parto aponta para possível fragilidade na atenção ao parto.

    Abstract in English:

    ABSTRACT OBJECTIVE: To analyze the trend of early neonatal infant mortality in the state of São Paulo according to preventability and region of residence. METHODS: Ecological study with secondary data from 2008 to 2017, obtained from the Sistema de Informação sobre Nascidos Vivos (Sinasc – Live Birth Information System) and the Sistema de Informação sobre Mortalidade (SIM – Mortality Information System). The causes of death were classified according to preventability groups, and the annual percentage changes in the death rates of each preventability group were estimated using the Joinpoint software. RESULTS: The early neonatal component showed a reduction trend with an annual percentage change of −1.18 (95%CI −1.63 to −0.72), less pronounced than the other age components of infant mortality. In the analysis according to preventability, the causes reducible by attention to the woman during pregnancy and those reducible by attention to the fetus and the newborn presented annual percentage change of −1.03 (95%CI: −1.92 to −0.13) and −2.6 (95%CI: −4.07 to −1.11), respectively. In the causes reducible by attention to women during delivery, no reduction trend was observed. Regional discrepancies occurred in the variation of early neonatal infant mortality rates according to type of preventability. CONCLUSIONS: Mortality up to the 6th day of life presented greater difficulty of reduction when compared with the other age components. The absence of a reduction trend in preventable deaths due to the attention to women during delivery points to possible fragility in the attention to delivery.
  • Occupational exposure to pesticides and health symptoms among family farmers in Brazil Original Articles

    Buralli, Rafael Junqueira; Ribeiro, Helena; Iglesias, Verónica; Muñoz-Quezada, María Teresa; Leão, Renata Spolti; Marques, Rejane Correa; Almeida, Milena Maria Cordeiro de; Guimarães, Jean Remy Davée

    Abstract in English:

    ABSTRACT OBJECTIVE: To explore the association of occupational pesticide exposure with acute and mental health symptoms. METHODS: Cross-sectional survey carried out with 78 Brazilian family farmers, who were pesticide applicators and helpers conveniently selected. Symptoms and exposure data were collected by interviews, and mental health outcomes by the Self-Reporting Questionnaire. Blood samples were analyzed to assess cholinesterase levels. Exposure indicators and symptoms were compared between applicators and helpers, and Poisson regression was performed to estimate prevalence ratios. RESULTS: Farmers reported exposure to multiple pesticides from early ages; they worked without safety training, technical support, and full protective equipment, and they had a high prevalence of acute and mental health symptoms (e.g., headache, mucosal irritation, tachycardia, and depressive signs). Applicators had more cholinesterase changes than helpers, but less symptoms. Helpers used less personal protection and had significantly higher prevalence ratio of headache, dyspnea, wheezing, cough, poor digestion, tiredness, and feeling worthless, after adjustment. CONCLUSIONS: Acute and mental health symptoms were observed, both among farmers and helpers. Thus, surveillance actions must be reinforced in Brazil, technical support and safety training improved, focused on applicators and helpers, who are occupationally and environmentally exposed to pesticides. Agricultural practices of these groups with less pesticide use should receive incentive.
  • The effects of sexual violence experienced in childhood and adolescence on undergraduate students Original Articles

    Silva, Flávia Calanca da; Monge, Aline; Landi, Carlos Alberto; Zenardi, Gabriel Amaral; Suzuki, Denise Chrysostomo; Vitalle, Maria Sylvia de Souza

    Abstract in Portuguese:

    RESUMO OBJETIVO: Investigar a prevalência de adolescentes e adultos jovens que foram vítimas de violência sexual em algum momento da vida e comparar a presença de sintomas depressivos e ansiosos, qualidade de vida e uso de álcool, tabaco e drogas ilícitas entre esta população e a que não sofreu abuso. MÉTODOS: Aplicaram-se questionários e instrumentos validados, em uma população de estudantes universitários, para avaliar: perfil e comportamento sexual, nível socioeconômico, presença ou não de violência sexual (Questionário sobre a Exposição a Eventos Traumatizantes), sintomas depressivos (Inventário de Depressão de Beck) e ansiosos (Inventário de Ansiedade de Beck), qualidade de vida (World Health Organization's Quality of Life Assessment) e o uso ou abuso de tabaco, álcool e drogas ilícitas (Teste para Triagem do Envolvimento com Fumo, Álcool e Outras Drogas). RESULTADOS: Dos 858 alunos que responderam à pesquisa, 71 (8,3%) foram vítimas de violência sexual, sendo 52 meninas (73,2%). No grupo vítima de abuso havia mais alunos que já tinham tido a coitarca (p = 0,029), alunas que já engravidaram (p = 0,001), estudantes com maiores escores para sintomas depressivos (p < 0,001) e ansiosos (p = 0,001), alunos com pior qualidade de vida (p < 0,001) e que usavam mais tabaco (p = 0,008) e maconha (p = 0,025) bem como abusavam de hipnóticos ou sedativos (p = 0,048) que no grupo não vítima. CONCLUSÃO: Os impactos causados pelo abuso são diversos e afetam, mesmo no longo prazo, a vida dos sobreviventes. Abordar o tema e o discutir, amplamente, em todas as esferas da sociedade é uma forma de mobilizar, sensibilizar e instrumentalizar o coletivo, desmistificando o assunto e chamando atenção para essa importante questão social.

    Abstract in English:

    ABSTRACT OBJECTIVE: This study aims to investigate the prevalence of adolescents and young adults who were victims of sexual violence at some point in their lives and to compare the presence of depressive and anxious symptoms, quality of life, and use of alcohol, tobacco, and illegal drugs among this population and those who were not abused. METHODS: Validated questionnaires and instruments were applied in a group of university students to assess: sexual profile and behavior, socioeconomic status, presence or not of sexual violence (Questionnaire on Exposure to Traumatizing Events), depressive (Beck Depression Inventory) and anxious symptoms (Beck Anxiety Inventory), quality of life (World Health Organization's Quality of Life Assessment) and the use or abuse of tobacco, alcohol, and illegal drugs (Smoking, Alcohol, and Substance Involvement Screening Test). RESULTS: Out of the 858 students who participated, 71 (8.3%) were victims of sexual violence, 52 girls (73.2%). In the victims of violence group there were more students who already had the first sexual intercourse (p = 0.029), students who already had become pregnant (p = 0.001), students with higher scores for depressive (p < 0.001) and anxious symptoms (p = 0.001), students with worse quality of life (p < 0.001), and who used more tobacco (p = 0.008) and marijuana (p = 0.025) as well as abused hypnotics or sedatives (p = 0.048) than in the non-victim group. CONCLUSION: The abuses are presented in several forms and affect, even in long term, the survivors' life. The sexual violence theme should be addressed and widely discussed in all spheres of society in order to mobilize, to sensitize, and provide society with knowledge, demystifying this subject and drawing attention to this important social issue.
  • Older adults with dementia: knowledge and attitudes of physicians in health units Original Articles

    Steiner, Ana Beatriz Quintes; Jacinto, Alessandro Ferrari; Citero, Vanessa de Albuquerque

    Abstract in Portuguese:

    RESUMO OBJETIVO: Descrever os conhecimentos e atitudes dos médicos generalistas da rede básica de saúde da cidade de São Paulo em relação a pacientes com demência e identificar padrões de atitudes. MÉTODOS: Foram sorteadas aleatoriamente 10% das unidades básicas de saúde da cidade de São Paulo (n = 45), distribuídas proporcionalmente em seis coordenadorias regionais de saúde. Foram entrevistados até dois médicos generalistas em cada unidade, obtendo-se ao todo 81 médicos entrevistados. Eles responderam à versão traduzida e adaptada transculturalmente para o Brasil de dois questionários britânicos, o knowledge quiz (conhecimentos sobre demências) e o attitude quiz (atitudes frente ao paciente dementado), além de um questionário sociodemográfico e ocupacional para o entendimento do perfil dos médicos generalistas que atuam na atenção primária. Realizaram-se análise descritiva dos dados, análise fatorial dos principais componentes do attitude quiz e estudo de associação entre atitudes e conhecimentos, além do teste de regressão linear múltipla para determinar a relação entre o perfil ocupacional e de conhecimento em demência sobre os padrões de atitudes. RESULTADOS: Os médicos entrevistados tinham mediana de tempo de formado de cinco anos; 35,8% trabalhavam exclusivamente com atenção primária, e menos de 40% tinham concluído, ou estavam cursando, residência médica ou especialização. Os médicos mostraram um conhecimento menor sobre diagnóstico de demência do que sobre a epidemiologia da doença e seu manejo terapêutico. Suas atitudes em relação a pacientes dementados resultaram em quatro fatores: otimismo proativo, otimismo delegador, desalento implícito e desalento explícito. O estudo de regressão mostrou que a atitude de desalento explícito diminui quanto maior for a jornada de trabalho semanal do médico nas unidades, e que a atitude otimista delegadora do médico diminui na mesma situação. CONCLUSÕES: O investimento em capacitação é fundamental para melhorar o desempenho do médico no campo da demência na atenção primária.

    Abstract in English:

    ABSTRACT OBJECTIVE: To describe the knowledge and attitudes of general practitioners of the basic health network of the city of São Paulo in relation to patients with dementia and identify patterns of attitudes. METHODS: A total of 10% of the basic health units in the city of São Paulo (n = 45) were randomly distributed into six regional health coordination centers. Up to two general practitioners were interviewed in each unit, with a total of 81 physicians interviewed. They answered the translated and cross-culturally adapted version for Brazil of two British questionnaires, the knowledge quiz (knowledge about dementias) and the attitude quiz (attitude towards the patient afflicted with dementia), as well as a sociodemographic and occupational questionnaire to understand the profile of general practitioners working in primary care. Descriptive data analysis, factor analysis of the main components of the attitude quiz and study of association between attitudes and knowledge were performed, in addition to the multiple linear regression test to determine the relationship between occupational profile and knowledge about attitude patterns in dementia. RESULTS: The physicians interviewed had a median of five-year graduation time; 35.8% worked exclusively with primary care, and less than 40% had completed, or were attending, medical residency or specialization. Physicians showed a lower knowledge about the diagnosis of dementia than about the epidemiology of the disease and its therapeutic management. Their attitudes towards patients afflicted with dementia resulted in four factors: proactive optimism, delegated optimism, implicit dismay, and explicit dismay. The regression study showed that the attitude of explicit dismay decreases the longer the weekly working hours of the physician in the units, and that the delegated optimistic attitude of the physician decreases in the same situation. CONCLUSION: Investment in training is essential to improve physicians' performance in the field of dementia in primary care.
  • Does socioeconomic inequality occur in the multimorbidity among Brazilian adults? Original Articles

    Costa, Ândria Krolow; Bertoldi, Andréa Dâmaso; Fontanella, Andréia Turmina; Ramos, Luiz Roberto; Arrais, Paulo Sergio Dourado; Luiza, Vera Lucia; Mengue, Sotero Serrate; Nunes, Bruno Pereira

    Abstract in Portuguese:

    RESUMO OBJETIVO: Avaliar a prevalência de multimorbidade e a associação desta com indicadores socioeconômicos entre adultos brasileiros. MÉTODOS: Estudo transversal que utilizou dados oriundos da Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos no Brasil, realizada entre 2013 e 2014. Multimorbidade foi definida como a coexistência, no mesmo indivíduo, de duas ou mais doenças crônicas, e é mensurada a partir de uma lista de 14 morbidades (autorrelato de diagnóstico médico na vida). Classe econômica e escolaridade foram os indicadores socioeconômicos utilizados, sendo as desigualdades avaliadas pelo Slope Index of Inequality (SII) e pelo Concentration Index (CIX), estratificadas por sexo. RESULTADOS: O estudo considerou 23.329 mil adultos (52,8% de mulheres), com média de idade de 37,9 anos. Hipertensão e colesterol alto foram as condições mais prevalentes. A prevalência de multimorbidade foi de 10,9% (IC95% 10,1–11,7), representando, aproximadamente, 11 milhões de indivíduos no Brasil, sendo 14,5% (IC95% 13,5–15,4) entre mulheres e 6,8% (IC95% 5,9–7,8) entre homens. A ocorrência de multimorbidade foi similar segundo os indicadores socioeconômicos. Nas análises de desigualdade, observou-se diferença absoluta e relativa para homens com maior poder aquisitivo (SII = 3,7; IC95% 0,3–7,0) e maior escolaridade (CIX = 7,1; IC95% 0,9–14,7), respectivamente. CONCLUSÕES: A frequência de adultos brasileiros com multimorbidade é alta, principalmente em termos absolutos. Desigualdades socioeconômicas na multimorbidade foram observadas somente entre homens.

    Abstract in English:

    ABSTRACT OBJECTIVE: To assess the prevalence of multimorbidity among Brazilian adults and its association with socioeconomic indicators. METHODS: Cross-sectional study that used data from the Pesquisa Nacional Sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos no Brasil (PNAUM – Brazilian National Survey on Access, Use and Promotion of Rational Use of Medicines), carried out between 2013 and 2014. The definition of multimorbidity was the coexistence, in a single individual, of two or more chronic diseases, measured through a list of 14 morbidities (self-reported medical diagnosis throughout life). Economic status and educational level were the socioeconomic indicators used, being the inequalities assessed through the Slope Index of Inequality (SII) and the Concentration Index, stratified by gender. RESULTS: The study comprehended 23,329 adults (52.8% of which were women), with an average age of 37.9 years. Hypertension and high cholesterol levels were the most prevalent conditions. The prevalence of multimorbidity was of 10.9% (95%CI 10.1–11.7) representing nearly 11 million individuals in Brazil, of which 14.5% (95%CI 13.5–15.4) were women and 6.8% (95%CI 5.9–7.8) were men. The occurrence of multimorbidity was similar according to the socioeconomic indicators. In the inequality analysis, we observed absolute and relative differences in men with a higher purchasing power (SII = 3.7; 95%CI 0.3–7.0) and higher educational level (CIX = 7.1; 95%CI 0.9–14.7), respectively. CONCLUSIONS: The frequency of comorbidities in Brazilian adults is high, especially in absolute terms. We only observed socioeconomic inequalities in multimorbidities among men.
  • Group Prenatal Care in Mexico: perspectives and experiences of health personnel Original Articles

    Ibañez-Cuevas, Midiam; Heredia-Pi, Ileana Beatriz; Fuentes-Rivera, Evelyn; Andrade-Romo, Zafiro; Alcalde-Rabanal, Jacqueline; Cacho, Lourdes Bravo-Bolaños; Guzmán-Delgado, Xochitl; Jurkiewicz, Laurie; Darney, Blair G

    Abstract in Spanish:

    RESUMEN OBJETIVO Identificar barreras y facilitadores de la implementación del modelo de Atención Prenatal en Grupo en México (APG), desde la perspectiva del personal de salud. MÉTODOS Estudio cualitativo descriptivo en cuatro clínicas de la Secretaría de Salud en dos estados de México (Morelos e Hidalgo) de junio de 2016 a agosto de 2018. Se realizaron 11 entrevistas semi-estructuradas a prestadores de servicios de salud. Se exploraron sus percepciones y experiencias durante la implementación del modelo de APG. Se identificaron barreras y facilitadores para su adopción en dos dimensiones: a) estructurales (espacio, recursos, personal de salud, volumen de pacientes, comunidad) y b) actitudinales (motivación, liderazgo, aceptabilidad, abordaje de problemas, clima y comunicación). RESULTADOS Las barreras más relevantes reportadas en el nivel estructural fueron la disponibilidad de espacio físico en las unidades y la sobrecarga de trabajo del personal de salud. Se identificó la dificultad para adoptar una relación menos jerárquica durante la atención a las gestantes en el nivel actitudinal. El principal facilitador a nivel actitudinal fue la aceptabilidad que los prestadores tienen del modelo. Un hallazgo específico para el contexto de la implementación en México fue la resistencia al cambio en la relación médico-paciente; resulta difícil abandonar el modelo jerárquico prevaleciente y cambiar a una relación más horizontal con las gestantes. CONCLUSIONES El análisis de la implementación del modelo de APG en México, desde la perspectiva del personal de salud, ha evidenciado barreras y facilitadores similares a las experiencias en otros contextos. Esfuerzos futuros para la adopción del modelo deberán enfocarse en la atención oportuna de las barreras identificadas, sobre todo aquellas señaladas en la dimensión actitudinal que pueden ser modificadas a través de capacitaciones continuas al personal de salud.

    Abstract in English:

    ABSTRACT OBJECTIVE: Identify barriers and facilitators to implementing the Group Prenatal Care model in Mexico (GPC) from the health care personnel's perspective. METHODS: We carried out a qualitative descriptive study in four clinics of the Ministry of Health in two states of Mexico (Morelos and Hidalgo) from June 2016 to August 2018. We conducted 11 semi-structured interviews with health care service providers, and we examined their perceptions and experiences during the implementation of the GPC model. We identified the barriers and facilitators for its adoption in two dimensions: a) structural (space, resources, health personnel, patient volume, community) and b) attitudinal (motivation, leadership, acceptability, address problems, work atmosphere and communication). RESULTS: The most relevant barriers reported at the structural level were the availability of physical space in health units and the work overload of health personnel. We identified the difficulty in adopting a less hierarchical relationship during the pregnant women's care at the attitudinal level. The main facilitator at the attitudinal level was the acceptability that providers had of the model. One specific finding for Mexico's implementation context was the resistance to change the doctor-patient relationship; it is difficult to abandon the prevailing hierarchical model and change to a more horizontal relationship with pregnant women. CONCLUSION: Analyzing the GPC model's implementation in Mexico, from the health care personnel's perspective, has revealed barriers and facilitators similar to the experiences in other contexts. Future efforts to adopt the model should focus on timely attention to identified barriers, especially those identified in the attitudinal dimension that can be modified by regular health care personnel training.
  • Catastrophic health expenditure and multimorbidity among older adults in Brazil Original Articles

    Bernardes, Gabriella Marques; Saulo, Helton; Fernandez, Rodrigo Nobre; Lima-Costa, Maria Fernanda; Andrade, Fabíola Bof de

    Abstract in Portuguese:

    RESUMO OBJETIVO: Estimar a relação entre gasto catastrófico em saúde (GCS) e multimorbidade em amostra nacional representativa da população brasileira com 50 anos de idade ou mais. MÉTODOS: Foram utilizados dados de 8.347 participantes do Estudo Longitudinal da Saúde dos Idosos Brasileiros (2015–2016). A variável dependente foi o GCS, definido pela razão entre as despesas com saúde do adulto de 50 anos ou mais e a renda domiciliar. A variável de interesse foi a multimorbidade (duas ou mais doenças crônicas), e a variável utilizada para estratificação foi o escore de riqueza. As principais análises foram baseadas na regressão logística multivariada. RESULTADOS: A prevalçncia de GCS foi de 17,9% e 7,5% para gastos correspondentes a 10% e 25% da renda domiciliar, respectivamente. A prevalçncia da multimorbidade foi de 63,2%. A multimorbidade apresentou associações positivas e independentes com GCS (OR = 1,95, IC95% 1,67–2,28 e OR = 1,40, IC95% 1,11–1,76 para gastos correspondentes a 10% e 25%, respectivamente). Os gastos associados à multimorbidade foram maiores entre aqueles com menor escore de riqueza. CONCLUSÕES: Os resultados chamam atenção para a necessidade de uma abordagem integrada da multimorbidade nos serviços de saúde, de forma a evitar os GCS, particularmente entre adultos mais velhos com piores condições socioeconômicas.

    Abstract in English:

    ABSTRACT OBJECTIVE: To estimate the relation between catastrophic health expenditure (CHE) and multimorbidity in a national representative sample of the Brazilian population aged 50 year or older. METHODS: This study used data from 8,347 participants of the Estudo Longitudinal de Saúde dos Idosos Brasileiros (ELSI – Brazilian Longitudinal Study of Aging) conducted in 2015–2016. The dependent variable was CHE, defined by the ratio between the health expenses of the adult aged 50 years or older and the household income. The variable of interest was multimorbidity (two or more chronic diseases) and the variable used for stratification was the wealth score. The main analyses were based on multivariate logistic regression. RESULTS: The prevalence of CHE was 17.9% and 7.5%, for expenditures corresponding to 10 and 25% of the household income, respectively. The prevalence of multimorbidity was 63.2%. Multimorbidity showed positive and independent associations with CHE (OR = 1.95, 95%CI 1.67–2.28, and OR = 1.40, 95%CI 1.11–1.76 for expenditures corresponding to 10% and 25%, respectively). Expenditures associated with multimorbidity were higher among those with lower wealth scores. CONCLUSIONS: The results draw attention to the need for an integrated approach of multimorbidity in health services, in order to avoid CHE, particularly among older adults with worse socioeconomic conditions.
  • Premature mortality due to cervical cancer: study of interrupted time series Original Articles

    Nascimento, Maria Isabel do; Massahud, Felipe Corrêa; Barbosa, Nathália Giácomo; Lopes, Cássio Destefani; Rodrigues, Vanessa da Costa

    Abstract in Portuguese:

    RESUMO OBJETIVO: Verificar o efeito do Pacto Pela Saúde na mortalidade prematura (30–69 anos) atribuída a câncer de colo uterino no Brasil e nas suas macrorregiões, utilizando modelagem de séries temporais interrompidas. MÉTODOS: A regressão segmentada foi usada para avaliar “mudança de nível” e “mudança de tendência” das taxas de mortes prematuras por câncer de colo uterino no período pós-Pacto (2010–2018), controlando pelo período pré-Pacto (1998–2006). Entendendo o triênio 2007–2009 como essencial para adesão e implantação da política ele foi excluído da modelagem principal, mas avaliado na análise de sensibilidade. RESULTADOS: De 1998 a 2018, houve mais de 119 mil óbitos por câncer de colo uterino, em mulheres de 30 a 69 anos, no Brasil. A região Norte experimentou as taxas mais altas (> 20 por 100 mil). Comparando à linha de base (1998–2006), a regressão segmentada mostrou progressiva elevação das mortes por câncer de colo uterino no Brasil como um todo (coeficiente angular = 0,513; IC95% 0,430 a 0,596) e nas regiões Sudeste (coeficiente = 0,515; IC95% 0,358 a 0,674), Sul (coeficiente = 0,925; IC95% 0,642 a 1,208), e Centro-Oeste (coeficiente = 0,590; IC95% 0,103 a 1,077). A região Nordeste apresentou os efeitos mais promissores com redução imediata no nível (-0,635; IC95% −1,177 a −0,092) e redução progressiva na tendência de mortes prematuras (coeficiente= −0,151; IC95% −0,231 a −0,007). CONCLUSÕES: As taxas de mortalidade prematuras por câncer de colo uterino são altas no Brasil e nas suas macrorregiões. Esta série temporal interrompida não foi capaz de revelar efetividade das iniciativas relacionadas ao Pacto pela Saúde sobre as mortes prematuras por câncer de colo uterino nacionalmente e tampouco em todas as macrorregiões igualmente. Os melhores resultados estão restritos à região Nordeste.

    Abstract in English:

    ABSTRACT OBJECTIVE: To verify the effect of the Pact for Health on premature mortality (30–69 years) attributed to cervical cancer in Brazil and its macroregions, using interrupted time series analysis. METHODS: Segmented regression was used to assess “change in level” and “change in trend” in premature mortality rates attributed to cervical cancer considering the post-Pact period (2010-2018), controlling by the pre-Pact period (1998–2006). Understanding the triennium 2007-2009 as essential for the adoption and implementation of the policy, it was excluded from the main modeling, but assessed in the sensitivity analysis. RESULTS: From 1998 to 2018, there were more than 119,000 deaths due to cervical cancer in women aged 30 to 69 years in Brazil. The Northern region experienced the highest rates (> 20 per 100,000). Comparing with baseline (1998–2006), segmented regression showed a progressive increase in changing trend from cervical cancer deaths in Brazil as a whole (coefficient = 0.513; 95%CI 0.430 to 0.596) and in the Southeast region (coefficient = 0.515; 95%CI 0.358 to 0.674), South region (coefficient = 0.925; 95%CI 0.642 to 1.208), and Midwest region (coefficient = 0.590; 95%CI 0.103 to 1.077). The Northeast region presented the most promising effects with immediate reduction in change level (-0.635; 95%CI −1.177 to −0.092) and progressive reduction in the changing trend of premature deaths (coefficient= −0.151; 95%CI −0.231 to −0.007). CONCLUSIONS: Premature mortality rates due to cervical cancer are high in Brazil and its macroregions. This interrupted time series was not able to reveal the effectiveness of initiatives related to the Pact for Health on premature deaths from cervical cancer nationally and in all macroregions equally. The best results are restricted to the Northeast region.
  • Health financing in Brazil and the goals of the 2030 Agenda: high risk of failure Original Articles

    Vieira, Fabiola Sulpino

    Abstract in Portuguese:

    RESUMO OBJETIVO: Examinar o financiamento do Sistema Único de Saúde (SUS) de 2010 a 2019 e analisar as tendências recentes da alocação de recursos federais para grandes áreas de atuação do sistema, bem como a possibilidade de alcance das metas do Objetivo de Desenvolvimento Sustentável (ODS) 3 da Agenda 2030. MÉTODOS: Dados da execução orçamentário-financeira dos entes da Federação foram obtidos. As transferências do Ministério da Saúde (MS) para as secretarias municipais e estaduais e suas aplicações diretas foram identificadas segundo grandes áreas finalísticas do SUS e áreas-meio. Estatísticas descritivas básicas, gráficos e tabelas foram utilizados para a análise da execução das despesas por essas áreas. RESULTADOS: O gasto público per capita com saúde aumentou entre 2010 e 2018. Contudo, em relação a 2014, teve redução de 3% em 2018. Constatou-se deslocamento da alocação de recursos federais em prejuízo das transferências aos estados (−21%). Também se observaram perdas da vigilância em saúde em favor da atenção básica e da assistência farmacêutica. No caso da atenção básica, o aumento do gasto veio atrelado a mudanças na política e à ampliação dos recursos alocados por emendas parlamentares. Já no caso da assistência farmacêutica, o aumento se deu pela incorporação de novos medicamentos, incluindo vacinas, pela judicialização, pelo aumento dos gastos com hemoderivados e pela centralização, no MS, da compra de itens de alto impacto orçamentário. CONCLUSÃO: Caso não haja mudança no quadro atual de financiamento do SUS, algo improvável sob a vigência da Emenda Constitucional nº 95, associada à redefinição das prioridades das políticas de saúde, o risco de não cumprimento das metas do ODS 3 da Agenda 2030 é muito alto.

    Abstract in English:

    ABSTRACT OBJECTIVE: To examine the financing of the Unified Health System (SUS) from 2010 to 2019 and analyze the recent trends in the allocation of federal resources to large areas of operation of the system, as well as the possibility of achieving the Sustainable Development Goal (SDG) 3 of the 2030 Agenda. METHODS: Data from the budgetary and financial execution of the federation entities were obtained. Transfers from the Brazilian Ministry of Health (MH) to the municipal and state departments and their direct applications were identified according to large final areas of SUS and middle areas. Basic descriptive statistics, graphs and tables were used to analyze the execution of expenses by these areas. RESULTS: Public spending per capita on health increased between 2010 and 2018. However, compared to 2014, it reduced 3% in 2018. There was a displacement of the allocation of federal resources to the detriment of transfers to the states (−21%). There are also losses of health surveillance in favor of primary care and pharmaceuticals. In the case of primary care, the increase in spending was tied to changes in policy and the expansion of resources allocated by parliamentary amendments. In the case of pharmaceuticals, the increase was due to the incorporation of new drugs, including vaccines, judicialization, increased spending on blood products and centralization, in the MH, of the purchase of items of high budgetary impact. CONCLUSION: If there is no change in the current SUS financing framework, something unlikely under Constitutional Amendment No. 95, associated with the redefinition of health policy priorities, the risk of non-compliance with the SDG 3 of the Agenda 2030 is very high.
  • Judicialization of medicines: effectiveness of rights or break in public policies? Original Articles

    Oliveira, Yonara Monique da Costa; Braga, Bárbara Suellen Fonseca; Farias, Andrezza Duarte; Pereira, Sylvia Patrícia Dantas; Ferreira, Maria Angela Fernandes

    Abstract in Portuguese:

    RESUMO OBJETIVO: Analisar se as demandas judiciais por medicamentos movidas contra o estado do Rio Grande do Norte estão de acordo com critérios médico-sanitários e de gestão da assistência farmacêutica estabelecidos pelas políticas públicas de acesso a medicamentos vigentes no Brasil. MÉTODOS: Foi conduzido um estudo descritivo e retrospectivo das ações judiciais individuais que pleiteavam medicamentos no estado do Rio Grande do Norte entre 2013 e 2017. Foram coletadas informações nos autos processuais sobre os medicamentos solicitados, os diagnósticos referidos e a origem da prescrição médica, a fim de se analisar as características médico-sanitárias e de gestão da assistência farmacêutica. RESULTADOS: Foram analisados 987 processos, em que foram solicitados 1.517 medicamentos. Desses, 60,7% não faziam parte do elenco da Relação Nacional de Medicamentos Essenciais, e em 75% dos casos havia alternativa terapêutica no Sistema Único de Saúde. Em 13,6% das ações, ao menos um medicamento foi prescrito para uso off label . Os prescritores dos serviços filantrópicos e privados solicitam frequentemente medicamentos não contemplados pela política de assistência farmacêutica. Mesmo os medicamentos judicializados que fazem parte da relação nacional são constantemente solicitados para indicações não padronizadas. CONCLUSÕES: As decisões judiciais para o fornecimento de medicamentos violam regras sanitárias e dificultam a gestão da assistência farmacêutica, o que pode enfraquecer a execução dessas políticas.

    Abstract in English:

    ABSTRACT OBJECTIVE: To analyze whether lawsuits for medicines filed against the state of Rio Grande do Norte agree with medical-sanitary and pharmaceutical assistance management criteria established by the public policies of access to medicines in force in Brazil. METHODS: This is a descriptive and retrospective study of the individual lawsuits that claimed medicines in the state of Rio Grande do Norte between 2013 and 2017. Information was collected from the procedural documents on the requested medicines, the diagnoses referred and the origin of the medical prescription, in order to analyze medical-sanitary and pharmaceutical assistance management characteristics. RESULTS: We analyzed 987 lawsuits, which requested 1,517 medications. Of these, 60.7% were not part of the National List of Essential Medicines, and, in 75% of the cases, there was a therapeutic alternative in the Brazilian Unified Health System. In 13.6% of the actions, at least one drug was prescribed for off-label use. Prescribers of philanthropic and private services often request medicines not covered by the pharmaceutical care policy. Even judicialized drugs that are part of the national list are constantly requested for non-standard indications. CONCLUSIONS: Court decisions for the supply of medicines violate health rules and make it difficult to manage pharmaceutical assistance, which may weaken the implementation of these policies.
  • Contribution of community health workers to primary health care performance in Brazil Original Articles

    Santos, Alaneir de Fátima dos; Rocha, Hugo André da; Lima, Ângela Maria de Lourdes Dayrell de; Abreu, Daisy Maria Xavier de; Silva, Érica Araújo; Araújo, Lucas Henrique Lobato de; Cavalcante, Isabela Cristina Carreiro; Matta-Machado, Antônio Thomaz Gonzaga da

    Abstract in English:

    ABSTRACT OBJECTIVE To associate the strength of community health workers interventions with primary health care strategies for women’s and children’s health, diabetes, and hypertension. METHODS This is a cross-sectional study assessing 29,778 family health teams working in primary health care in Brazil in 2014. The association between community health workers activity levels and primary health care facilities was analyzed using multiple logistic regression. RESULTS We found higher levels of community health workers activities strongly associated with primary health care practices (OR = 6.88) for those activities targeting hypertension management, followed by children’s health (OR = 6.56), and women’s health (OR = 6.21). CONCLUSIONS At a time when Brazil discusses whether community health workers should or should not remain in the same scale-up and skill level as they currently are, our results reinforce the importance of these workers for the care model advocated by the Brazilian Unified Health System.
  • Homicide impunity in Brazil between 2006 and 2016 Original Articles

    Nery, Felipe Souza; Nadanovsky, Paulo

    Abstract in Portuguese:

    RESUMO OBJETIVO Descrever o nível e a tendência temporal da impunidade do homicídio no Brasil. MÉTODOS Trata-se de estudo ecológico no qual dois índices de impunidade foram calculados a partir do número total de homicídios em determinado período, de cinco anos, dividido pelo número de indivíduos na prisão por homicídio (impunidade do homicídio) ou por qualquer causa (impunidade geral) dois anos após o final desse período. O modelo de regressão linear com correção de autocorrelação serial de Prais-Winsten foi utilizado para estimar a tendência temporal dos índices de impunidade. RESULTADOS No Brasil, entre 2009 e 2014, foram identificados 328.714 homicídios, contudo apenas 84.539 presos cumpriam pena por esse tipo de delito em 2016, revelando que houve 244.175 mais casos de homicídio no Brasil do que presos por esse crime. O índice de impunidade do homicídio variou de 3,9, em 2006, a 3,3 em 2014. Todos os estados apresentaram valores acima de 1. O Rio de Janeiro destacou-se negativamente, com valores acima de 20. Os menores índices de impunidade do homicídio foram encontrados nos estados de São Paulo, Santa Catarina e Distrito Federal, com valores abaixo de 2. Oito estados mostraram tendência de redução no índice de impunidade geral. CONCLUSÕES A maioria dos estados brasileiros apresentou valores altíssimos nos índices de impunidade. No entanto, detectamos um sinal positivo de que a sociedade brasileira começou, a partir de 2010–2012, a combater de forma efetiva a impunidade dos crimes violentos graves, incluindo o homicídio. São Paulo iniciou essa tendência positiva em meados dos anos 1990 e apresenta atualmente índices de impunidade similares aos dos países desenvolvidos.

    Abstract in English:

    ABSTRACT OBJECTIVE To describe the level and temporal trends of homicide impunity in Brazil. METHODS This is an ecological study that calculated two impunity indexes by dividing the total number of homicides committed in a 5-year period by the number of individuals arrested for murder (homicide impunity) or any other cause (general impunity) two years after this period. The Prais-Winsten linear regression model with serial autocorrelation correction was used to estimate the temporal trend of the impunity indexes. RESULTS Between 2009 and 2014, 328,714 homicides were recorded in Brazil, but only 84,539 prisoners were serving sentences for this kind of crime in 2016. This shows that the number of homicides in Brazil exceeded in 244,175 the number of individuals in prisons for this crime. The impunity index ranged from 3.9 in 2006 to 3.3 in 2014. All states reached values above 1. Rio de Janeiro stood out negatively, with values above 20. São Paulo, Santa Catarina, and Distrito Federal showed the lowest impunity indexes for homicide, with values below 2. Eight states showed a downward trend in the overall impunity index. CONCLUSIONS Most Brazilian states presented extremely high impunity indexes values. However, from 2010 to 2012, Brazilian society started to effectively combat impunity for serious violent crimes, including homicide. In São Paulo, this positive trend arose in the mid-1990s and that state currently shows impunity indexes values similar to those of developed countries.
  • Patient and public involvement in health technology decision-making processes in Brazil Original Articles

    Lopes, Ana Carolina de Freitas; Novaes, Hillegonda Maria Dutilh; Soárez, Patricia Coelho de

    Abstract in Portuguese:

    RESUMO OBJETIVO Caracterizar e discutir os processos formais de participação social previstos e implementados pelas instituições Agência Nacional de Vigilância Sanitária (Anvisa), Comissão Nacional de Incorporação de Tecnologias no SUS (Conitec) e Agência Nacional de Saúde Suplementar (ANS). MÉTODOS Estudo exploratório, descritivo, comparativo, conduzido por meio de análise de documentos publicados até 2018 no sítio eletrônico e da legislação específica de cada instituição. RESULTADOS Os espaços de participação social identificados incluem a representação em colegiados e participação direta por meio de uma demanda inicial ou em consultas públicas, audiências públicas e ouvidorias. A Anvisa conduziu 187 consultas públicas entre 1999 e 2018, e contabilizou 10.699 contribuições. Em 76 (41%) consultas públicas não há informações sobre as contribuições recebidas. A Conitec conduziu 234 consultas públicas, e recebeu 53.174 contribuições entre 2011 e 2018. Identificou-se que 70 (23%) recomendações da Conitec foram emitidas sem consulta pública, e 26 (8%) recomendações preliminares foram alteradas após consulta pública. As alterações de recomendação aconteceram especialmente em casos com grande volume de contribuições. A ANS conduziu 8 consultas públicas sobre o rol de procedimentos e eventos em saúde entre 2000 e 2018, e recebeu pelo menos 31.498 contribuições. Em três consultas públicas não há informações sobre o número de contribuições recebidas. CONCLUSÕES Observa-se recente avanço normativo e de desempenho institucional em favor da participação social em espaços decisórios notadamente técnicos, embora de forma bastante heterogênea entre as instituições analisadas. O poder deliberativo da participação social de influenciar as decisões em saúde ainda necessita de estudo aprofundado, incluindo a caracterização dos participantes e a legitimidade das decisões subsequentes.

    Abstract in English:

    ABSTRACT OBJECTIVE The study aims to characterize and discuss the processes of patient and public involvement (PPI) in the Brazilian Health Regulatory Agency (Anvisa), the National Committee for Health Technology Incorporation (Conitec), and the National Agency for Supplementary Health (ANS) in Brazil. METHODS This is an exploratory, descriptive, and comparative study, conducted by analyzing the public documents and regulation of the three institutions. RESULTS The mechanisms for PPI included public consultations, public hearings, participation in advisory committees, and health technology evaluation requests. Anvisa conducted 187 public consultations between 1999 and 2018, gathering 10,699 contributions. In total, 76 (41%) public consultations did not present information about the contributions received. Conitec carried out 234 public consultations and received 53,174 contributions between 2011 and 2018. It was identified that 70 (23%) recommendations from Conitec did not go through public consultation, and 26 (8%) recommendations changed after public consultation. Recommendation changes seemed to have occurred especially in cases with a greater number of contributions in the public consultation process. ANS conducted eight public consultations regarding the list of health procedures and events covered by health insurances between 2000 and 2018, and it received 31,498 contributions. For three public consultations, there was no information about the number of contributions received. CONCLUSIONS There are regulatory advances and institutional activity supporting PPI in highly technical decision-making processes in Brazil, although heterogeneously among the analyzed institutions. The power of PPI to influence health technology deliberative processes still requires in-depth studies, including the characterization of stakeholders and the legitimacy of decisions.
  • Cost analysis in a Traditional, Complementary and Integrative Medicine unit in Brazil Original Articles

    Assunção, Marcone César Tabosa; Aquino, Camilla Maria Ferreira de; Sousa, Islândia Maria Carvalho de; Carvalho Neto, Manoel Raymundo de; Jordão, Vitor Pereira; Bezerra, Adriana Falangola Benjamin

    Abstract in Portuguese:

    RESUMO OBJETIVO Analisar os custos de um serviço especializado em Medicinas Tradicionais Complementares e Integrativas (MTCI) no Nordeste brasileiro, com o intuito de fornecer dados sobre o custo atrelado à implantação e manutenção de serviços dessa natureza e identificar o custo médio por usuário para o Sistema Único de Saúde. MÉTODOS Trata-se de uma avaliação econômica do tipo parcial, com caráter descritivo, de natureza quantitativa, que utilizou dados secundários, posteriormente agrupados em planilhas do Microsoft Excel. O método utilizado para analisar tais custos foi o de custeio por absorção, a partir do qual o serviço foi dividido em três centros de custeio: produtivo, administrativo e auxiliar. RESULTADOS Após a análise dos dados, o custo total do serviço em 2014 foi estimado em R$ 1.270.015,70, com proporção de 79,69% de custos diretos. O custo médio por usuário neste período foi R$ 36,79, considerando o total de 34.521 usuários em práticas individuais e coletivas. CONCLUSÕES O serviço apresenta um custo por usuário compatível com um serviço especializado, contudo, as MTCI oferecem abordagem compreensiva e holística, as quais podem impactar de forma positiva a qualidade de vida.

    Abstract in English:

    ABSTRACT OBJECTIVE To analyze the costs of a specialized service in Traditional Complementary and Integrative Medicines (TCIM) in Northeast Brazil to provide data on the cost linked to the implementation and maintenance of services of this nature and to identify the average cost per user for the Unified Health System. METHODS This is a partial, descriptive, quantitative economic assessment, which used secondary data, later grouped in Microsoft Excel spreadsheets. The method used to analyze such costs was absorption costing, from which the service was divided into three costing centers: productive, administrative and auxiliary. RESULTS After analyzing the data, the total cost of the service in 2014 was estimated at R$ 1,270,015.70, with a proportion of 79.69% of direct costs. The average cost per user in this period was R$ 36.79, considering the total of 34,521 users in individual and collective practices. CONCLUSIONS The service has a cost per user compatible with a specialized service; however, TCIM offers a comprehensive and holistic approach, which can have a positive impact on quality of life.
  • Violence against pregnant women and associated factors in the city of Governador Valadares Original Articles

    Defilipo, Érica Cesário; Chagas, Paula Silva de Carvalho; Ribeiro, Luiz Cláudio

    Abstract in Portuguese:

    RESUMO OBJETIVO Caracterizar a violência contra a mulher durante a gestação e verificar a associação com os fatores socioeconômicos, demográficos, obstétricos, comportamentais, de assistência à saúde e doenças na gestação. MÉTODOS Estudo transversal realizado com puérperas cujo parto ocorreu no Hospital Municipal de Governador Valadares, em Minas Gerais, no período de maio de 2017 a julho de 2018. A coleta de dados foi realizada por meio de entrevista, e informações complementares foram obtidas pela análise do cartão de pré-natal e prontuário. Para a análise dos dados, foi utilizada regressão logística. RESULTADOS Participaram do estudo 771 puérperas. Dessas, 62 (8,0%) relataram ter sofrido violência física, psicológica ou sexual durante a gestação. As gestantes com maior chance de terem sofrido violência foram as dependentes de álcool (RC = 4,97; IC95% 2,30–10,75; p < 0,001), as que não realizaram o pré-natal (RC = 3,88; IC95% 1,00–15,09; p = 0,050), as que usaram os serviços de saúde de forma emergencial durante a gravidez (RC = 2,47; IC95% 1,42–4,30; p = 0,001) e que apresentaram diabetes gestacional (RC = 2,59; IC95% 1,06–6,32; p = 0,037) e doenças sexualmente transmissíveis (RC = 3,85; IC95% 1,41–10,50; p = 0,009). CONCLUSÃO A violência contra a gestante está associada a fatores comportamentais e relacionados à assistência à saúde e doenças na gestação. É imprescindível o reconhecimento dos fatores associados pelos profissionais de saúde, por meio de ações de rastreamento de situações de violência contra a mulher desde o início do pré-natal, a fim de possibilitar intervenção precoce.

    Abstract in English:

    ABSTRACT OBJECTIVE To characterize violence against women during pregnancy and to verify its association with socioeconomic, demographic, obstetric, behavioral factors, health care and diseases during pregnancy. METHODS Cross-sectional study carried out with puerperal women whose birth took place at the Municipal Hospital of Governador Valadares, in Minas Gerais, from May 2017 to July 2018. Data collection was performed through interviews, and complementary information was obtained by analyzing the prenatal file and medical records. For data analysis, logistic regression was used. RESULTS The total of 771 puerperal women participated in the study. Of these, 62 (8.0%) reported having suffered physical, psychological or sexual violence during pregnancy. The pregnant women most likely to have suffered violence were alcohol dependent (OR = 4.97; 95%CI 2.30–10.75; p < 0.001), those who did not perform prenatal care (OR = 3.88; 95%CI 1.00–15.09; p = 0.050), those who used health services in an emergency during pregnancy (OR = 2.47; 95%CI 1.42–4.30; p = 0.001) and who had gestational diabetes (OR = 2.59; 95%CI 1.06–6.32; p = 0.037) and sexually transmitted diseases (OR = 3.85; 95%CI 1.41–10.50; p = 0.009). CONCLUSION Violence against pregnant women is associated with behavioral factors and related to health care and diseases during pregnancy. It is essential to recognize factors associated by health professionals through actions to track situations of violence against women since the beginning of prenatal care, in order to enable early intervention.
  • Physical inactivity during leisure and school time is associated with the presence of common mental disorders in adolescence Original Articles

    Ferreira, Vanessa Roriz; Jardim, Thiago Veiga; Póvoa, Thaís Inácio Rolim; Viana, Ricardo Borges; Sousa, Ana Luiza Lima; Jardim, Paulo César Veiga

    Abstract in Portuguese:

    RESUMO OBJETIVO: Investigar a associação da inatividade física no lazer e na escola com os transtornos mentais comuns durante a adolescência. MÉTODOS: A amostra foi composta por 73.399 adolescentes (12–17 anos), participantes do Estudo de Riscos Cardiovasculares em Adolescentes (Erica). Esse estudo transversal, nacional e de base escolar foi realizado em 2013 e 2014, nos municípios brasileiros com mais de 100 mil habitantes. A atividade física no lazer foi categorizada de acordo com o volume de prática semanal, e os adolescentes foram classificados em ativos (≥ 300 minutos/semana), inativos (0 minuto/semana) e insuficientemente ativos (1–299 minutos/semana). A prática esportiva e a participação em aulas de educação física na escola também foram analisadas. A presença de transtornos mentais comuns foi avaliada a partir do general health questionnaire, com ponto de corte maior ou igual a 3. Odds ratios (OR) foram estimados utilizando regressão logística múltipla. RESULTADOS: A chance de transtornos mentais comuns foi 16% maior no grupo que relatou ser inativo (0 minuto/semana) no lazer (OR = 1,16; IC95% 1,06–1,27). A prevalência de transtornos mentais comuns foi maior entre jovens que não praticaram esportes (37,2% vs. 25,9%; OR = 1,14; IC95% 1,04–1,25) e não participaram das aulas de educação física na escola (39,5% vs. 29,6%; OR = 1,25; IC95% 1,15–1,36). Atividade física insuficiente (1–299 minutos/semana) não aumentou a razão de chances de transtornos mentais comuns. Praticar atividade física no lazer, independentemente da duração e frequência semanal, reduziu em 26% as chances de transtornos mentais comuns nessa população. CONCLUSÕES: A inatividade física no lazer e na escola foi associada à presença de transtornos mentais comuns na adolescência. Os resultados sugerem que prática esportiva, educação física escolar e atividade física durante o lazer, mesmo sem atingir a recomendação atual, têm relação com a saúde mental dos jovens.

    Abstract in English:

    ABSTRACT OBJECTIVE: To investigate the association of physical inactivity in leisure and school time with common mental disorders during adolescence. METHODS: The sample consisted of 73,399 adolescents (12–17 years old), participants in the Estudo de Riscos Cardiovasculares em Adolescentes (Erica — Study of Cardiovascular Risks in Adolescents). This cross-sectional, national and school-based study was conducted in 2013 and 2014 in Brazilian municipalities with more than 100,000 inhabitants. Leisure time physical activity was categorized according to weekly practice volume, and adolescents were classified as active (≥ 300 minutes/week), inactive (0 minute/week) and insufficiently active (1–299 minutes/week). Sports practice and participation in physical education classes at school were also analyzed. The presence of common mental disorders was assessed based on the general health questionnaire, with a cutoff point greater than or equal to 3. Odds ratios (OR) were estimated using multiple logistic regression. RESULTS: The chance of common mental disorders was 16% higher in the group that reported being inactive (0 minute/week) at leisure time (OR = 1.16; 95%CI 1.06 (1.27). The prevalence of common mental disorders was higher among young people who did not practice sports (37.2% vs. 25.9%; OR = 1.14; 95%CI 1.04–1.25) and did not participate in physical education classes at school (39.5% vs. 29.6%; OR = 1.25; 95%CI 1.15–1.36). Insufficient physical activity (1–299 minutes/week) did not increase the OR of common mental disorders. Practicing physical activity during leisure time, regardless of duration and weekly frequency, reduced the chances of common mental disorders in this population by 26%. CONCLUSIONS: Physical inactivity during leisure and school time is associated with the presence of common mental disorders in adolescence. The results suggest that sports practice, school physical education and physical activity during leisure time, even without reaching the current recommendation, are related to the mental health of young people.
  • Knowledge, attitudes and practices of university adolescents about syphilis: a cross-sectional study in the Northeast Original Articles

    Carvalho, Rodolfo Xavier da Costa; Araújo, Telma Maria Evangelista de

    Abstract in Portuguese:

    RESUMO OBJETIVO: Analisar conhecimentos, atitudes e práticas de adolescentes universitários sobre a sífilis. MÉTODOS: Estudo transversal, analítico, do tipo censitário, desenvolvido com o universo de adolescentes de 18 e 19 anos (n = 598), matriculados em três instituições de ensino superior presencial em município do Piauí (n = 598), que juntas totalizam 20 cursos nas áreas de Ciências da Saúde, Sociais Aplicadas, Exatas e da Terra, Engenharias e Linguística, Letras e Arte. A coleta de dados ocorreu de março a maio de 2019, a partir de um questionário adaptado da Pesquisa de Conhecimentos, Atitudes e Práticas da População Brasileira de 2013, do Ministério da Saúde, constituído por perguntas referentes a variáveis sociodemográficas (sexo, idade, arranjo familiar, escolaridade dos pais, cor ou raça, atividade remunerada e renda familiar), conhecimento, atitude e prática em relação à doença, sendo as três últimas classificadas por escores. As variáveis que apresentaram valor de p ≤ 0,20 na análise bivariada, por meio do teste do qui-quadrado de Pearson, foram incluídas em três modelos logísticos multivariados, e os desfechos em cada modelo foram o conhecimento, a atitude e a prática, respectivamente; permanecendo ao final aquelas a nível de p < 0,05. RESULTADOS: O sexo masculino possui chance 39,6% menor de ter conhecimento adequado/regular (ORa = 0,604; IC95% 0,415–0,878), enquanto as maiores chances estão associadas a “morar sozinho, com parentes e amigos” (ORa = 4,567; IC95% 1,417–14,719) e a ter atitude muito positiva/positiva (ORa = 6,937; IC95% 4,562–10,550). Menores chances de prática adequada estão associadas ao sexo masculino (ORa = 0,480; IC95% 0,301–0,766) e à menor escolaridade paterna (ORa = 0,440; IC95% 0,241–0,806). CONCLUSÃO: O conhecimento e a atitude da maioria dos participantes do estudo em relação à sífilis não foram suficientes para adoção de uma prática sexual adequada para a prevenção da doença, revelando a necessidade de se investigar outras variáveis que possam estar implicadas nesta incoerência cognitiva.

    Abstract in English:

    ABSTRACT OBJECTIVE: To analyze knowledge, attitudes and practices of university adolescents about syphilis. METHODS: Cross-sectional, analytical, census-type study, developed with the universe of adolescents aged 18 and 19 years (n = 598), enrolled in three institutions of higher education in a municipality of Piauí (n = 598), which total 20 courses in the areas of Health Sciences, Applied Social Sciences, Exact and Earth, Engineering and Linguistics, Letters and Art. Data collection occurred from March to May 2019, based on a questionnaire adapted from the Pesquisa de Conhecimentos, Atitudes e Práticas da População Brasileira of 2013 (PCAP – Survey of Knowledge, Attitudes and Practices in the Brazilian Population), consisting of questions related to sociodemographic variables (gender, family arrangement, father's schooling, mother's schooling, skin color or race, employment, household income), knowledge, attitude and practice regarding the disease, the last three being classified by scores. The variables that presented p ≤ 0.20 in the bivariate analysis, by Pearson's chi-square test, were included in three multivariate logistic models, and the outcomes in each model were knowledge, attitude and practice, respectively; remaining at the end those at the level of p < 0.05. RESULTS: Boys have a 39.6% lower chance of having adequate/regular knowledge (ORa = 0.604; 95%CI 0.415–0.878), whereas the highest chances are associated with “living alone, with relatives and friends” (ORa = 4.567; 95%CI 1.417–14.719) and having a very positive/positive attitude (ORa = 6.937; 95%CI 4.562–10.550). Lower chances of an adequate practice are associated with boys (ORa = 0.480; 95%CI 0.301–0.766) and lower father's schooling (ORa = 0.440; 95%CI 0.241–0.806). CONCLUSION: Most participants’ knowledge and attitude regarding syphilis were not sufficient to the adoption of an adequate sexual practice for the prevention of the disease, showing the need to investigate other variables that may be implicated in this cognitive incoherence.
  • Cancer mortality in the Capitals and in the interior of Brazil: a four-decade analysis Original Articles

    Silva, Gulnar Azevedo e; Jardim, Beatriz Cordeiro; Ferreira, Vanessa de Melo; Junger, Washington Leite; Girianelli, Vania Reis

    Abstract in Portuguese:

    RESUMO OBJETIVO: Descrever a tendência da mortalidade por câncer geral e tipos mais frequentes entre homens e mulheres residentes nas capitais e demais municípios das cinco macrorregiões do Brasil entre 1978 e 2017. MÉTODOS: Estudo de séries temporais com dados de mortalidade corrigidos por redistribuição das causas maldefinidas. Foi calculada a mortalidade proporcional de câncer para Brasil e regiões. A variação percentual anual das taxas para o total de câncer e tipos específicos em cada segmento e na desagregação selecionada foi calculada por regressão linear generalizada com ligação gaussiana. RESULTADOS: A proporção de câncer aumentou progressivamente para ambos os sexos de 1978 a 2017. Diferenças importantes entre as capitais e o interior das macrorregiões foram vistas com dados desagregados. Os maiores declínios ocorreram para o câncer de estômago, exceto nas regiões Norte e interior da Nordeste, e de colo do útero, com queda generalizada, com exceção do interior da região Norte. O câncer de pulmão teve queda entre homens nas regiões Sudeste e Sul e aumento generalizado entre mulheres. Os cânceres de mama e de próstata tenderam a diminuir nas regiões Sudeste e Sul e entre residentes das capitais, mostrando, porém, aumento no interior das regiões Norte e Nordeste. O câncer colorretal teve tendência geral de aumento; nas capitais houve estabilidade entre homens da região Sul e entre mulheres das regiões Sudeste e Centro-Oeste e queda entre mulheres da região Sul a partir de 2007. CONCLUSÕES: A mortalidade por câncer apresentou grande variação entre os residentes de capitais e do interior das grandes regiões do país. Diminuição clara da mortalidade foi vista para os principais tipos nas regiões Sudeste e Sul. As regiões Norte e Nordeste apresentam padrões compatíveis com cânceres associados à pobreza ao mesmo tempo que se destacam pelo grande aumento daqueles relacionados ao estilo de vida sedentário.

    Abstract in English:

    ABSTRACT OBJECTIVE: to describe the trend of mortality from general cancer and more frequent types among men and women living in the Capitals and other municipalities of the five macro-regions of Brazil between 1978 and 2017. METHODS: Time series study with mortality data corrected by redistribution of ill-defined causes. Proportional cancer mortality was calculated for Brazil and regions. The annual percentage change in rates for total cancer and specific types in each segment and in the selected unit of analysis was calculated by generalized linear regression with Gaussian binding. RESULTS: the proportion of cancer increased progressively for both sexes from 1978 to 2017. Important differences between the Capitals and the interior of the macro-regions were seen with disaggregated data. The greatest declines occurred for stomach cancer, except in the northern and interior regions of the Northeast, and for the cervix cancer, with a generalized fall, with the exception of the interior of the northern region. Lung cancer decreased among men in the Southeast and South regions and had a generalized increase among women. Breast and prostate cancers tended to decrease in the Southeast and South regions and among residents of the Capitals but showing an increase in the interior of the North and Northeast regions. Colorectal cancer had a general tendency to increase; with stability among men in the Capitals of the South region and among women of the Southeast and Midwest regions and, since 2007, a decrease among women in the South region. CONCLUSIONS: Cancer mortality showed great variation among residents of capitals and the interior of the country's major regions. Clear decrease in mortality was seen for the main types in the Southeast and South regions. The North and Northeast regions have patterns compatible with cancers associated with poverty, while the large increase of the cancers related to sedentary lifestyle stand out.
  • Mortality trend due to Hepatitis B and C in the city of São Paulo, 2002–2016 Original Articles

    Sato, Ana Paula Sayuri; Koizumi, Inês Kazue; Farias, Norma Suely de Oliveira; Silva, Célia Regina Ciccolo da; Cardoso, Maria Regina Alves; Figueiredo, Gerusa Maria

    Abstract in Portuguese:

    RESUMO OBJETIVO: Descrever a mortalidade por hepatites B e C como causa básica no município de São Paulo, verificando a tendência dessas taxas, e avaliar a associação dessas doenças a outras no período de 2002 a 2016. MÉTODOS: Trata-se de um estudo de série temporal sobre mortalidade por hepatites B e C segundo sexo, com dados do Sistema de Informação de Mortalidade. A regressão de Prais Winsten foi usada na análise de tendência das taxas. RESULTADOS: Os achados do presente estudo mostraram tendência de declínio da mortalidade por hepatites B e C nos últimos anos, particularmente entre pessoas do sexo masculino. Essas infecções foram causas associadas importantes ao carcinoma de células hepáticas e ao HIV. Destaca-se a proporção de óbitos com menos de 70 anos de idade. CONCLUSÕES: O estudo fornece uma linha de base para pesquisas de tendência de mortalidade e de impacto de intervenções, visto o histórico de ampliação da detecção e oferta de tratamentos, incluindo os mais recentes antivirais no Brasil, desde 2015.

    Abstract in English:

    ABSTRACT OBJECTIVE: To describe mortality due to hepatitis B and C as underlying cause in the municipality of São Paulo, verifying the trend of these rates, and to assess the association of these diseases with others, from 2002 to 2016. METHODS: This is a time series study on mortality due to hepatitis B and C according to sex, with data from the Sistema de Informação de Mortalidade (SIM – Mortality Information Sistem). Prais Winsten regression was used in rate trend analysis. RESULTS: The findings of this study showed a trend of decline of mortality from hepatitis B and C in recent years, particularly among males. These infections were important associated causes of liver cell carcinoma and HIV. The proportion of deaths under 70 years of age stands out. CONCLUSIONS: The study provides a baseline for research on mortality trend and the impact of interventions, given the history of expanded detection and supply of treatments, including the most recent antivirals in Brazil, since 2015.
  • Factors associated with neonatal near miss in Brazil Original Articles

    Pereira, Theonas Gomes; Rocha, Daniele Marano da; Fonseca, Vânia Matos; Moreira, Maria Elisabeth Lopes; Gama, Silvana Granado Nogueira da

    Abstract in Portuguese:

    RESUMO OBJETIVO: Este estudo avalia a associação entre fatores sociodemográficos, características maternas, organização dos serviços de saúde e near miss neonatal em maternidades públicas e privadas do Brasil. MÉTODOS: Trata-se de uma coorte prospectiva de nascidos vivos da pesquisa Nascer no Brasil, realizada entre 2011 e 2012. As variáveis foram estabelecidas a partir da literatura e organizadas em três níveis: distal, intermediário e proximal. A avaliação foi realizada a partir dos resultados das análises bivariadas e de seus respectivos valores-p, com nível de significância < 0,20, pelo teste de Wald. Para a análise multivariada, foram inseridas as variáveis contidas no nível distal, conservadas no modelo quando significativas (p < 0,05). O mesmo foi feito no ajuste dos níveis intermediário e proximal. RESULTADOS: No nível distal, nenhuma variável apresentou associação significativa com o desfecho. No nível intermediário, idade da mãe maior ou igual a 35 anos (risco relativo – RR = 1,32; IC95% 1,04–1,66), parto cesáreo (RR = 1,34; IC95% 1,07–1,67), uso de fumo (RR = 1,48; IC95% 1,04–2,10), síndrome hipertensiva gestacional (RR = 2,29; IC95% 1,98–3,14), diabetes pré-gestacional (RR = 2,63; IC95% 1,36–5,05) e gestação gemelar (RR = 2,98; IC95% 1,90–4,68) foram variáveis associadas ao desfecho. No nível proximal, o pré-natal não adequado (RR = 1,71; IC95% 1,36–2,16) e a localização do hospital/maternidade na capital (RR = 1,89; IC95% 1,40–2,55) foram associados ao near miss neonatal. CONCLUSÃO: Os resultados mostram que o near miss neonatal foi influenciado pelas variáveis da organização dos serviços de saúde e pelas características maternas.

    Abstract in English:

    ABSTRACT OBJECTIVE: This study evaluates the association between sociodemographic factors, maternal characteristics, organization of health services and neonatal near miss in public and private maternity hospitals in Brazil. METHODS: This is a prospective cohort of live births from the Nascer no Brasil survey, carried out between 2011 and 2012. Variables were established from the literature and organized on three levels: distal, intermediate, and proximal. The assessment was performed based on results of the bivariate analyzes and their respective p-values, with a significance level <0.20, using the Wald test. For multivariate analysis, the variables contained at the distal level were inserted, preserved in the model when significant (p < 0.05). This was also done when adjusting the intermediate and proximal levels. RESULTS: At the distal level, no variable was significantly associated with the outcome. At the intermediate level, mother's age greater than or equal to 35 years (relative risk – RR = 1.32; 95%CI 1.04–1.66), cesarean delivery (RR = 1.34; 95%CI 1.07–1.67), smoking (RR = 1.48; 95%CI 1.04–2.10), gestational hypertensive syndrome (RR = 2.29; 95%CI 1.98–3.14), pre-gestational diabetes (RR = 2.63; 95%CI 1.36–5.05) and twin pregnancy (RR = 2.98; 95%CI 1.90–4.68) were variables associated with the outcome. At the proximal level, inadequate prenatal care (RR = 1.71; 95%CI 1.36–2.16) and the hospital/maternity being located in a capital city (RR = 1.89; 95%CI 1.40–2.55) were associated with neonatal near miss. CONCLUSIONS: The results show that neonatal near miss was influenced by variables related to the organization of health services and by maternal characteristics.
  • Aging with health: aging in place strategies of a Portuguese population aged 65 years or older Original Articles

    Bárrios, Maria João; Marques, Rita; Fernandes, Ana Alexandre

    Abstract in Portuguese:

    RESUMO OBJETIVO: Identificar as estratégias desenvolvidas por pessoas em processo de envelhecimento para se manter residindo na própria casa, apesar das fragilidades e das dificuldades com que deparam. MÉTODOS: A pesquisa foi realizada a partir de um inquérito a uma população com 65 anos ou mais no município português de Portimão. Os dados foram recolhidos por questionário, em 2017, e submetidos a análise estatística e análise de conteúdo. RESULTADOS: A maioria dos inquiridos tem habitação própria, onde se sente segura e satisfeita, e revela ter consciência e preocupação em relação às alterações que deve executar em sua casa para ali poder permanecer. Além das condições habitacionais e de habitabilidade, as condições de saúde, os recursos económicos, a rede social e os serviços disponíveis assumem um papel preponderante no envelhecimento na comunidade. CONCLUSÕES: Foi possível identificar uma diversidade nas estratégias utilizadas para permanecerem em suas casas à medida que envelhecem e uma multiplicidade de formas como mobilizaram os recursos que têm à disposição, bem como constrições do ageing in place.

    Abstract in English:

    ABSTRACT OBJECTIVE: To identify the strategies developed by people in the aging process to keep living in their own home, despite the weaknesses and difficulties they face. METHODS: The research was carried out based on a survey of population aged 65 years or older in the Portuguese municipality of Portimão. Data were collected by questionnaire, in 2017, and submitted to statistical and content analysis. RESULTS: Most respondents own their household, where they feel safe and satisfied, and they show awareness and concern about the changes they have to make in their home to stay there. In addition to housing and livability conditions, health, economic resources, social network, and available services play a major role in the community. CONCLUSIONS: We identified several strategies used by older adults to stay in their households as they age and the ways they mobilize their available resources, as well as constraints of aging in place.
  • Frailty in community-dwelling older people: comparing screening instruments Original Articles

    Carneiro, Jair Almeida; Souza, Andressa Samantha Oliveira; Maia, Luciana Colares; Costa, Fernanda Marques da; Moraes, Edgar Nunes de; Caldeira, Antônio Prates

    Abstract in Portuguese:

    RESUMO OBJETIVO: Comparar os instrumentos Edmonton Frail Scale (EFS) e Índice de Vulnerabilidade Clínico-Funcional-20 (IVCF-20) quanto ao grau de concordância e de correlação, bem como comparar modelos descritivos com variáveis associadas à fragilidade em idosos brasileiros comunitários. MÉTODOS: Estudo transversal, aninhado a uma coorte de base populacional e domiciliar. A amostragem na linha de base foi probabilística, por conglomerados, em dois estágios. No primeiro, utilizou-se como unidade amostral o setor censitário. No segundo, definiu-se o número de domicílios segundo a densidade populacional de indivíduos com idade ≥ a 60 anos. A estatística Kappa analisou a concordância, e o coeficiente de Pearson avaliou a correlação entre os instrumentos. Os fatores associados à fragilidade e ao alto risco de vulnerabilidade clínico-funcional foram identificados por análise múltipla de regressão de Poisson com variância robusta. RESULTADOS: A estatística Kappa foi 0,599, e o coeficiente de correlação de Pearson foi de 0,755 (p < 0,001). A prevalência da fragilidade foi de 28,2% pela EFS, e a prevalência do alto risco de vulnerabilidade clínico-funcional foi de 19,5% pelo IVCF-20. As variáveis associadas à fragilidade, após análise múltipla, em ambos os instrumentos, foram: idade igual ou superior a 80 anos, histórico de acidente vascular encefálico, polifarmácia, autopercepção negativa de saúde, queda nos últimos 12 meses e internação nos últimos 12 meses. Escolaridade inferior a quatro anos, doença osteoarticular e perda de peso foram associadas a fragilidade apenas pela EFS, enquanto possuir cuidador esteve associado a alto risco de vulnerabilidade clínico-funcional somente pelo IVCF-20. CONCLUSÕES: Embora as análises revelem concordância moderada e forte correlação positiva entre os instrumentos, a prevalência de fragilidade apontada é discrepante. O resultado destaca a necessidade de padronizar o instrumento para aferir a fragilidade em idosos comunitários.

    Abstract in English:

    ABSTRACT OBJECTIVE: To compare the Edmonton Frail Scale (EFS) and Clinical-Functional Vulnerability Index-20 (CFVI-20) instruments regarding degree of agreement and correlation and compare descriptive models with frailty-associated variables in community-dwelling older people in Brazil. METHODS: Cross-sectional study, nested in a population-based and household cohort. Baseline sampling was calculated based on a probabilistic approach by conglomerate in two stages. In the first stage, census tract was used as sampling unit. In the second, the number of households was defined according to the population density of individuals aged ≥ 60 years. The Kappa statistic evaluated the agreement between instruments and Pearson's coefficient their correlation. Factors associated with frailty and high risk of clinical-functional vulnerability were identified by multiple analysis of Poisson regression with robust variance. RESULTS: Kappa statistics was 0.599 and Pearson's correlation coefficient 0.755 (p < 0.001). The EFS found a 28.2% prevalence of frailty, and the CFVI-20 found a 19.5% prevalence of high risk of clinical-functional vulnerability. Age equal to or greater than 80 years, history of stroke, polypharmacy, negative self-perceived health, fall in the past 12 months, and hospitalization in the past 12 months were variables associated with frailty in both instruments after multiple analysis. Less than four years of education, osteoarticular disease, and weight loss were associated with frailty only by EFS, and having a caregiver was associated with a high risk of clinical-functional vulnerability only by CFVI-20. CONCLUSIONS: Although the analyses show moderate agreement and strong positive correlation between the instruments, the indicated prevalence of frailty is discrepant. Our results attest the need to standardize the instrument for assessing frailty in community-dwelling older people.
  • Mortality by road traffic injuries in Brazil (2000–2016): capital cities versus non-capital cities Original Articles

    Aquino, Érika Carvalho de; Antunes, José Leopoldo Ferreira; Morais Neto, Otaliba Libânio de

    Abstract in Portuguese:

    RESUMO OBJETIVO: Comparar a magnitude e tendência da mortalidade por acidentes de transporte terrestre (ATT) nas capitais e demais municípios de cada estado brasileiro nos anos de 2000 a 2016. MÉTODOS: Foi realizada análise de séries temporais das taxas de mortalidade por ATT padronizadas por idade, comparando as capitais e o aglomerado de municípios não capitais em cada estado. Os dados sobre óbitos foram obtidos do Sistema de Informações sobre Mortalidade. Foram considerados como óbitos por ATT aqueles cuja causa básica tenha sido designada pelos códigos V01 a V89 do CID-10, com redistribuição dos garbage codes. Para o cálculo das taxas de mortalidade, foram utilizadas as projeções populacionais do Instituto Brasileiro de Geografia e Estatística de 2000 a 2015 e a população calculada por interpolação polinomial para 2016. A análise de tendências foi realizada pelo método de Prais-Winsten, utilizando o programa Stata 14.0. RESULTADOS: Ocorreram 601.760 óbitos por ATT no período (114.483 de residentes em capitais). A mortalidade por ATT não apresentou tendência crescente em nenhuma das capitais no período em estudo. Já entre os municípios não capitais, a tendência foi crescente em 14 estados. O maior aumento foi observado no Piauí (TIA = 7,50%; IC95% 5,50 – 9,60). Ocorreu tendência decrescente da mortalidade por ATT em 14 capitais, dentre as quais Curitiba apresentou maior decréscimo (TIA = −4,82%; IC95% −6,61 – −2,92). Apenas São Paulo e Rio Grande do Sul apresentaram tendência decrescente da mortalidade por ATT nos municípios não capitais (TIA = 2,32%; IC95% −3,32 – −1.3 e TIA = 1,2%, IC95% −2,41 – 0,00, respectivamente). CONCLUSÕES: É possível concluir que as taxas de mortalidade por ATT em municípios não capitais no Brasil apresentaram tendência alarmantes quando comparadas às observadas nas capitais. O desenvolvimento de ações eficazes de segurança no trânsito está quase sempre limitado às capitais e grandes cidades brasileiras. Os municípios com maior risco devem ser priorizados para o fortalecimento das políticas públicas de prevenção e controle.

    Abstract in English:

    ABSTRACT OBJECTIVES: To compare the magnitude and trend of mortality by road traffic injuries (RTI) in the capitals and other municipalities of each Brazilian state between 2000 and 2016. METHODS: A time series analysis of mortality rates by RTI standardized by age was performed, comparing the capitals and the cluster of non-capital municipalities in each state. Data on deaths were obtained from the Sistema de Informações sobre Mortalidade (SIM – Mortality Information System). RTI deaths were considered to be those, whose root cause was designated by ICD-10 codes V01 to V89, with redistribution of garbage codes. To estimate mortality rates, we used the population projections of the Brazilian Institute of Geography and Statistics (IBGE) from 2000 to 2015 and the population estimated by polynomial interpolation for 2016. The trend analysis was performed using the Prais-Winsten method, using the Stata 14.0 program. RESULTS: There were 601,760 deaths due to RTI in the period (114,483 of residents in capital cities). Mortality by RTI did not present an increasing trend in any of the Capitals in the period under study. Among non-capital municipalities, the trend was growing in 14 states. The greatest increase was observed in Piaui (AIR = 7.50%; 95%CI 5.50 – 9.60). There was a decreasing trend in RTI mortality in 14 capitals, among which Curitiba showed the greatest decrease (AIR = −4.82%; 95%CI −6.61 – −2.92). Only São Paulo and Rio Grande do Sul showed a decreasing trend in mortality by RTI in non-capital cities (AIR = 2.32%; 95%CI −3.32 – −1.3 and AIR = 1.2%, 95%CI −2.41 – 0.00, respectively). CONCLUSIONS: We conclude that RTI mortality rates in non-capital cities in Brazil showed alarming trends when compared with those observed in capital cities. The development of effective traffic safety actions is almost always limited to Brazilian capitals and large cities. Municipalities with higher risk should be prioritized to strengthen public policies for prevention and control.
  • Do primary and specialized care physicians know and use coordination mechanisms? Original Articles

    Mendes, Lívia dos Santos; Almeida, Patty Fidelis de

    Abstract in Portuguese:

    RESUMO OBJETIVOS: Analisar se médicos da atenção primária à saúde e da atenção especializada conhecem e utilizam mecanismos de coordenação do cuidado entre níveis assistenciais. MÉTODOS: Estudo transversal, do tipo inquérito, com aplicação do instrumento COORDENA-BR a médicos da atenção primária e da atenção especializada da rede pública de um município de médio porte, no período de junho a outubro de 2019. Foi abordado o conhecimento, frequência de envio e recebimento, finalidade, características e dificuldades para a utilização dos mecanismos de feedback ou adaptação mútua e de padronização para promoção de coordenação do cuidado entre níveis assistenciais. RESULTADOS: Instrumentos de feedback como formulários de referência e contrarreferência, resumo de alta hospitalar e WhatsApp são amplamente conhecidos por profissionais dos dois níveis, sem diferenças significativas. Sessões clínicas e protocolos são pouco reconhecidos, sobretudo na atenção especializada, o que pressupõe baixa utilização de mecanismos de padronização para obtenção de maior coordenação do cuidado entre níveis assistenciais. Apesar do elevado reconhecimento e facilidade de uso, instrumentos de feedback tradicionais como guias de referência e contrarreferência não são amplamente utilizados. Menor frequência de médicos conhecia os protocolos, principalmente na atenção especializada, e destacaram dificuldades para sua aplicação, como insuficiência de exames e indisponibilidade de insumos na rede. As sessões clínicas eram pouco conhecidas e tinham baixa frequência de participação. Pressão assistencial, baixa institucionalização e falta de tempo foram barreiras identificadas para a incorporação dos mecanismos de coordenação do cuidado ao processo de trabalho na atenção primária e especializada, além daquelas relacionadas à oferta de serviços na rede. CONCLUSÃO: Argumenta-se que a fragmentação do sistema e dos cuidados poderá ser enfrentada na complementariedade de medidas que possibilitem conhecer, desenvolver habilidades profissionais, institucionalizar e promover condições organizacionais para a efetiva utilização de mecanismos de coordenação em toda rede de atenção à saúde.

    Abstract in English:

    ABSTRACT OBJECTIVES: To analyze if primary and specialized care physicians know and use care coordination mechanisms between healthcare levels. METHODS: Cross-sectional survey study, with the application of the COORDENA-BR instrument to primary and specialized care physicians in a public heathcare network, medium-sized municipality, from June to October 2019. The questionnaire addresses knowledge, frequency of sending and receiving, purpose, characteristics and difficulties in using feedback or mutual adaptation and standardization mechanisms to promote coordination of care service between healthcare levels. RESULTS: Feedback instruments such as referral and reply letters, hospital discharge report and WhatsApp are widely known by professionals of both levels, without significant differences. Clinical sessions and protocols are not well-known, especially in specialized care, which supposes a low usage of standardization mechanisms to a better coordination between the healthcare levels. Despite being well-known and easy, traditional feedback instruments such as referral and reply letters are not widely used. Fewer physicians knew the protocols, mainly in specialized care. They pointed difficulties in their application, such as insufficient exams and unavailable supplies in the healthcare network. Clinical sessions were unknown and registered low participation frequency. Care overload, low institutionalization and time constraints were barriers identified for the incorporation of care coordination mechanisms in the work process in primary and specialized care, in addition to those related to the provision of health services in the network. CONCLUSION: We conclude the fragmentation of the system and care can be faced in the complementarity of measures that make it possible to know the mechanisms, develop professional skills, institutionalize and promote organizational conditions for the effective use of coordination mechanisms throughout the healthcare network.
  • Academic productivism: when job demand exceeds working time Original Articles

    Teixeira, Talita da Silveira Campos; Marqueze, Elaine Cristina; Moreno, Claudia Roberta de Castro

    Abstract in Portuguese:

    RESUMO OBJETIVOS: Avaliar a associação entre a percepção da pressão por publicações com a satisfação e o estresse no trabalho. MÉTODOS: Estudo transversal com 64 orientadores de pós-graduação de uma universidade pública da cidade de São Paulo. A coleta de dados ocorreu por meio de um questionário on-line que incluiu: dados sociodemográficos, laborais e de saúde; Escala de Satisfação no Trabalho do Occupational Stress Indicator e modelo Desequilíbrio Esforço-Recompensa (DER). Para avaliar a percepção da pressão por publicação foi criada uma escala numérica na qual o orientador deveria atribuir uma nota de 0 a 10 para o quanto se sentia pressionado a publicar seus trabalhos (sendo 0 nenhuma pressão e 10 muita pressão). Posteriormente, foi utilizado o modelo linear generalizado para testar os fatores associados à alta percepção de pressão para publicação, ajustado pelo tempo de trabalho, função de gestão acadêmica e bolsa produtividade. RESULTADOS: Maiores proporções da percepção de elevada pressão para publicação foram encontradas entre orientadores que já haviam trabalhado em instituição de ensino superior, que realizavam parte do trabalho em casa e que apresentavam estresse laboral. Associou-se essa percepção a um maior esforço e comprometimento excessivo no trabalho, bem como a um maior desequilíbrio entre o esforço empregado e a recompensa recebida no trabalho. CONCLUSÕES: Os achados desta pesquisa sugerem que a organização do trabalho e a saúde mental dos trabalhadores estejam inter-relacionados: quanto maior a percepção de pressão por publicação maior o estresse. No entanto, esse resultado parece não se refletir na satisfação (ou insatisfação) do trabalho. O prolongamento aparentemente deliberado das horas de trabalho oculta a precarização e intensificação do trabalho a que os professores têm sido submetidos nos últimos anos pelas políticas públicas que mercantilizam a educação no Brasil.

    Abstract in English:

    ABSTRACT OBJECTIVE: To assess the association between the perception of pressure to publish academic work with job satisfaction and stress. METHODS: Cross-sectional study with 64 graduate advisors from a public university in the city of São Paulo. Data collection conducted via an online questionnaire that included: sociodemographic, work and health data; Occupational Stress Indicator Job Satisfaction Scale and Effort-Reward Imbalance (ERI) model. To assess the perception of pressure to publish academic work the advisors answered a numerical scale, assigning a score from 0 to 10 to how pressured they felt to publish their work (being 0 no pressure and 10 high pressure). Later, the generalized linear model was used to test the factors associated to high perception of pressure to publish academic work, adjusted for working time, academic management role and productivity grant. RESULTS: Advisors who had already worked in a higher education institution, who performed part of the work at home and who reported work stress were more likely to show perception of extreme pressure to publish academic work. This perception was associated with greater effort and over-commitment, as well as a greater imbalance between the effort employed and the reward received at work. CONCLUSIONS: The findings suggest that the professors’ work organization and mental health are interrelated: the higher the perception of pressure to publish academic work, the greater the stress. However, this result does not seem to be reflected in the job satisfaction (or dissatisfaction). The apparently deliberate extension of working hours hides the precariousness and increased work to which professors have been subjected in recent years by public policies that commercialize education in Brazil.
  • Effect of early determinants on adolescent fat-free mass: RPS cohort of São Luís – MA Original Articles

    Lima, Raina Jansen Cutrim Propp; Batista, Rosângela Fernandes Lucena; Ribeiro, Cecília Claudia Costa; Simões, Vanda Maria Ferreira; Lima Neto, Pedro Martins; Bettiol, Heloisa; Silva, Antônio Augusto Moura da

    Abstract in English:

    ABSTRACT OBJECTIVE: To analyze the effects of early determinants on adolescent fat-free mass. METHODS: A cohort study with 579 adolescents evaluated at birth and adolescence in a birth cohort in São Luís, Maranhão. In the proposed model, estimated by structural equation modeling, socioeconomic status (SES) at birth, maternal age, pregestational body mass index (BMI), gestational smoking, gestational weight gain, type of delivery, gestational age, sex of the newborn, length and weight at birth, adolescent socioeconomic status, “neither study/nor work” generation, adolescent physical activity level and alcohol consumption were tested as early determinants of adolescent fat-free mass (FFM). RESULTS: A higher pregestational BMI resulted in higher FFM in adolescence (Standardized Coefficient, SC = 0.152; p < 0.001). Being female implied a lower FFM in adolescence (SC = −0.633; p < 0.001). The negative effect of gender on FFM was direct (SC = −0.523; p < 0.001), but there was an indirect negative effect via physical activity level (SC = −0.085; p < 0.001). Women were less active (p < 0.001). An increase of 0.5 kg (1 Standard Deviation, SD) in birth weight led to a gain of 0.25 kg/m2 (0.106 SD) in adolescent FFM index (p = 0.034). Not studying or working had a negative effect on the adolescent's FFM (SC = −0.106; p = 0.015). Elevation of 1 SD in the adolescent's physical activity level represented an increase of 0.5 kg/m2 (0.207 SD) in FFM index (p < 0.001). CONCLUSIONS: The early determinants with the greatest effects on adolescent FFM are gender, adolescent physical activity level, pregestational BMI, birth weight and belonging to the “neither-nor” generation.
  • HIV continuum of care among trans women and travestis living in São Paulo, Brazil Original Articles

    Rocha, Aline Borges Moreira da; Barros, Cláudia; Generoso, Igor Prado; Bastos, Francisco I.; Veras, Maria Amélia

    Abstract in English:

    ABSTRACT OBJECTIVE: To examine the HIV care cascade among trans women and travestis in São Paulo – Brazil, the most populous city in South America. METHODS: Using data from a cross-sectional study carried out between November 2016 and May 2017 in the city of São Paulo (Divas Research). Respondent driven sampling (RDS) was used to recruit 386 transgender women and travestis who participated in a HIV risk survey and were tested for HIV. The cascade was defined as HIV prevalence, HIV diagnosed, Antiretroviral (ART) Prescription, and currently on ART. A multiple analysis model was conducted to identify the association between sociodemographics and the cascade gaps. RESULTS: Of the trans women living with HIV, 80.9% were already diagnosed, 76.6% of them had been prescribed, of which 90.3% were currently on treatment. Those who were registered in care had a higher rate of ART (aPR 2.06; 95%CI 1.09-3.88). Trans women between 31-40 years old (aPR 1.65; 95%CI 1.09-2.50) and those older than 40 (aPR 1.59; 95%CI 1.04-2.43) had higher prevalence of ART. CONCLUSIONS: Our data suggest an increase in the testing and treatment policy implementation among trans women in the city of São Paulo, although gaps have been found in the linkage to care. However, young trans women and those not registered in health care service may benefit from efforts to engage this part of the population in care to improve HIV treatment and care outcomes.
  • Cross-cultural adaptation and content validity of leisure attitude measurement for older adults Original Articles

    Castro, Vivian Carla de; Nishida, Fernanda Shizue; Derhun, Flavia Maria; Hungaro, Anai Adario; Silva, Eraldo Schunk; Carreira, Lígia

    Abstract in English:

    ABSTRACT OBJECTIVE: To adapt the Leisure Attitude Measurement to the Brazilian culture and to evaluate the face and content validity of the Brazilian version for older population. METHODS: Methodological study of cross-cultural adaptation in five stages: initial translation; synthesis of translations; back translation; evaluation by a committee of experts using a face and content validity assessment instrument; pre-test with 36 elderly, selected by convenience, with the application of a pre-test evaluation instrument. Data were analyzed descriptively and internal consistency measured by Cronbach's alpha coefficient. RESULTS: Evidenced face and content validity of the adapted version, as well as its equivalence with the original version. In the pretest, the elderly were 71.5 years old on average, 66.7% were women, 47.2% had a stable union, 66.7% lived with family members, 47.2% had 12 or more years of education and 58.3% received two minimum wages or more. The instrument revealed good internal consistency with a coefficient of 0.95 for the total global instrument and 0.88, 0.92 and 0.88 for the cognitive, affective and behavioral domains, respectively. CONCLUSIONS: The instrument's adaptation to the Brazilian culture was successful and allows to assess the attitude of the elderly in relation to leisure in a reliable manner, even though the results are a preliminary version, to be concluded after the psychometric analysis. The instrument could be incorporated in various health fields in Brazil and will allow the production of standardized data, comparison between cultures and strategies to promote positive attitudes towards leisure.
  • Monitoring of oral health teams after National Primary Care Policy 2017 Original Articles

    Lucena, Edson Hilan Gomes de; Lucena, Carolina Dantas Rocha Xavier de; Alemán, Josiane Aparecida de Souza; Pucca Júnior, Gilberto Alfredo; Pereira, Antônio Carlos; Cavalcanti, Yuri Wanderley

    Abstract in Portuguese:

    RESUMO OBJETIVO Realizar um monitoramento do quantitativo de equipes de saúde bucal implantadas na Estratégia Saúde da Família após a Política Nacional de Atenção Básica 2017. METODOLOGIA Estudo de natureza quantitativa, descritiva e analítica que utilizou os dados dos relatórios públicos do histórico de cobertura de saúde bucal disponível na plataforma e-Gestor da Atenção Básica do Ministério da Saúde de todos os municípios brasileiros (5.570). A sobrevida dos municípios que não reduziram o quantitativo de equipes de saúde bucal foi analisada segundo a região do país, índice de desenvolvimento humano, índice de desigualdade de Gini e porte populacional. A regressão de Cox foi utilizada para analisar os fatores associados à diminuição do número de equipes implantadas após 1, 3, 6, 9, 12, 15, 18 e 21 meses da publicação da portaria da política nacional de 2017, considerando-se a hazard ratio (HR) e p < 0,05. RESULTADOS Após 21 meses de publicação da política, 6,7% dos municípios brasileiros reduziram a quantidade de equipes de saúde bucal. Essa redução foi maior nas regiões Sul (6,7%) e Nordeste (4,8%), nos municípios com índice de desenvolvimento humano mais alto, ou seja, maior ou igual a 0,7 (5,6%), mais desiguais quanto à distribuição de renda (índice de Gini > 0,62) e de maior porte populacional (mais de 100.000 habitantes). Municípios das regiões Nordeste (HR = 1,220) e Sul (HR = 1,771) apresentaram maior chance de redução do número de equipes comparados aos da região Norte. Municípios mais desiguais (HR = 6,405) e com maior porte populacional (HR = 4,273) também apresentaram maior chance de reduzir a cobertura de equipes de saúde bucal. CONCLUSÃO Os municípios que reduziram a quantidade de equipes de saúde bucal na Estratégia Saúde da Família são das regiões Sul e Nordeste, com maior desigualdade social e maior porte populacional. Esse cenário pode impactar significativamente o acesso da população aos serviços de saúde bucal do Sistema Único de Saúde, principalmente entre os que mais necessitam.

    Abstract in English:

    ABSTRACT OBJECTIVE To monitor the number of oral health teams implemented in the Family Health Strategy after National Primary Care Policy 2017. METHODS This is a study of quantitative, descriptive and analytical nature that used the data from the public reports of the history of oral health coverage available in the e-Manager platform of Primary Care of the Ministry of Health of all Brazilian municipalities (5,570). The survival rate of the municipalities that did not reduce the number of oral health teams was analyzed according to the region of the country, human development index, Gini inequality index and population size. Cox regression was used to analyze the factors associated with the decrease in the number of teams implanted after 1, 3, 6, 9, 12, 15, 18 and 21 months of publication of the 2017 national policy ordinance, considering the hazard ratio (HR) and p < 0.05. RESULTS After 21 months of publication of the policy, 6.7% of Brazilian municipalities reduced the number of oral health teams. This reduction was higher in the South (6.7%) and Northeast (4.8%), in municipalities with the highest human development index, i.e., greater than or equal to 0.7 (5.6%), more unequal in terms of income distribution (Gini index > 0.62) and larger population size (more than 100,000 inhabitants). Municipalities in the Northeast (HR = 1.220) and South (HR = 1.771) regions had a higher chance of reducing the number of teams compared with those in the North region. More unequal municipalities (HR = 6.405) and with larger population size (HR = 4.273) were also more likely to reduce the coverage of oral health teams. CONCLUSION The municipalities that reduced the number of oral health teams in the Family Health Strategy are from the South and Northeast regions, with greater social inequality and larger population size. This scenario can significantly affect the population’s access to dental health services in the Unified Health System, especially among those in need.
  • Covid-19 and its impact on immunization programs: reflections from Brazil Comments

    Matos, Camila Carvalho de Souza Amorim; Barbieri, Carolina Luísa Alves; Couto, Marcia Thereza

    Abstract in English:

    ABSTRACT Due to social distancing guidelines and the displacement of both human and material resources to fight the covid-19 pandemic, individuals seeking healthcare services face certain challenges. Immunization programs have already been a worrisome topic for health authorities due to declines in vaccine uptake rates and are now especially affected by the covid-19 pandemic. Disbelief in science, dissemination of fake news about vaccines, socioeconomic vulnerability and social inequality are some of the challenges faced. This commentary article discusses the impacts of the covid-19 pandemic on immunization programs in Brazil. In light of advances (and notability) of Brazil's national immunization program, established in the 1970s, the programs face challenges, such as the recent drop in vaccine uptake rates. In addition to this health crisis, there is also Brazil's current political crisis, which will undoubtedly require assistance from researchers, policymakers and society to be fixed.
  • Pandemic and vaccine coverage: challenges of returning to schools Comments

    Sato, Ana Paula Sayuri

    Abstract in Portuguese:

    RESUMO Desde março de 2020, o Brasil enfrenta a pandemia da doença do coronavírus 2019 (covid-19), que modificou intensamente o modo de viver da população e o uso dos serviços de saúde, nos quais o comparecimento presencial caiu drasticamente, inclusive para a vacinação infantil, devido às medidas de distanciamento social para mitigar a transmissão do vírus. Diversos países registraram queda substancial das coberturas vacinais em crianças, especialmente nas menores de dois anos de idade. No Brasil, dados administrativos apontam o impacto da pandemia de covid-19 no agravamento dessa queda, que já constituía um desafio importante do Programa Nacional de Imunizações nos últimos anos. Muitas crianças estarão suscetíveis a doenças imunopreveníveis, o que reforça a necessidade de avaliar a situação vacinal dos escolares antes do retorno às aulas presenciais.

    Abstract in English:

    ABSTRACT Since March 2020, Brazil has faced the pandemic of the coronavirus disease 2019 (Covid-19), which has severely modified the way in which the population lives and uses health services. As such, face-to-face attendance has dropped dramatically, even for child vaccination, due to measures of social distancing to mitigate the transmission of the virus. Several countries have recorded a substantial drop in vaccination coverage in children, especially of those under two years of age. In Brazil, administrative data indicate the impact of the covid-19 pandemic on this downward trend, which was already an important challenge of the National Immunization Program in recent years. Many children will be susceptible to immunopreventable diseases, which reinforces the need to assess the vaccine status of schoolchildren before returning to face-to-face classes.
  • International Classification of Diseases – 11th revision: from design to implementation Comments

    Almeida, Manuella Santos Carneiro; Sousa Filho, Luis Ferreira de; Rabello, Patrícia Moreira; Santiago, Bianca Marques

    Abstract in Portuguese:

    RESUMO A Organização Mundial da Saúde lançou em maio de 2019 a nova Classificação Internacional de Doenças (CID), 11ᵃ revisão. Como contribuição a essa transição, o objetivo deste texto é apresentar as principais mudanças da versão revisada da classificação e indicar os desafios mais prementes. Após 30 anos da publicação da CID-10, identificam-se desafios importantes quanto à nova classificação, que foi apresentada para adoção dos Estados-membros e entrará em vigor em janeiro de 2022. A finalidade da pré-visualização é permitir aos países planejar o uso e treinar seus profissionais. A nova versão é completamente digital, diminuindo assim os erros de notificação e facilitando a divulgação e consolidação da nova versão. A atualização deixa transparecer os avanços da compreensão cientifica e exige dos governos ações estruturantes e eficiência na implementação, para que todos que tratam da assistência possam se comunicar numa mesma linguagem, em escala mundial.

    Abstract in English:

    ABSTRACT The World Health Organization launched in May 2019 the new International Classification of Diseases (ICD), 11th revision. As a contribution to this transition, this article aims to present the main changes of the revised version of the classification and indicate the most pressing challenges. After 30 years of the ICD-10 publication, we identified significant challenges regarding the new classification, which was presented for adoption by several countries and will be in force in January 2022. The purpose of the preview is to allow countries to plan its use and train their professionals. The new version is completely digital, thus reducing notification errors and facilitating the dissemination and consolidation of this new version. The update highlights the advances in scientific understanding, and it demands structural actions and implementation efficiency from governments, so that everyone who deals with assistance can speak the same language, on a global scale.
  • Prevalence of smoking and associated factors in people living with HIV undergoing treatment Original Articles

    Teixeira, Luciane de Souza Leal; Ceccato, Maria das Graças Braga; Carvalho, Wânia da Silva; Costa, Juliana de Oliveira; Bonolo, Palmira de Fátima; Mendes, Jullye Campos; Silveira, Micheline Rosa

    Abstract in Portuguese:

    RESUMEN OBJETIVO: Estimar a prevalência do tabagismo e avaliar os fatores a ele associados em pessoas vivendo com HIV (PVHIV). MÉTODOS: Trata-se de estudo transversal de uma coorte prospectiva concorrente com 462 indivíduos em início de terapia antirretroviral atendidos em três serviços de assistência especializada ao HIV/aids em Belo Horizonte entre 2015 e 2017. Os status de tabagismo utilizados foram: fumante atual (FA), ex-fumante (EF) e não fumante (NF). Realizou-se regressão logística multinomial, sendo NF a categoria de referência. RESULTADOS: A maioria dos participantes eram homens (81,4%), jovens (de até 34 anos; 57,2%) e não brancos (75,7%). Do total de indivíduos, 27,7% eram FA, 22,9% EF, e 49,4% NF. A maioria dos tabagistas eram fumantes leves (65,1%), consumiam até 10 cigarros por dia e fumavam havia mais de 10 anos (63,3%), tendo começado em média aos 17,2 anos de idade (DP = 5,1). Na análise multivariada, maiores chances de ser FA se associaram a: ser do sexo feminino, ter até 9 anos de escolaridade, usar ou já ter usado álcool e drogas ilícitas (maconha, cocaína e crack) e apresentar sinais e/ou sintomas de ansiedade ou depressão. Maiores chances de ser EF se associaram a ter até 9 anos de escolaridade e usar ou já ter usado álcool e drogas e ilícitas (maconha e crack). CONCLUSÕES: Os resultados mostram que o tabagismo é altamente prevalente entre PVHIV, indicando a necessidade de os serviços de assistência especializada em HIV priorizarem intervenções a fim de cessá-lo, com abordagem sobre o uso de álcool e drogas ilícitas, especialmente voltadas para pessoas jovens, com baixa escolaridade e com sinais e/ou sintomas de ansiedade ou depressão.

    Abstract in English:

    ABSTRACT OBJECTIVE: To estimate the prevalence of smoking and evaluate the factors associated with this outcome in people living with HIV (PLHIV). METHODS: This is a cross-sectional study of a prospective concurrent cohort of 462 individuals initiating antiretroviral therapy at three HIV/AIDS specialized services in Belo Horizonte between 2015 and 2017. The following smoking status were used: current smoker (CS), former smoker (FS) and non-smoker (NS). Multinomial logistic regression was performed with NS as the reference category. RESULTS: Most participants were men (81.4%), young (up to 34 years old; 57.2%) and non-white (75.7%). Of the total number of individuals, 27.7% were CS, 22.9% FS, and 49.4% NS. Most smokers were light smokers (65.1%), consumed up to 10 cigarettes per day and had been smoking for more than 10 years (63.3%), starting on average at 17.2 years of age (SD = 5.1). In the multivariate analysis, higher chances of being CS were associated with: being female, having up to 9 years of schooling, current or prior use of alcohol and illicit drugs (marijuana, cocaine and crack) and presenting signs and/or symptoms of anxiety or depression. Higher chances of being FS were associated with having up to 9 years of schooling and current or prior use of alcohol and illicit drugs (marijuana and crack). CONCLUSIONS: The results show that smoking is highly prevalent among PLHIV, indicating the need for HIV specialized services to prioritize smoking cessation interventions. These interventions should consider the use of alcohol and illicit drugs and be targeted especially to young people, those with low schooling and with signs and/or symptoms of anxiety or depression.
  • Risk factors associated with antineoplastic chemotherapy-induced nausea and vomiting Original Articles

    Simino, Giovana Paula Rezende; Reis, Ilka Afonso; Acurcio, Francisco de Assis; Andrade, Eli Iola Gurgel; Brazil, Natalia Maria Linhares; Cherchiglia, Mariângela Leal

    Abstract in Portuguese:

    RESUMO OBJETIVO: Estimar a incidência e avaliar os fatores de risco para náuseas e vômitos induzidos por antineoplásicos com alto e moderado potencial emético em pacientes adultos, no primeiro ciclo de tratamento. MÉTODOS: Estudo de coorte prospectiva, com 269 adultos acompanhados durante o primeiro ciclo de quimioterapia antineoplásica. A incidência de náuseas e vômitos foi avaliada na fase aguda (0–24 horas), na fase tardia (24 horas–5° dia) e na fase total (0–5° dia). RESULTADOS: 152 pacientes foram submetidos a quimioterápico com alto potencial emético e 117 a moderado potencial emético. A frequência relativa de náuseas foi maior quando comparada à de vômitos na fase aguda (p < 0,001) e na fase tardia (p < 0,001). Os fatores de risco identificados foram: faixa etária ≤ 49 anos (odds ratio = 0,47; IC95% 0,23–0,95) e 50–64 anos (odds ratio = 0,45; IC95% 0,23–0,87), uso de tabaco (odds ratio = 0,35; IC95% 0,14–0,88) e alto potencial emético dos quimioterápicos (odds ratio 0,55; IC95% 0,31–0,95). CONCLUSÃO: A incidência de náuseas foi maior do que a de vômitos, e na fase tardia os efeitos adversos foram mais frequentes. Os resultados sugerem que os fatores de risco para náuseas e vômitos induzidos por quimioterapia são o tabaco, a idade (adultos jovens) e o alto potencial emético do quimioterápico.

    Abstract in English:

    ABSTRACT OBJECTIVE: To estimate the incidence and to evaluate risk factors for antineoplastic nausea and vomiting with high and moderate emetogenic chemotherapy in adult patients in the first treatment cycle. METHODS: Prospective cohort study with follow-up of 269 adults during the first cycle of antineoplastic chemotherapy. The incidence of nausea and vomiting was evaluated in the acute phase (0–24 hours), in the late phase (24 hours–5th day) and in the total phase (0–5th day). RESULTS: In total, 152 patients underwent high emetogenic chemotherapy and 117 moderate emetogenic chemotherapy. The relative frequency of nausea was higher when compared with vomiting in the acute phase (p < 0.001) and in the late phase (p < 0.001). The risk factors identified were: age group ≤ 49 years (odds ratio = 0.47; 95%CI 0.23–0.95) and 50–64 years (odds ratio = 0.45; 95%CI 0.23–0.87), tobacco use (odds ratio = 0.35; 95%CI 0.14–0.88), and high emetogenic chemotherapy (odds ratio 0.55; 95%CI 0.31–0.95). CONCLUSION: The incidence of nausea was higher than that of vomiting, and adverse effects were more frequent in the late phase. The results suggest the risk factors for chemotherapy-induced nausea and vomiting are tobacco, age (young adults), and high emetogenic chemotherapy.
  • Bolsa Família program and incomplete childhood vaccination in two Brazilian cohorts Original Articles

    Silva, Francelena de Sousa; Queiroz, Rejane Christine de Sousa; Branco, Maria dos Remédios Freitas Carvalho; Simões, Vanda Maria Ferreira; Barbosa, Yonna Costa; Rodrigues, Marcelo Augusto Ferraz Ruas do Amaral; Barbieri, Marco Antonio; Bettiol, Heloísa; Saraiva, Maria da Conceição Pereira; Scorzafave, Luiz Guilherme; Habenschus, Maria Isabel Accoroni Theodoro; Silva, Antônio Augusto Moura da

    Abstract in Portuguese:

    RESUMEN OBJETIVO: Estimar o efeito de ser beneficiário do Programa Bolsa Família (PBF) na vacinação de crianças de 13 a 35 meses. MÉTODOS: Partiu-se de todos os registros de nascimentos de residentes de Ribeirão Preto (SP) e de amostragem probabilística com ⅓ dos nascimentos de residentes de São Luís (MA), selecionando-se crianças de baixa renda, nascidas em 2010, pertencentes às coortes Brazilian Ribeirão Preto and São Luís Birth Cohort Studies e elegíveis ao PBF. As informações do Cadastro Único (CadÚnico) foram utilizadas para categorizar o recebimento de benefício do PBF (sim ou não). A amostra final foi de 532 crianças em Ribeirão Preto e 1.229 em São Luís. A variável-desfecho foi esquema vacinal infantil, construída com as vacinas BCG, tetravalente, tríplice viral, hepatite B, poliomielite, rotavírus e febre amarela. As variáveis de ajuste foram: classe econômica, escolaridade da mãe e cor de pele da mãe. Consideraram-se elegíveis ao benefício do PBF crianças com renda familiar per capita mensal de até R$ 280,00 e/ou da classe econômica D/E. Para estimar o efeito de ser beneficiário do PBF na vacinação de crianças de baixa renda, construiu-se um modelo teórico por meio de gráfico acíclico direcionado. Nas análises estatísticas, foi usada ponderação pelo inverso da probabilidade de exposição e pareamento por escore de propensão. RESULTADOS: Considerando renda familiar per capita mensal de até R$ 280,00, ser beneficiário do PBF não teve efeito no esquema vacinal infantil, segundo ponderação pelo inverso da probabilidade de exposição (SL-coeficiente: −0,01; IC95% −0,07 a 0,04; p = 0,725 e RP-coeficiente: 0,04; IC95% −0,02 a 0,10; p = 0,244) e pareamento pelo escore de propensão (SL-coeficiente: −0,01; IC95% −0,07 a 0,05; p = 0,744 e RP-coeficiente: 0,04; IC95% −0,02 a 0,10; p = 0,231). CONCLUSÕES: O recebimento do benefício do PBF não exerceu influência sobre a vacinação infantil, que é uma das condicionalidades do programa. Isso pode indicar que essa condicionalidade não está sendo adequadamente acompanhada.

    Abstract in English:

    ABSTRACT OBJECTIVE: To estimate the effect of being a beneficiary of the Bolsa Família Program (BFP) in the vaccination of children aged 13 to 35 months. METHODS: Our study was based on all birth records of residents of Ribeirão Preto (SP) and probabilistic sampling with 1/3 of the births of residents of São Luís (MA), selecting low-income children, born in 2010, belonging to the cohorts Brazilian Ribeirão Preto and São Luís Birth Cohort Studies and eligible for the Bolsa Família program. The information of Cadastro Único (CadÚnico – Single Registry) was used to categorize the receipt of benefit from the BFP (yes or no). The final sample consisted of 532 children in Ribeirão Preto and 1,229 in São Luís. The outcome variable was a childhood vaccine regimen, constructed with BCG, tetravalent, triple viral, hepatitis B, poliomyelitis, rotavirus and yellow fever vaccines. The adjustment variables were: economic class, mother's schooling and mother's skin color. Children with monthly per capita family income of up to R$ 280.00 and/or economic class D/E were considered eligible for the benefit of the BFP. A theoretical model was constructed using a directed acyclic graph to estimate the effect of being a beneficiary of the BFP in the vaccination of low-income children. In the statistical analyses, weighing was used by the inverse of the probability of exposure and pairing by propensity score. RESULTS: Considering a monthly per capita family income of up to R$ 280.00, being a beneficiary of the BFP had no effect on the childhood vaccination schedule, according to weighing by the inverse of the probability of exposure (SL-coefficient: −0.01; 95%CI −0.07 to 0.04; p = 0.725 and RP-coefficient: 0.04; 95%CI −0.02 to 0.10; p = 0.244) and pairing by propensity score (SL-coefficient: −0.01; 95%CI −0.07 to 0.05; p = 0.744 and RP-coefficient: 0.04; 95%CI −0.02 to 0.10; p = 0.231). CONCLUSIONS: The receipt of the benefit of the BFP did not influence childhood vaccination, which is one of the conditionalities of the program. This may indicate that this conditionality is not being adequately monitored.
  • AIDS in men in the city of São Paulo, 1980–2012: spatial and space-time analysis Original Articles

    Pellini, Alessandra Cristina Guedes; Chiaravalloti-Neto, Francisco; Zanetta, Dirce Maria Trevisan

    Abstract in Portuguese:

    RESUMO OBJETIVOS: Identificar aglomerados espaciais e espaço-temporais de altas taxas de incidência de aids em homens residentes no município de São Paulo desde o primeiro caso da doença em 1980. MÉTODOS: As notificações de HIV/aids foram obtidas do Sistema de Informação de Agravos de Notificação (57.440 homens) entre janeiro de 1980 e junho de 2012. Os casos foram geocodificados por endereço de residência; em seguida, análises de varredura puramente espacial, espaço-temporal e de variação espacial nas tendências temporais foram realizadas para três conjuntos de dados: total de casos de aids em homens com 13 anos de idade ou mais, homens com 50 anos ou mais e óbitos por aids. RESULTADOS: Foi possível geocodificar uma expressiva proporção de casos de aids (93,7%). Na análise de varredura puramente espacial, considerando-se todo o período avaliado, a epidemia de aids nos homens apresentou importante concentração espacial no Centro e em áreas contíguas das regiões Norte, Sudeste e Oeste do município, independentemente da faixa etária e da evolução para o óbito (riscos relativos entre 1,22 e 5,90). Levando-se em conta simultaneamente o espaço e o tempo, diversos aglomerados foram encontrados, espalhados por todas as regiões do município (riscos relativos entre 1,44 e 8,61). Na análise da variação espacial nas tendências temporais, os aglomerados nas regiões mais periféricas apresentaram maior incremento percentual anual das taxas da doença (de até 7,58%), denotando a tendência de “periferização” da epidemia nos homens na cidade de São Paulo. CONCLUSÕES: Este estudo permitiu a detecção de aglomerados geográficos de alto risco para a aids nos homens, apontando para áreas prioritárias no município, tanto para ações programáticas como para nortear outros estudos.

    Abstract in English:

    ABSTRACT OBJECTIVES: To identify spatial and space-time clusters with high incidence rates of AIDS in men living in the city of São Paulo since the first case of the disease in 1980. METHODS: HIV/AIDS notifications were obtained from the Notifiable Diseases Information System (57,440 men) between January 1980 and June 2012. The cases were geocoded by residence address; then analyses of purely spatial, space-time and spatial variation in temporal trends were performed for three sets of data: total cases of AIDS in men aged 13 years or older, men aged 50 years or older, and deaths from AIDS. RESULTS: It was possible to geocode a significant proportion of AIDS cases (93.7%). In the purely spatial scanning analysis, considering the entire period evaluated, the AIDS epidemic in men presented an important spatial concentration in the Center and in contiguous areas of the North, Southeast and West regions of the municipality, regardless of age group and evolution to death (relative risks between 1.22 and 5.90). Considering space and time simultaneously, several clusters were found, spread throughout all regions of the municipality (relative risks between 1.44 and 8.61). In the analysis of spatial variation in temporal trends, the clusters in the most peripheral regions presented a higher annual percentage increase in disease rates (up to 7.58%), denoting the tendency of “peripherization” of the epidemic in men in the city of São Paulo. CONCLUSIONS: This study allowed the detection of geographic clusters of high risk for AIDS in men, pointing to priority areas in the municipality, both for programmatic actions and to guide other studies.
  • Nutrition gap in children, urban-rural: the key education and food. Colombia, 2015 Original Articles

    Bermúdez, Jhael N.; Ayala, Daniel; Herrán, Oscar F.

    Abstract in Spanish:

    RESUMEN OBJETIVO: Analizar el estado de nutrición en menores de cinco años de áreas urbanas y rurales en Colombia. MÉTODOS: Estudio analítico, con base en datos de corte transversal, recolectados por la ENSIN-2015. La muestra fue de 12.256 niños colombianos entre cero y cuatro años. Se calcularon razones de prevalencia (RP) y sus respectivos intervalos al 95% de confianza (IC95%). Las RP se obtuvieron de modelos de regresión binomial con el déficit o el exceso, como la variable dependiente y la zona geográfica como la principal explicación. Variables del contexto se utilizaron para ajustar las RP estimadas y limpiar el efecto confusor de éstas. RESULTADOS: La prevalencia de desnutrición aguda (peso/talla) fue de 1,6%, la de exceso de 5,6%. No existieron diferencias por zona geográfica, en el indicador (peso/talla). El retraso talla/edad – desnutrición crónica – fue mayor en la zona rural (RP = 1,2; IC95% 1,00–1,53; p = 0,050). Las prevalencias ajustadas por variables que dan cuenta del desarrollo estructural, social y económico, mostraron que la escolaridad del jefe y la inseguridad alimentaria del hogar explican la desnutrición. CONCLUSIONES: El indicador talla/edad es el mejor para establecer el nivel de desarrollo. Medidas contra la cobertura, pertinencia, calidad en la educación y el acceso a los alimentos impactarán negativamente el estado de nutrición en los niños.

    Abstract in English:

    ABSTRACT OBJECTIVE: To analyze the nutritional situation of children under five years old from both urban and rural areas of Colombia. METHOD: Analytical study, based on cross-sectional data, collected from ENSIN-2015. The sample consisted of 12,256 children aged between 0 and 4 years old. We calculated the prevalence ratios (PR) with their respective 95% confidence interval (95%CI). PR were assessed by binomial regression models with malnutrition or overweight as the dependent variable and geographic area as the explanatory variable. We used context variables to adjust the estimated PR and control the confounder within. RESULTS: Acute malnutrition (weight-for-height) had a prevalence of 1.6%, while overweight had a 5.6% rate. No differences per geographic zone in the weight-for-height indicator were found. Stunted growth – chronic malnutrition – was higher in the rural area (PR = 1.2; 95%CI 1–1.53; p = 0.050). Prevalences adjusted by variables related to structural, social and economic developement showed that both the household chief's educational level and the food insecurity of the area account for malnutrition. CONCLUSION: The height-for-age indicator works better to establish development level. Measures against coverage, relevance and quality of education and access to food can harm the nutritional status of the children.
  • School-based obesity prevention interventions in Latin America: A systematic review Review

    Chavez, Rosemary Cosme; Nam, Eun Woo

    Abstract in English:

    ABSTRACT OBJECTIVE To evaluate the implementation and effectiveness of school-based interventions to prevent obesity conducted in Latin America and provide suggestions for future prevention efforts in countries of the region. METHODS Articles published in English, Spanish, and Portuguese between 2000 and 2017 were searched in four online databases (Google Scholar, PubMed, LILACS, and REDALYC). Inclusion criteria were: studies targeting school-aged children and adolescents (6–18 years old), focusing on preventing obesity in a Latin American country using at least one school-based component, reporting at least one obesity-related outcome, comprising controlled or before-and-after design, and including information on intervention components and/or process. RESULTS Sixteen studies met the inclusion criteria. Most effective interventions (n = 3) had moderate quality and included multi-component school-based programs to promote health education and parental involvement focused on healthy eating and physical activity behaviors. These studies also presented a better study designs, few limitations for execution, and a minimum duration of six months. CONCLUSIONS Evidence-based prevention experiences are important guides for future strategies implemented in the region. Alongside gender differences, an adequate duration, and the combined use of quantitative and qualitative evaluation methods, evidence-based prevention should be considered to provide a clearer and deeper understanding of the true effects of school-based interventions.
  • Sexually transmitted infections in women deprived of liberty in Roraima, Brazil Original Articles

    Benedetti, Maria Soledade Garcia; Nogami, Audrey Stella Akemi; Costa, Beatriz Belo da; Fonsêca, Herbert Iago Feitosa da; Costa, Igor dos Santos; Almeida, Itallo de Souza; Miranda, Luana de; Conchy, Matheus Mychael Mazzaro; Bentes, Renan da Silva; Higa, Suzani Naomi; Israel, Tháles de Souza; Fonseca, Allex Jardim da

    Abstract in Portuguese:

    RESUMO OBJETIVO Avaliar a prevalência de infecção por vírus da imunodeficiência humana (HIV), sífilis e hepatite B entre mulheres privadas de liberdade do estado de Roraima e sua correlação com percepções, conhecimento e fatores comportamentais. MÉTODO Trata-se de estudo de corte transversal, com amostragem sistemática simples, realizado na Cadeia Pública Feminina de Boa Vista, estado de Roraima, no ano de 2017. Foram avaliadas 168 detentas (93,8% da população) por meio de entrevista face a face e testes rápidos. RESULTADOS A prevalência de alguma infecção sexualmente transmissível (IST) foi de 20,2%, sendo 4,7% de HIV, 15,5% de sífilis, e 0,0% de hepatite B. A análise multivariada confirmou como fatores de risco para adquirir uma IST: ter mais de 30 anos de idade [ odds ratio (OR) ajustada: 2,57; IC95% 1,03–6,40); baixa escolaridade (OR ajustada: 2,77; IC95% 1,08–5,05); pouco conhecimento sobre o uso da camisinha (OR ajustada: 2,37; IC95% 1,01–7,31); e achar que não há risco de contrair sífilis (OR ajustada: 2,36; IC95% 1,08–6,50). CONCLUSÃO A população privada de liberdade constitui um grupo de alta vulnerabilidade às IST. A elevada prevalência dessas infecções pode ser explicada por déficits de conhecimento sobre o assunto, percepções distorcidas e condições peculiares ao aprisionamento, que resultam em comportamento de risco. Ressalta-se a necessidade de implantar programas educativos de prevenção, diagnóstico e tratamento de IST para essa população.

    Abstract in English:

    ABSTRACT OBJECTIVE To evaluate the prevalence of HIV, syphilis and hepatitis B infection among women deprived of liberty in the state of Roraima, Brazil, and its correlation with perceptions, knowledge and behavioral factors. METHOD This is a cross-sectional study, with simple systematic sampling, conducted at the Public Female Prison in Boa Vista, State of Roraima, in 2017. A total of 168 inmates (93.8% of the population) were evaluated by in-person interviews and rapid tests. RESULTS The prevalence of sexually transmitted infections (STI) was 20.2%, being 4.7% HIV, 15.5% syphilis, and 0.0% hepatitis B. Multivariate analysis confirmed as risk factors for acquiring an STI: being over 30 years of age [adjusted odds ratio (OR): 2.57; 95%CI 1.03–6.40); low schooling (adjusted OR: 2.77; 95%CI 1.08–5.05); little knowledge about condom use (adjusted OR: 2.37; 95%CI 1.01–7.31); and believing that there is no risk of contracting syphilis (adjusted OR: 2.36; 95%CI 1.08–6.50). CONCLUSION The population deprived of liberty is a group of highly vulnerable to STI. The high prevalence of these infections can be explained by knowledge deficits on the subject, distorted perceptions and conditions peculiar to imprisonment, which result in risky behavior. We emphasize the need to implement educational programs for preventing, diagnosing and treating STI for this population.
  • Intimate partner violence during pregnancy: prevalence and associated factors Original Articles

    Silva, Ranielle de Paula; Leite, Franciéle Marabotti Costa

    Abstract in Portuguese:

    RESUMO OBJETIVO Identificar a prevalência das violências durante a gestação e verificar a associação com as características socioeconômicas, comportamentais e clínicas da gestante. MÉTODOS Estudo transversal em uma maternidade de baixo risco do município de Cariacica, Espírito Santo. Foram entrevistadas 330 puérperas de agosto a outubro de 2017. Informações sobre as características socioeconômicas, comportamentais, reprodutivas e clínicas, assim como experiências de vida, foram coletadas por meio de questionário. Para identificar os tipos de violência, foi utilizado o instrumento da Organização Mundial da Saúde. Foi realizada análise bivariada e multivariada bruta e ajustada por regressão de Poisson com variância robusta. RESULTADOS As prevalências foram 16,1% (IC95% 2,5–20,4) para violência psicológica, 7,6% (IC95% 5,1–11,0) para a física e 2,7% (IC95% 1,4–5,2) para a sexual. A violência psicológica manteve-se associada a idade, renda familiar, início da vida sexual, doença na gravidez, desejo de interromper a gestação e número de parceiros. A violência física esteve associada a escolaridade, início da vida sexual e doença na gravidez. Já a violência sexual manteve-se associada a situação conjugal e desejo de interromper a gestação (p < 0,05). CONCLUSÕES A violência psicológica perpetrada pelo parceiro íntimo foi a de maior prevalência entre as gestantes. Mulheres mais jovens, com menor renda e escolaridade, que iniciaram a vida sexual até os 14 anos e que desejaram interromper a gravidez vivenciaram com maior frequência a violência durante a gestação.

    Abstract in English:

    ABSTRACT OBJECTIVE To identify the prevalence of violence during pregnancy and the association with the socioeconomic, behavioral and clinical characteristics of pregnant women. METHODS Cross-sectional study in a low-risk maternity hospital in the municipality of Cariacica, Espírito Santo. A total of 330 puerperal women were interviewed from August to October 2017. Information on socioeconomic, behavioral, reproductive and clinical characteristics, as well as life experiences, was collected through a questionnaire. To identify the types of violence, the proper World Health Organization instrument was used. Gross bivariate and multivariate analysis was performed and adjusted for Poisson regression with robust variance. RESULTS Prevalence was 16.1% (95%CI 2.5–20.4) for psychological violence, 7.6% (95%CI 5.1–11.0) for physical violence and 2.7% (95%CI 1.4–5.2) for sexual violence. Psychological violence remained associated with age, family income, beginning of sexual life, disease in pregnancy, desire to interrupt pregnancy and number of partners. Physical violence was associated with schooling, beginning of sexual life and disease in pregnancy. Sexual violence remained associated with marital status and desire to interrupt pregnancy (p < 0.05). CONCLUSIONS Psychological violence by an intimate partner was the most prevalent among pregnant women. Women that were younger, had lower income and less schooling, who started their sexual life before the age of 14 and who wished to interrupt pregnancy, experienced violence more frequently during pregnancy.
  • Ultra-processed products industry operating as an interest group Review

    Mariath, Aline Brandão; Martins, Ana Paula Bortoletto

    Abstract in Portuguese:

    RESUMO A participação da indústria de produtos ultraprocessados nos esforços para reduzir a obesidade e doenças crônicas associadas à má alimentação tem sido questionada, sobretudo porque há evidências de sua interferência no processo de formulação de políticas públicas. Este artigo se alicerça na teoria da ação coletiva e na literatura de ciência política para discutir o papel desse setor como um grupo de interesse especial que utiliza seu significativo poder econômico para influenciar decisões governamentais em seu favor. No Brasil, sua atuação ocorre principalmente por meio de associações. Ainda não se pode assegurar, todavia, que seus interesses prevaleçam no processo decisório. Sugere-se a realização de pesquisas que determinem o grau de sucesso de suas ações, identifiquem as condições associadas à convergência dos resultados das políticas com seus interesses e apontem em que medida as organizações da sociedade civil são capazes de fazer os interesses públicos se sobreporem aos privados.

    Abstract in English:

    ABSTRACT The participation of the ultra-processed products industry in efforts to reduce obesity and diet-related non-communicable diseases has been questioned, especially because there is evidence of its interference in policy-making processes. This article builds on the Collective Action Theory and the literature of political science to discuss the role of this sector as a special interest group that uses its significant economic power to influence government decisions in its favor. In Brazil, its participation occurs mainly with industry associations. However, it has not yet been established whether their interests prevail in the decision-making process. It has been suggested that research should be carried out to determine the degree of success of their actions, identifying the conditions associated with the convergence of policy results with their interests and indicating to what extent civil society organizations are able to make public interests override private ones.
  • Notes for the study on health systems: multifaceted analysis and tracer indicators Original Articles

    Onocko-Campos, Rosana Teresa; Campos, Gastão Wagner de Sousa; Amaral, Carlos Eduardo Menezes; Tanaka, Oswaldo Yoshimi

    Abstract in Portuguese:

    RESUMO OBJETIVO Apresentar a abordagem metodológica utilizada em pesquisa que analisou a utilização e o funcionamento da atenção especializada, partindo do acesso via atenção básica, em quatro grandes cidades brasileiras: Fortaleza (CE), Campinas (SP), São Paulo (SP) e Porto Alegre (RS). MÉTODOS Apresentação e discussão dos componentes quanti-qualitativos da estratégia de pesquisa proposta. RESULTADOS Foram estudadas quatro condições traçadoras: hipertensão arterial grave, gravidez de alto risco, câncer de mama e transtorno mental grave. Para cada agravo foram construídos indicadores a partir de dados dos sistemas de informação de saúde destacando frequências, tendência temporal e diferenças por localidade. Essa contextualização inicial foi enriquecida com um estudo descritivo-qualitativo do funcionamento de cada rede municipal de serviços. A seguir, realizou-se um estudo transversal por meio de inquérito com 7.053 usuários dos serviços especializados para cada agravo. Por fim, foram realizadas entrevistas em profundidade com atores-chave para complementar aspectos operacionais selecionados da rede de cada município. Os resultados de todas essas fontes de dados foram triangulados, permitindo explorar a variabilidade das implantações do SUS em diferentes cenários regionais. CONCLUSÕES O modelo analítico multifacetado apresentado permite compreender aspectos relevantes do funcionamento do Sistema Único de Saúde, atentando para as singularidades, heterogeneidades e desigualdades que caracterizam sua implantação no Brasil e destacando o funcionamento das redes locais para os agravos estudados.

    Abstract in English:

    ABSTRACT OBJECTIVE To present the methodological approach used in a research that analyzed the use and performance of specialized health care, from primary care access, in four major Brazilian cities: Fortaleza (CE), Campinas (SP), São Paulo (SP) and Porto Alegre (RS). METHODS Presentation and discussion of the quantitative-qualitative components of the proposed research strategy. RESULTS Four tracing conditions were studied: systemic arterial hypertension, high-risk pregnancy, breast cancer and severe mental disorder. For each health condition, indicators were constructed based on health information systems data, pointing out frequencies, temporal trends and local differences. This initial contextualization was enriched with a descriptive-qualitative study of the performance of each municipal health service network. Next, a cross-sectional study was conducted through a survey of 7,053 users of specialized services for each health condition. Finally, in-depth interviews were conducted with key actors to complement selected operational aspects of each municipality’s network. The results of all these data sources were triangulated, allowing us to explore the variability of SUS implementations in different regional scenarios. CONCLUSIONS The multifaceted analytical model presented allows us to understand relevant aspects of the Unified Health System performance, paying attention to the singularities, heterogeneities and inequalities that characterize its implementation in Brazil and emphasizing the performance of local networks for the addressed health conditions.
  • Who was affected by the shortage of penicillin for syphilis in Rio de Janeiro, 2013–2017? Original Articles

    Araujo, Rachel Sarmeiro; Souza, Ana Sara Semeão de; Braga, José Ueleres

    Abstract in Portuguese:

    RESUMO OBJETIVO Analisar o desabastecimento da penicilina benzatina (PB), caracterizando sua evolução temporal e distribuição espacial no município do Rio de Janeiro de 2013 a 2017. MÉTODOS Trata-se de estudo ecológico misto realizado com notificações de sífilis gestacional e congênita, registros de distribuição de PB e de dados sociodemográficos da população dos bairros do município do Rio de Janeiro. Para mensurar o desabastecimento foi calculado por trimestre um indicador de abastecimento de PB para cada bairro, entre 2013 e 2017. Mapas temáticos foram produzidos para identificar áreas e períodos com maior desabastecimento de PB, o qual foi descrito segundo condições sociodemográficas, rede de serviços de saúde e aspectos epidemiológicos da incidência de sífilis por bairro. RESULTADOS O desabastecimento de PB no município do Rio de Janeiro, no período de 2013 a 2017, não foi homogêneo no espaço ou no tempo. A evolução temporal e a distribuição espacial da escassez de PB revelam que o desabastecimento afetou de formas distintas os habitantes do município, sendo menor em 2013 e 2016 e mais intenso em 2014, 2015 e 2017, principalmente nos bairros das áreas programáticas AP3 e AP5, mais pobres e com maiores taxas de sífilis gestacional e congênita. CONCLUSÕES Analisar o desabastecimento de PB e sua evolução temporal e distribuição espacial no município do Rio de Janeiro permitiu reconhecer que os habitantes do município são afetados de diferentes modos. Compreender esse processo ajuda a planejar ações para enfrentar crises de desabastecimento, minimizando possíveis impactos no controle da sífilis, além de reduzir a desigualdade no acesso ao tratamento.

    Abstract in English:

    ABSTRACT OBJECTIVE To analyze the shortage of benzathine penicillin G (BPG), characterizing its temporal evolution and spatial distribution in the city of Rio de Janeiro from 2013 to 2017. METHODS This ecological study used gestational and congenital syphilis notifications, BPG distribution records, and sociodemographic data from the population of Rio de Janeiro. To quantify the shortage, a BPG supply indicator was estimated per quarter for each neighborhood between 2013 and 2017. Thematic maps were created to identify areas and periods with greater BPG shortage, described according to sociodemographic factors, health services network, and epidemiological features in the incidence of syphilis. RESULTS BPG shortage in Rio de Janeiro from 2013 to 2017 was not homogeneous in space nor in time. The temporal evolution and spatial distribution of BPG scarcity shows that the shortage affected the inhabitants of the municipality in different ways. Shortage was lower in 2013 and 2016 and more severe in 2014, 2015, and 2017, particularly in neighborhoods within the programmatic areas PA3 and PA5, poorer and with higher prevalence rates of gestational and congenital syphilis. CONCLUSIONS Analyzing BPG shortage and its temporal evolution and spatial distribution in Rio de Janeiro allowed us to realize that the inhabitants are affected in different ways. Understanding this process contributes to the planning of actions to face shortage crises, minimizing possible impacts on the management of syphilis and reducing inequality in access to treatment.
  • TB-HIV co-infection: spatial and temporal distribution in the largest Brazilian metropolis Original Articles

    Cavalin, Roberta Figueiredo; Pellini, Alessandra Cristina Guedes; Lemos, Regina Rocha Gomes de; Sato, Ana Paula Sayuri

    Abstract in Portuguese:

    RESUMO OBJETIVO Descrever a distribuição espacial e temporal da coinfecção TB-HIV, assim como o perfil das características da população coinfectada no município de São Paulo. MÉTODOS Estudo ecológico e de série temporal com dados do Sistema de Controle de Pacientes com Tuberculose (TBWeb), incluindo todos os casos novos de tuberculose coinfectados pelo HIV residentes no município no período de 2007 a 2015. Tendências temporais do agravo foram analisadas por regressão de Prais-Winsten. Os casos foram geocodificados pelo endereço de residência para a elaboração de mapas com as taxas de incidência suavizadas pelo método bayesiano empírico local. Os índices de Moran global e local avaliaram a autocorrelação espacial. O perfil dos indivíduos foi descrito e as características dos casos com e sem residência fixa foram comparadas pelos testes de qui-quadrado ou exato de Fisher. RESULTADOS Foram analisados 6.092 casos novos de coinfecção TB-HIV (5.609 com residência fixa e 483 sem residência fixa). A proporção de coinfecção TB-HIV variou de 10,5% a 13,7%, com queda de 3,0% ao ano (IC95% -3,4 – -2,6), e foi maior nos indivíduos sem residência fixa em todo o período. As taxas de incidência apresentaram diminuição de 3,6% ao ano (IC95% -4,4% – -2,7%), declinando de 7,0 para 5,3 por 100 mil habitantes/ano. A coinfecção apresentou autocorrelação espacial positiva e significativa, com padrão espacial heterogêneo e um aglomerado de alto risco na região central do município. A cura foi alcançada em 55,5% dos casos com residência fixa e em 32,7% daqueles sem residência. CONCLUSÕES Os dados indicam um importante avanço no controle da coinfecção TB-HIV no período analisado. Todavia, foram identificadas áreas e populações que se apresentaram desigualmente afetadas pelo agravo, e que devem ser priorizadas no aprimoramento das ações de prevenção e controle da coinfecção.

    Abstract in English:

    ABSTRACT OBJECTIVE To describe the spatial and temporal distribution of TB-HIV co-infection, as well as the profile of the characteristics of the co-infected population in the municipality of São Paulo. METHODS This is an ecological and time series study with data from the Tuberculosis Patient Control System (TBWeb), including all new cases of tuberculosis co-infected individuals with HIV living in the municipality from 2007 to 2015. Time trends of the disease were analyzed using Prais-Winsten regression. The cases were geocoded by the address of residence for the elaboration of maps with the incidence rates smoothed by the local empirical Bayesian method. The global and local Moran indexes evaluated spatial autocorrelation. Individuals’ profiles were described and the characteristics of the cases with and without fixed residence were compared by Pearson’s chi-square or Fisher’s exact tests. RESULTS We analyzed 6,092 new cases of TB-HIV co-infection (5,609 with fixed residence and 483 without fixed residence). The proportion of TB-HIV co-infection ranged from 10.5% to 13.7%, with a drop of 3.0% per year (95%CI -3.4 – -2.6) and was higher in individuals without fixed residence. Incidence rates decreased by 3.6% per year (95%CI -4.4% – -2.7%), declining from 7.0 to 5.3 per 100,000 inhabitants/year. Co-infection showed positive and significant spatial autocorrelation, with heterogeneous spatial pattern and a high-risk cluster in the central region of the municipality. Cure was achieved in 55.5% of cases with fixed residence and in 32.7% of those without a fixed residence. CONCLUSIONS The data indicate an important advance in the control of TB-HIV co-infection in the period analyzed. However, we identified areas and populations that were unequally affected by the disease and that should be prioritized in the improvement of actions to prevent and control co-infection.
  • Nascer no Brasil: continuity of care during pregnancy and postpartum period for women and newborns Original Articles

    Bittencourt, Sonia Duarte de Azevedo; Cunha, Elenice Machado; Domingues, Rosa Maria Soares Madeira; Dias, Barbara Almeida Soares; Dias, Marcos Augusto Bastos; Torres, Jacqueline Alves; Leal, Maria do Carmo

    Abstract in Portuguese:

    RESUMO OBJETIVO Estimar a adequação da linha de cuidado da atenção à saúde durante a gestação e o pós-parto em puérperas e recém-natos usuários do Sistema Único de Saúde e verificar os fatores associados à maior adequação. MÉTODOS Foram utilizados os dados obtidos na entrevista hospitalar, no cartão de pré-natal e na primeira entrevista telefônica de 12.646 mulheres participantes do estudo Nascer no Brasil, realizado em 2011 e 2012. Na primeira etapa da análise, descrevem-se as características sociodemográficas e obstétricas das mulheres e a estimativa de adequação de indicadores de cuidado pré-natal e pós-parto. Na segunda etapa, apresenta-se a cascata de cuidados das ações relativas ao cuidado da mulher e do recém-nascido. Por último, verificam-se os fatores maternos associados à adequação da linha de cuidado, por meio de regressão logística múltipla. RESULTADOS Apenas dois dos quatro indicadores do pré-natal foram considerados satisfatórios: início até a 16ª semana de gestação e número adequado de consultas. Atingiram patamar parcial de adequação a orientação sobre qual maternidade procurar para ter o parto, a orientação para comparecer ao serviço de saúde para realizar a consulta de puerpério e a realização do teste do pezinho. A consulta de puerpério, a primeira consulta de rotina do recém-nascido e o recebimento do teste do pezinho apresentaram adequação insatisfatória. Na análise conjunta dos indicadores que dizem respeito à efetiva utilização dos serviços, apenas 1,5% das mães e seus bebês receberam todos os cuidados em saúde recomendados. Mulheres residentes no Norte, Nordeste e Centro-Oeste, com menor escolaridade e multíparas apresentaram as menores chances de continuidade do cuidado. CONCLUSÕES Os indicadores avaliados sinalizam que quase a totalidade das mulheres e seus filhos apresentaram uma assistência parcial e desarticulada, indicando que a coordenação do cuidado ainda é um desafio na atenção à saúde de mulheres e crianças no período gravídico puerperal.

    Abstract in English:

    ABSTRACT OBJECTIVE To estimate the adequacy of health care during pregnancy and the postpartum period in puerperal women and newborn users of the Unified Health System and verify the factors associated with greater adequacy. METHODS We used data obtained in the hospital interview, the prenatal card and the first telephone interview of 12,646 women participating in the study Nascer no Brasil (Birth in Brazil), conducted in 2011 and 2012. In the first stage of the analysis, the sociodemographic and obstetric characteristics of women and the estimation of adequacy of prenatal and postpartum care indicators are described. In the second stage, the cascade of care for actions related to puerperal women and their newborns is presented. Finally, maternal factors associated with the adequacy of the line of care are verified by means of multiple logistic regression. RESULTS Only two of the four prenatal indicators were considered satisfactory: initiation up to the 16th week of pregnancy and adequate number of appointments. The guidance on which maternity to go for delivery, as well as the guidance to perform the puerperal appointment and the performance of the heel prick test have reached partial level of adequacy. The puerperal appointment, the first routine appointment of the newborn and the obtaining of the heel prick test results presented unsatisfactory adequacy. In the joint analysis of indicators regarding the effective use of services, only 1.5% of mothers and their babies received all recommended health care. Multiparous women living in the North, Northeast and Midwest, with lower schooling, presented the lowest chances of continuity of care. CONCLUSIONS The indicators evaluated indicate that almost all women and their children presented partial and disjointed care, showing that the coordination of care is still a challenge in the health care of women and children in the puerperal pregnancy period.
  • Effect of implementation intention on walking in people with diabetes: an experimental approach Original Articles

    Silva, Marco Antonio Vieira da; São-João, Thaís Moreira; Cornelio, Marilia Estevam; Mialhe, Fábio Luiz

    Abstract in English:

    ABSTRACT OBJECTIVE To evaluate the effect of implementation intentions as an intervention strategy to promote walking in adults with type 2 diabetes mellitus (T2DM). METHODS We conducted a controlled and randomized trial, with 12 months of follow-up, involving 65 people with T2DM recruited from primary health care units and allocated them in the control group (CG, n = 32) and intervention group (IG, n = 33). The IG received the implementation intention strategy to promote walking and the CG remained in follow-up for conventional treatment in primary health care. The researchers were blinded by anthropometric measurements and the filling of the instruments. RESULTS After twelve months of follow up, the IG presented a statistically significant increase in the leisure time physical activity when compared with the CG (p = 0.0413) and showed a significant decrease in waist circumference (p = 0.0061). No significant difference was observed regarding body mass index and glycated hemoglobin among groups. CONCLUSIONS Implementation intention was effective in promoting walking and improving clinical indicators in adults with T2DM.
  • High-risk human papillomavirus infection and associated factors in the anal canal of HIV-positive patients in Medellín, 2017–2018 Original Articles

    Posada, Daniela Herrera; Acevedo, Lucia Stella Tamayo; Arredondo, Marleny Valencia; Vásquez, Gloria Inéz Sánchez

    Abstract in Spanish:

    RESUMEN OBJETIVO Estimar la prevalencia de la infección anal por el virus del papiloma humano de alto riesgo y factores asociados en pacientes con el virus de inmunodeficiencia humana (VIH) de Medellín. MÉTODOS Estudio descriptivo transversal en 300 pacientes VIH positivos, adultos, con historia de relaciones sexuales anales, atendidos en dos instituciones de salud de Medellín 2017-2018. Se aplicó una encuesta estructurada sobre características socio-demográficas, comportamiento sexual y antecedentes clínicos. El VPH se detectó en muestras de exfoliado anal mediante la prueba COBAS 4800. Se realizó análisis exploratorio de factores de riesgo asociados al VPH-AR mediante la prueba Chi cuadrado de independencia y razones de prevalencia cruda y ajustadas por regresión de Poisson, con intervalos del 95%.de confianza. RESULTADOS La prevalencia global de VPHAR fue 82,7%; VPH 16 de 32,7%, VPH 18 de 21,7% y otros tipos 78,3%. La prevalencia de VPHAR en mujeres fue de 68,2% y en hombres, 83,8%. Los factores de riesgo asociados al VPH-AR luego del ajuste fueron tener menos de 30 años, algún grado de educación básica primaria, pareja ocasional e inicio de relaciones sexuales antes de 18 años. CONCLUSIONES La alta frecuencia de infección por VPHAR, así como la existencia de co-infecciones por múltiples tipos en la población de estudio muestra la susceptibilidad que tienen para desarrollar algún grado de Neoplasia Intraepitelial Anal. Es importante establecer programas de promoción de la salud sexual con enfoque de atención primaria.

    Abstract in English:

    ABSTRACT OBJECTIVE To estimate the prevalence of high-risk human papillomavirus (HR-HPV) anal infection and associated factors in human immunodeficiency virus (HIV) positive patients in Medellín. METHODS Descriptive cross-sectional study in 300 HIV-positive patients, adults, with history of anal intercourse, treated in two health care services of Medellín 2017–2018. We conducted a structured survey on sociodemographics, sexual behavior and medical history. HPV was detected in anal swabs tested by the COBAS 4800 system. Exploratory data analysis of risk factors associated with HR-HPV was conducted by chi-square test of independence and both raw and adjusted prevalence ratios used the Poisson regression model, at a 95% confidence interval. RESULTS The high-risk HPV had a prevalence of 82.7%; HPV16 had a prevalence of 32.7%, HPV18 a prevalence of 21.7% and other HPV types scored 78.3%. The high-risk HPV prevalence in women was of 68.2% and 83.8% in men. The risk factors associated with high-risk HPV after adjustment were age under 30 years, elementary education, casual sex partners, and first sexual activity before 18 years old. CONCLUSIONS The high incidence of high-risk HPV, along with the occurrence of coinfections by multiple types in the study population shows their susceptibility to develop some type of anal intra-epithelial neoplasia. It is important to establish sexual health programs focused on primary health care.
  • Zika virus syndrome, lack of environmental policies and risks of worsening by cyanobacteria proliferation in a climate change scenario Brief Communication

    Oliver, Sofia Lizarralde; Ribeiro, Helena

    Abstract in Portuguese:

    RESUMO No Brasil, quase metade da população não tem acesso a coleta e tratamento de esgotos. Os efluentes não tratados, devido a contaminação das águas de reservatórios para abastecimento humano, geram florações de cianobactérias – e esses microrganismos produzem toxinas, como a saxitoxina, uma neurotoxina bastante potente e presente nos reservatórios da região Nordeste. Estudo recente confirmou que a ingestão crônica de água contaminada com neurotoxinas associada a infeção pelo zika vírus em camundongos prenhes poderia levar a desfecho semelhante a microcefalia. Cianobactérias são beneficiadas por tempo quente e matéria orgânica na água, e essas condições estão sendo intensificadas pelas mudanças climáticas, segundo nossos estudos anteriores. Aqui, ressaltamos que, à luz dos novos achados, a arbovirose do zika, associada às mudanças do clima, se amplifica e se agrava, sobretudo em países de média ou baixa renda, com baixos níveis de cobertura de saneamento.

    Abstract in English:

    ABSTRACT Almost half of the Brazilian population has no access to sewage collection and treatment. Untreated effluents discharged in waters of reservoirs for human supply favor the flowering of cyanobacteria – and these microorganisms produce toxins, such as saxitoxin, which is a very potent neurotoxin present in reservoirs in the Northeast region. A recent study confirmed that chronic ingestion of neurotoxin-infected water associated with Zika virus infection could lead to a microcephaly-like outcome in pregnant mice. Cyanobacteria benefit from hot weather and organic matter in water, a condition that has been intensified by climate change, according to our previous studies. Considering the new findings, we emphasize that zika arbovirus is widespread and worsened when associated with climate change, especially in middle- or low-income countries with low levels of sanitation coverage.
  • Covid-19 telescreening in SUS users with risk conditions: case report Brief Communication

    Soares, Daniela Arruda; Medeiros, Danielle Souto; Kochergin, Clavdia Nicolaevna; Cortes, Matheus Lopes; Mistro, Sostenes; Oliveira, Márcio Galvão; Louzado, José Andrade; Bezerra, Vanessa Moraes; Amaro Jr, Edson; Guimarães, Hélio Penna; Silva, Juliede Rosa da; Oliveira, Maria Tânia Silva; Sousa, Jéssica de Oliveira; Carvalho, Vivian Carla Honorato dos Santos de

    Abstract in Portuguese:

    RESUMO O presente relato de experiência tem como objetivo descrever a concepção e os dados preliminares da implementação de um programa de telerrastreio e telemonitoramento da covid-19 para usuários do Sistema Único de Saúde com condições de risco para agravamento. Foi implantado um sistema de telerrastreio por meio do qual estudantes de graduação na área da saúde contactam os pacientes via telefone, conforme periodicidade e critérios predefinidos, para monitorar a evolução do quadro. Em oito semanas, foram realizadas 2.190 tentativas de contato remoto com indivíduos de cinco unidades de saúde. O número efetivo de indivíduos monitorados no momento da escrita deste artigo é de 802.

    Abstract in English:

    ABSTRACT This case report aims to describe the conception and preliminary data of the implementation of a telescreening and telemonitoring program of covid-19 for users of the Unified Health System with risk conditions. A system of telerscreening was implemented through which undergraduate students in the health area contact patients by telephone, according to periodicity and predefined criteria, to monitor the evolution of the condition. In eight weeks, 2,190 attempts at remote contact were made with individuals from five health units. The effective number of individuals monitored at the time this writing is 802.
  • Cost-benefit analysis of pharmacist interventions over 36 months in a university hospital Original Articles

    Cazarim, Maurilio de Souza; Rodrigues, João Paulo Vilela; Calcini, Priscila Santos; Einarson, Thomas R.; Pereira, Leonardo Régis Leira

    Abstract in English:

    ABSTRACT OBJECTIVE: To perform a cost-benefits analysis of a clinical pharmacy (CP) service implemented in a Neurology ward of a tertiary teaching hospital. METHODS: This is a cost-benefit analysis of a single arm, prospective cohort study performed at the adult Neurology Unit over 36 months, which has evaluated the results of a CP service from a hospital and Public Health System (PHS) perspective. The interventions were classified into 14 categories and the costs identified as direct medical costs. The results were analyzed by the total and marginal cost, the benefit-cost ratio (BCR) and the net benefit (NB). RESULTS: The total 334 patients were followed-up and the highest occurrence in 506 interventions was drug introduction (29.0%). The marginal cost for the hospital and avoided cost for PHS was US$182±32 and US$25,536±4,923 per year; and US$0.55 and US$76.4 per patient/year. The BCR and NB were 0.0, -US$26,105 (95%CI −31,850 − –10,610), -US$27,112 (95%CI −33,160–11,720) for the hospital and; 3.0 (95%CI 1.97–4.94), US$51,048 (95%CI 27,645–75,716) and, 4.6 (95%CI 2.24–10.05), US$91,496 (95%CI 34,700–168,050; p < 0.001) for the PHS, both considering adhered and total interventions, respectively. CONCLUSIONS: The CP service was not directly cost-benefit at the hospital perspective, but it presented savings for forecast cost related to the occurrence of preventable morbidities, measuring a good cost-benefit for the PHS.
  • Factors associated with diarrheal disease in the rural Caribbean region of Colombia Original Articles

    Galezzo, Maria-Angelica; Günther, Wanda Maria Risso; Diaz-Quijano, Fredi Alexander; Susa, Manuel Rodriguez

    Abstract in Spanish:

    RESUMEN OBJETIVO: Analizar factores asociados con enfermedad diarreica en área rural del Caribe colombiano. MÉTODO: Estudio transversal en área rural dispersa del departamento del Cesar, Colombia, entre noviembre de 2017 y junio de 2018. Se indagó sobre morbilidad auto-reportada de enfermedad diarreica y se recolectaron y analizaron muestras de agua en 42 domicilios. Fue realizado un análisis descriptivo de condiciones socioeconómicas, ambientales y sanitarias y evaluamos su asociación con enfermedad diarreica mediante modelo robusto de regresión de Poisson. Cada modelo fue ajustado con variables sugeridas por diagramas causales específicos. RESULTADOS: Se evidenciaron condiciones precarias de abastecimiento de agua, higiene y saneamiento básico en la zona de estudio. Todas las muestras de agua se clasificaron entre los niveles de riesgo alto e inviable sanitariamente. La prevalencia de enfermedad diarreica fue 7,5% en todas las edades y 23,5% en niños menores de cinco años. Las variables estación lluviosa (RP = 0,24; IC95% 0,07–0,85), niños menores de cinco años (RP = 4,05; IC95% 1,70–9,68), abastecimiento de agua desde pozo profundo (RP = 16,90; IC95% 2,45–116,67), abastecimiento de agua desde estanco (RP = 11,47; IC95% 1,27–103,29), tenencia de baño (RPA = 0,23; IC95% 0,06–0,96) y presencia de cerdos (RP = 0,20; IC95% 0,05–0,74) mostraron asociaciones estadísticamente significativas con la ocurrencia de enfermedad diarreica. CONCLUSIÓN: Condiciones de abastecimiento de agua, higiene y saneamiento básico estuvieron asociadas con la ocurrencia de enfermedad diarreica, afectando alrededor de un cuarto de la población menor de cinco años. Urge un diseño efectivo de políticas que contribuyan al mejoramiento de condiciones ambientales y saneamiento en áreas rurales.

    Abstract in English:

    ABSTRACT OBJECTIVE: To analyze factors associated with diarrheal disease in the rural Caribbean region of Colombia. METHOD: A cross-sectional study conducted in the rural area of the Cesar Department, Colombia, between November 2017 and June 2018. Self-reported cases of diarrheal disease were surveyed, and water samples from 42 households were collected and analyzed. Descriptive statistics were employed in the analysis of socioeconomic status, environmental and sanitary conditions, and we evaluated their association with the diarrheal disease using the Poisson regression models. Each model was adjusted with variables suggested by specific directed acyclic graphs. RESULTS: Poor water supply conditions, hygiene and basic sanitation were reported in the study area. All water samples were classified either as high risk for health problems or unfit for human consumption. The diarrheal disease had a prevalence of 7.5% across all ages and of 23.5% in children under five years old. The variables rainy season (PR = 0.24; 95%CI 0.07–0.85), children under five years old (PR = 4.05; 95%CI 1.70–9.68), water from deep wells (PR = 16.90; 95%CI 2.45–116.67), water from artificial ponds (PR = 11.47; 95%CI 1.27–103.29), toilets availability (PRA = 0.23; 95%CI 0.06–0.96), and swine presence (PR = 0.20; 95%CI 0.05–0.74) were significantly associated with the occurrence of diarrheal disease. CONCLUSION: Water supply, hygiene and basic sanitation conditions have been associated with the diarrheal disease, affecting almost a quarter of the population under five years old. There is an urge for the design of effective policies that improve environmental and sanitation conditions in rural areas.
  • Erratum Errata

  • Dietary changes in the NutriNet Brasil cohort during the covid-19 pandemic Original Articles

    Steele, Eurídice Martínez; Rauber, Fernanda; Costa, Caroline dos Santos; Leite, Maria Alvim; Gabe, Kamila Tiemann; Louzada, Maria Laura da Costa; Levy, Renata Bertazzi; Monteiro, Carlos Augusto

    Abstract in Portuguese:

    RESUMO OBJETIVO Descrever características da alimentação dos participantes da coorte NutriNet Brasil imediatamente antes e na vigência da pandemia de covid-19. MÉTODOS Os dados deste estudo provêm de coorte de adultos criada para investigar prospectivamente a relação entre alimentação e morbimortalidade por doenças crônicas não transmissíveis no Brasil. Para este estudo, foram selecionados os primeiros participantes (n = 10.116) que responderam por duas vezes a questionário simplificado sobre sua alimentação no dia anterior, a primeira vez ao ingressar no estudo, entre 26 de janeiro e 15 de fevereiro de 2020, e a segunda entre 10 e 19 de maio de 2020. O questionário indaga sobre o consumo de marcadores de alimentação saudável (hortaliças, frutas e leguminosas) e não saudável (alimentos ultraprocessados). Comparações de indicadores baseados no consumo desses marcadores antes e na vigência da pandemia são apresentadas para o conjunto da população estudada e segundo sexo, faixa etária, macrorregião de residência e escolaridade. Testes qui-quadrado e testes t foram utilizados para comparar proporções e médias, respectivamente, adotando-se p < 0,05 para identificar diferenças significantes. RESULTADOS Para o conjunto dos participantes, identificou-se aumento modesto, porém estatisticamente significante, no consumo de marcadores de alimentação saudável e estabilidade no consumo de marcadores de alimentação não saudável. Esse padrão favorável de mudanças na alimentação com a pandemia se repetiu na maior parte dos estratos sociodemográficos. Padrão menos favorável de mudanças, com tendência de aumento no consumo de marcadores de alimentação saudável e não saudável, foi observado nas macrorregiões Nordeste e Norte e entre pessoas com menor escolaridade, sugerindo desigualdades sociais na resposta à pandemia. CONCLUSÕES Caso confirmada, a tendência de aumento no consumo de alimentos ultraprocessados nas regiões economicamente menos desenvolvidas e por pessoas com menor escolaridade preocupa, pois a ingestão desses alimentos eleva o risco de obesidade, hipertensão e diabetes, cuja presença aumenta a gravidade e a letalidade da covid-19.

    Abstract in English:

    ABSTRACT OBJECTIVE To describe the dietary characteristics of participants in the NutriNet Brasil cohort immediately before and during the covid-19 pandemic. METHODS Our data stem from an adult cohort created to prospectively investigate the relationship between diet and morbidity and mortality from chronic non-communicable diseases in Brazil. For this study, we selected the first participants (n = 10,116) who answered twice to a simplified questionnaire on their diet the day before, the first time when entering the study, between January 26 and February 15, 2020, and the second between May 10 and 19, 2020. The questionnaire inquiries about the consumption of healthy (vegetables, fruits and legumes) and unhealthy (ultra-processed foods) eating markers. Comparisons of indicators based on the consumption of these markers before and during the pandemic are presented for the study population and according to gender, age group, macro-region of residence and schooling. Chi-square tests and t-tests were used to compare proportions and means, respectively, adopting p < 0.05 to identify significant differences. RESULTS For all participants, we found a modest but statistically significant increase in the consumption of healthy eating markers and stability in the consumption of unhealthy food markers. This favorable pattern of dietary changes during the pandemic occurred in most sociodemographic strata. We observed a less favorable changing pattern, with a tendency to increasing consumption of healthy and unhealthy food markers, in the Northeast and North macro-regions and among people with less schooling, suggesting social inequalities in the response to the pandemic. CONCLUSIONS If confirmed, the trend of increased consumption of ultra-processed foods in underdeveloped regions and by people with less schooling is concerning, as eating these foods increases the risk of obesity, hypertension and diabetes, whose presence increases the severity and lethality of covid-19.
  • Nutritional profile of ultra-processed foods consumed by children in Rio de Janeiro Original Articles

    Anastácio, Carine de Oliveira Avelar; Oliveira, Juliana Martins; Moraes, Milena Miranda de; Damião, Jorginete de Jesus; Castro, Inês Rugani Ribeiro de

    Abstract in Portuguese:

    RESUMO OBJETIVO Analisar a composição nutricional dos alimentos ultraprocessados consumidos por crianças usuárias de unidades básicas de saúde. MÉTODOS Trata-se de estudo seccional com amostra probabilística representativa de 536 crianças de 6 a 59 meses de idade atendidas em uma unidade de saúde no município do Rio de Janeiro. Informações nutricionais foram extraídas dos rótulos dos alimentos ultraprocessados referidos em recordatório de 24 horas. Os 351 alimentos citados foram divididos em 22 grupos e 38 subgrupos de acordo com o tipo de produto e caracterizados segundo as médias dos valores encontrados para energia, gorduras totais, gorduras saturadas, gorduras trans e sódio em 100 gramas do produto, além de presença, número e tipo de “outros edulcorantes”. Para examinar a ocorrência de excesso de nutrientes críticos, o Modelo de Perfil Nutricional da Organização Pan-Americana da Saúde foi aplicado para cada alimento e para a média dos teores de nutrientes obtida para cada grupo. RESULTADOS Os alimentos ultraprocessados consumidos continham alto valor energético e elevados teores de gorduras totais, gorduras saturadas, gorduras trans e sódio. Do total de alimentos ultraprocessados, 66% apresentaram excesso de pelo menos um nutriente crítico, com destaque para requeijões e queijos ultraprocessados, macarrões instantâneos e carnes industrializadas e embutidos, que apresentaram 100% dos alimentos com excesso de gorduras totais, de gorduras saturadas e de sódio. Dos 21 grupos, extrapolaram o limite estabelecido pela Organização Pan-Americana da Saúde: para gorduras totais, 10 grupos; para gorduras saturadas, 11; para gorduras trans, 3; e para sódio, 13. Requeijões e queijos ultraprocessados; carnes industrializadas e embutidos; e biscoitos superaram esse limite em todos os parâmetros. Do conjunto de alimentos ultraprocessados analisados, 13,4% continham “outros edulcorantes” (oito diferentes tipos). CONCLUSÕES Os AUP analisados apresentaram perfil nutricional desequilibrado e dois terços apresentaram excesso de pelo menos um nutriente crítico. Fazem-se necessárias ações educativas e medidas regulatórias para melhor informar a população e desencorajar o seu consumo.

    Abstract in English:

    ABSTRACT OBJECTIVE To analyze the nutritional composition of ultra-processed foods consumed by children that attend basic health units. METHODS This is a cross-sectional study with a representative probabilistic sample of 536 children aged between 6 and 59 months treated at a health unit in the city of Rio de Janeiro. Nutritional information was extracted from labels of the ultra-processed foods referred to in a 24-hour recall. The 351 foods mentioned were divided into 22 groups and 38 subgroups according to the type of product, and they were characterized according to the averages of the values for energy, total fats, saturated fats, trans fats and sodium in 100 grams of the product, in addition to presence, number, and type of “other sweeteners”. The nutritional Profile Model of the Pan American Health Organization was applied for each food and for the average of nutrient content obtained for each group to examine the occurrence of critical nutrients excess. RESULTS Ultra-processed foods contained high energy value and high levels of total fats, saturated fats, trans fats, and sodium. Out of the total of ultra-processed foods, 66% presented excess of at least one critical nutrient, with emphasis on requeijões and ultra-processed cheeses, instant noodles, and industrialized and sausage-like meats, which presented 100% of foods with excess of total fats, saturated fats and sodium. Out of the 21 groups, the following exceeded the limit established by the Pan American Health Organization: for total fats, 10 groups; for saturated fats, 11; for trans fats, 3; and sodium, 13. Requeijões and ultra-processed cheeses; industrialized and sausage-like meats; and biscuits exceeded this limit in all parameters. Out of the set of ultra-processed foods analyzed, 13.4% contained “other sweeteners” (eight different types). CONCLUSIONS The ultra-processed foods analyzed presented unbalanced nutritional profile, and two thirds presented excess of at least one critical nutrient. Educational actions and regulatory measures are necessary to better inform the population and to discourage its consumption.
  • Factors associated with self-reported exposure to chemical substances at work in Brazil: results from the National Health Survey, 2013 Original Articles

    Assunção, Ada Ávila; Abreu, Mery Natali Silva; Souza, Priscila Sílvia Nunes

    Abstract in Portuguese:

    RESUMO OBJETIVO Descrever os fatores associados e a prevalência de exposição autorrelatada a substâncias químicas no trabalho em uma amostra de adultos brasileiros que participaram da Pesquisa Nacional de Saúde, realizada entre 2013 e 2014. MÉTODOS A amostra para análise da exposição foi constituída por trabalhadores com 18 anos ou mais de idade que responderam à questão E1 do módulo E: “Na semana de 21 a 27 de julho de 2013 (semana de referência), você trabalhou ou estagiou, durante pelo menos uma hora, em alguma atividade remunerada em dinheiro?” Os dados sociodemográficos, situação e comportamentos de saúde foram analisados com regressão logística binária uni e multivariada. O modelo foi ajustado pelas variáveis de todos os blocos, adotando-se o nível de significância de 5%. Obtiveram-se os valores de odds ratio (OR) e respectivos intervalos de confiança. RESULTADOS Mulheres (OR = 0,74; IC95% 0,66–0,82) tiveram menor chance de exposição a substâncias químicas. As maiores chances foram observadas nos grupos com nível fundamental de instrução ou sem instrução (OR = 1,77; IC95% 1,50–2,08), nível médio de instrução (OR = 1,62; IC95% 1,37–1,91), idade entre 25 e 54 anos (OR = 1,26; IC95% 1,07–1,48), fumantes atuais (OR = 1,21; IC95% 1,07–1,37), com problemas de cansaço (OR = 1,35; IC95% 1,21–1,50), com dificuldade auditiva (OR = 1,24; IC95% 1,04–1,48) e que relataram ter sofrido acidente de trabalho (OR = 2,00; IC95% 1,57–2,54). CONCLUSÕES Os resultados inéditos abrangem o conjunto da força de trabalho. Associações positivas com cansaço, dificuldade auditiva, acidentes de trabalho e tabagismo, assim como a associação inversa com o nível de escolaridade, além das diferenças de gênero, são consistentes. A ausência de associação com asma foi surpreendente. A fim de preencher lacunas nas investigações sobre doenças crônicas não transmissíveis em adultos, sugere-se aperfeiçoar o instrumento da Pesquisa Nacional de Saúde na dimensão ocupacional.

    Abstract in English:

    ABSTRACT OBJECTIVE To describe the prevalence of self-reported exposure to chemical substances at work and its associated factors in a sample of Brazilian adults that participated in the National Health Survey, conducted between 2013 and 2014. METHODS Our sample consisted of adults aged 18 years or older that answered question E1 of module E: “In the week of July 21-27, 2013 (reference week), did you work as regular employee or intern for at least an hour in any activity paid with cash?” Sociodemographic data, situation and health behaviors were analyzed with single and multivariate binary logistic regression. The model was adjusted by the variables of all groups, adopting a 5% significance level. The values of odds ratio (OR) and respective confidence intervals were obtained. RESULTS Women (OR = 0.74; 95%CI 0.66–0.82) had a lower chance of exposure to chemicals. The highest chances were observed in groups with no instruction or that attended up to middle-school (OR = 1.77; 95%CI 1.50–2.08), high school (OR = 1.62; 95%CI 1.37–1.91), age between 25 and 54 years (OR = 1.26; 95%CI 1.07–1.48), current smokers (OR = 1.21; 95%CI 1.07–1.37), who reported tiredness (OR = 1.35; 95%CI 1.21–1.50), hearing difficulties (OR = 1.24; 95%CI 1.04–1.48) and who reported having suffered an accident at work (OR = 2.00; 95%CI 1.57–2.54). CONCLUSIONS The unprecedented results cover the entire workforce. Positive associations with hearing loss, smoking and history of work accidents are consistent, as well as the inverse association with education level and gender differences. The absence of association with asthma was surprising. To fill gaps in investigations on chronic non-communicable diseases, we suggested improving the PNS collection instrument in the occupational dimension.
  • Trends in prostate cancer mortality in the state of São Paulo, 2000 to 2015 Original Articles

    Luizaga, Carolina Terra de Moraes; Ribeiro, Karina Braga; Fonseca, Luiz Augusto Marcondes; Eluf Neto, José

    Abstract in Portuguese:

    RESUMO OBJETIVO Estimar a magnitude e identificar padrões de mudança na mortalidade por câncer de próstata no estado de São Paulo e nas 17 redes regionais de atenção à saúde, segundo grupos etários a partir dos 50 anos, no período de 2000 a 2015. MÉTODOS As taxas de mortalidade ajustadas por idade (por 100 mil homens) foram calculadas pelo método direto usando a população mundial de Segi como padrão. A análise de regressão Joinpoint foi utilizada para calcular as variações percentuais anuais médias (AAPC), com intervalo de confiança de 95% (IC95%), por rede regional e grupo etário (50–59, 60–69, 70–79 e 80 anos ou mais). RESULTADOS Para o estado de São Paulo, as taxas ajustadas de mortalidade foram de 15,2, 13,3 e 11,9/100 mil homens, respectivamente, nos períodos de 2000 a 2005, 2006 a 2010 e 2011 a 2015, com tendência de decréscimo significativo (AAPC = -2,10%; IC95% -2,42 – -1,79) a cada ano. Das 17 redes, 11 apresentaram reduções médias anuais significativas, que variaram entre -1,72% e -3,05%. A partir dos 50 anos, verificou-se redução mais acentuada nos grupos de 50 a 59 (AAPC = -2,33%; IC95% -3,04 – -1,62) e 60 a 69 anos (AAPC = -2,84%; IC95% -3,25 – -2,43). CONCLUSÕES Embora as reduções na mortalidade ainda sejam discretas, indicam progresso nas ações de controle do câncer de próstata. Ações de rastreamento e mudanças nas condutas terapêuticas nas últimas décadas podem estar modificando a incidência e a sobrevida, resultando em mudanças no perfil de mortalidade. Estudos mais detalhados serão úteis na compreensão dos fatores que levam às variações inter-regionais encontradas.

    Abstract in English:

    ABSTRACT OBJECTIVE To estimate the magnitude and identify patterns of change in prostate cancer mortality in the state of São Paulo and in the 17 regional health care networks, according to age groups from 50 years onwards, in the period between 2000 to 2015. METHODS Age-adjusted mortality rates (per 100,000 men) were calculated by the direct method using the Segi world population as standard. Joinpoint regression was used to calculate the average annual percent change (AAPC), with a confidence interval of 95% (95%CI), by regional network and age group (50–59, 60–69, 70–79 and 80 years or more). RESULTS For the state of São Paulo, age-adjusted mortality rates were 15.2, 13.3 and 11.9 per 100,000 men, respectively, in the periods between 2000 to 2005, 2006 to 2010 and 2011 to 2015, with a significant decrease trend (AAPC = -2.10%; 95%CI -2.42 – -1.79) each year. Among the 17 networks, 11 presented significant mean annual reductions, ranging from -1.72% to -3.05%. From the age of 50 onwards, there was a sharper reduction in the groups from 50 to 59 (AAPC = -2.33%; 95%CI -3.04 – -1.62) and 60 to 69 years (AAPC = -2.84%; 95%CI – 3.25 – -2.43). CONCLUSION Although reductions in mortality are still slight, they indicate progress in prostate cancer control actions. Screening actions and changes in therapeutic behaviors in recent decades may be modifying incidence and survival, resulting in changes in the mortality profile. More detailed studies will be useful in understanding the factors that lead to the interregional variations found.
  • Recent HIV Infection among men who have sex with men and transgender women in Tijuana Original Articles

    Skaathun, Britt; Pines, Heather A.; Patterson, Thomas L; Semple, Shirley J; Pekar, Jonathan; Harvey-Vera, Alicia; Rangel, Gudelia; Mehta, Sanjay R.

    Abstract in English:

    ABSTRACT OBJECTIVE To characterize recent HIV infections among newly diagnosed men who have sex with men and transgender women in Tijuana. METHODS Limiting Antigen (LAg)-Avidity testing was performed to detect recent HIV infection within a cohort of newly-diagnosed men who have sex with men and transgender women in Tijuana. Logistic regression was used to determine characteristics associated with recent infection. A partial transmission network was inferred using HIV-1 pol sequences. Tamura-Nei 93 genetic distances were measured between all pairs of sequences, and the network was constructed by inferring putative transmission links (genetic distances ≤ 1.5%). We assessed whether recent infection was associated with clustering within the inferred network. RESULTS Recent infection was detected in 11% (22/194) of newly-diagnosed participants. Out of the participants with sequence data, 60% (9/15) with recent infection clustered compared with 31% (43/139) with chronic infection. Two recent infections belonged to the same cluster. In adjusted analyses, recent infection was associated with years of residence in Tijuana (OR = 1.5; 95%CI 1.01–1.09), cocaine use (past month) (OR = 8.50; 95%CI 1.99–28.17), and ever experiencing sexual abuse (OR = 2.85; 95%CI 1.03–7.85). DISCUSSION A total of 11% of men newly diagnosed with HIV who have sex with men and transgender women in Tijuana were recently infected. The general lack of clustering between participants with recent infection suggests continued onward HIV transmission rather than an outbreak within a particular cluster.
  • Potential pregnancy days lost: an innovative measure of gestational age Comments

    Diniz, Carmen Simone G; Reis-Queiroz, Jessica; Kawai, Carlos A.; Queiroz, Marcel Reis; Bonilha, Eliana de Aquino; Niy, Denise Yoshie; Lansk, Sonia; Sena, Brena

    Abstract in Portuguese:

    RESUMO No Brasil, o excesso de intervenções que antecipam o parto, como cesarianas e induções, tem resultado no encurtamento da gestação, com consequências negativas nos desfechos materno-infantis. Neste comentário apresentamos uma medida inovadora da idade gestacional que estamos desenvolvendo: a variável contínua “dias potenciais de gravidez perdidos”. Utilizando dados do Sistema de Informações de Nascidos Vivos, contamos, quando possível, os dias faltantes entre o período até o nascimento e a duração média da gestação (280 dias), ou então as semanas perdidas. Essa medida pode ser usada como variável desfecho (de características socioeconômico-demográficos da mãe, do tipo de parto, de financiamento etc.) ou de exposição (para desfechos neonatais, infantis e maternos). O indicador pode ser usado em coortes municipais e nacionais e em estudos de intervenção, para analisar hospitais e territórios. Discutimos os limites e alcances das medidas de idade gestacional e, diante de suas imprecisões, a importância de estudar suas tendências.

    Abstract in English:

    ABSTRACT In Brazil, the excess of interventions that anticipate childbirth, such as cesarean sections and labor inductions, has resulted in the shortening of pregnancy, with negative consequences on maternal-infant outcomes. This commentary presents a novel way to measure gestational age: the continuous variable “Potential pregnancy days lost.” Using data from the Live Birth Information System (SINASC), we counted the missing days between the period until childbirth and the average duration of pregnancy (280 days), or the lost weeks. This measure can be used as an outcome variable (socioeconomic-demographic characteristics of the mother, type of childbirth, financing, etc.) or exposure variable (for neonatal, infant, and maternal outcomes). The indicator can be used in municipal and national cohorts and intervention studies to analyze hospitals and regions. We discuss the limits and scope of gestational age measures and, given their inaccuracies, the importance of studying their trends.
  • Brazilian public policy for chronic kidney disease prevention: challenges and perspectives Comments

    Silva, Patrícia Aparecida Barbosa; Silva, Líliam Barbosa; Santos, Joseph Fabiano Guimarães; Soares, Sônia Maria

    Abstract in Portuguese:

    RESUMO A doença renal crônica é uma patologia com aumento exponencial em suas prevalências no mundo. Essa tendência tem ocorrido principalmente pelo envelhecimento populacional e crescimento das condições crônicas, o que faz da prevenção um tópico prioritário em saúde pública. Destarte este comentário vem instigar o debate sobre os avanços e desafios nas políticas públicas direcionadas ao enfrentamento da progressão dessa doença e seus fatores de risco em uma realidade contemporânea que requer mudanças nos modelos de gestão das condições crônicas. As experiências brasileira e internacional evidenciam que ações de prevenção da doença renal crônica em grupos de risco ainda são incipientes, especialmente em países de baixa renda. Há necessidade de investimento nessa área, apoiando a planificação do cuidado individualizado, interdisciplinar e compartilhado com a atenção primária à saúde, assim como a responsabilização do usuário pelo seu cuidado, com proatividade e estabelecimento e monitoramento de metas para atingir resultados satisfatórios.

    Abstract in English:

    ABSTRACT Chronic kidney disease is a pathology with exponential increasing prevalence worldwide. This trend derives mainly from population aging and the growth of chronic conditions, making prevention a priority in public health. Thus, this observation instigates debates on the advances and challenges in public policies aimed at facing the progression of this disease and its risk factors in a contemporary reality that requires changes in the management models of chronic conditions. Brazilian and international experiences show that actions to prevent chronic kidney disease in risk groups remain incipient, especially in low-income countries. This area requires investment, supporting planning individualized, interdisciplinary and shared care with primary health care, as well as the user’s responsibility for their care, with proactivity and establishment and monitoring of goals to achieve satisfactory results.
  • Regular use of dental services among university students in southern Brazil Original Articles

    Echeverria, Mariana Silveira; Silva, Alexandre Emidio Ribeiro; Agostini, Bernardo Antônio; Schuch, Helena Silveira; Demarco, Flávio Fernando

    Abstract in Portuguese:

    RESUMO OBJETIVO Verificar a prevalência e os fatores associados ao uso regular de serviços odontológicos em acadêmicos da Universidade Federal de Pelotas (UFPel). MÉTODOS Este estudo transversal entrevistou 1.865 estudantes de 18 anos ou mais de idade, ingressantes em 2017, matriculados no segundo semestre letivo de 2017 e no primeiro de 2018 em cursos presenciais da UFPel. Consideraram-se usuários regulares os indivíduos que relataram ir regularmente ao dentista com ou sem problemas dentários percebidos. A fim de testar fatores associados ao uso regular de serviços odontológicos, foram coletadas variáveis demográficas, socioeconômicas e de saúde bucal. As análises estatísticas foram baseadas em modelos de regressão de Poisson. RESULTADOS A prevalência de uso regular de serviços odontológicos foi de 45,0% (IC95% 42,7–47,3). Os universitários de classe econômica elevada (RP = 1,47; IC95% 0,91–2,36), com última consulta odontológica particular (RP = 1,29; IC95% 1,03–1,61), autopercepção positiva da saúde bucal (RP = 2,33; IC95% 1,79–3,03) e sem relato de dor de dente nos últimos seis meses (RP = 1,22; IC95% 1,03–1,45) apresentaram maiores prevalências de uso regular dos serviços odontológicos. CONCLUSÃO Os resultados apontam para desigualdades no uso regular dos serviços odontológicos relacionadas a fatores socioeconômicos e um menor uso entre os universitários com piores condições de saúde bucal. Esses resultados sugerem que políticas públicas de prevenção e promoção em saúde em instituições de ensino superior devem ser realizadas para garantir qualidade de vida entre esses jovens.

    Abstract in English:

    ABSTRACT OBJECTIVE To verify the prevalence and factors associated with regular use of dental services in university students of the Universidade Federal de Pelotas (UFPel). METHODS This cross-sectional study interviewed 1,865 students aged 18 years or older, starting bachelor’s degrees in 2017, enrolled in the second academic semester of 2017 and in the first of 2018 in classroom courses at UFPel. We considered regular users those who reported regularly going to the dentist with or without perceived dental problems. To test factors associated with regular use of dental services, demographic, socioeconomic and oral health variables were collected. Statistical analyses were based on Poisson regression models. RESULTS The prevalence of regular use of dental services was 45.0% (95%CI 42.7–47.3). University students of high economic class (PR = 1.47; 95%CI 0.91–2.36), with last private dental appointment (PR = 1.29; 95%CI 1.03–1.61), positive self-perception of oral health (PR = 2.33; 95%CI 1.79–3.03) and no report of toothache in the last six months (PR = 1.22; 95%CI 1.03–1.45) showed higher prevalence of regular use of dental services. CONCLUSION The results point to inequalities in the regular use of dental services related to socioeconomic factors and a lower use among university students with worse oral health conditions. These results suggest that public health prevention and promotion policies in higher education institutions must be carried out to ensure quality of life among these young adults.
  • The zero impact of the Vehicle Inspection Program on public health in São Paulo, SP Original Articles

    Araujo, Orlei Ribeiro de; Araujo, Milena Corrêa

    Abstract in Portuguese:

    RESUMO OBJETIVO Analisar o impacto de duas intervenções (introdução e suspensão da inspeção veicular obrigatória) sobre a morbidade e mortalidade por condições associadas à poluição do ar no período de 2008 a 2017. MÉTODOS Séries temporais interrompidas (método Arima), com dados disponíveis em repositórios públicos. RESULTADOS Houve 229.337 internações por doenças respiratórias em crianças até 5 anos de idade, com 1.053 óbitos (coeficiente médio de mortalidade mensal para a população da idade: 1,12/100.000). Para infarto agudo do miocárdio em maiores de 40 anos, houve 137.876 internações, com 19.492 óbitos (3,7/100.000). Para as neoplasias malignas do aparelho respiratório em maiores de 40 anos, foram 11.010 internações, com 2.898 óbitos (0,5/100.000). Para doenças pulmonares obstrutivas crônicas em maiores de 60 anos, foram 20.807 internações, com 2.627 óbitos (1,5/100.000). Para os acidentes vasculares cerebrais, foram 69.180 internações e 10.866 óbitos (2,1/100.000). Não houve nenhum coeficiente de regressão significativo para a introdução ou suspensão do programa em relação às internações e óbitos. Para asma em crianças até 14 anos, houve 38.207 internações e 25 óbitos (0,007/100.000), e os coeficientes mostram aumento de 0,05 óbitos/100.000 pessoas por mês (p = 0,01) no período pós-introdução da inspeção. Em modelo para os poluentes MP2,5 e CO, em estação de monitoramento da região central do município, não houve correlação entre as concentrações medidas e a introdução ou a suspensão da inspeção. CONCLUSÕES Não há evidências de que o programa tenha tido qualquer efeito benéfico mensurável sobre a morbidade e a mortalidade por doenças respiratórias e do aparelho circulatório.

    Abstract in English:

    ABSTRACT OBJECTIVE To analyze the impact of two interventions (implementation and suspension of mandatory vehicle inspection) on morbidity and mortality due to conditions related to air pollution, from 2008 to 2017. METHODS Interrupted time series (ARIMA models), using data available in public repositories. RESULTS A total of 229,337 children of up to 5 years old were hospitalized due to respiratory diseases, and 1,053 died (average monthly mortality ratio for this population: 1.12/100,000). Exact 137,876 individuals over 40 years old were hospitalized for an acute myocardial infarction, and 19,492 died (3.7/100,000). A total of 11,010 individuals over 40 years old were hospitalized with malignant neoplasms of the respiratory system; 2,898 died (0.5/100,000). A total of 20,807 individuals over 60 years old were hospitalized with chronic obstructive pulmonary diseases; 2,627 died (1.5/100,000). As for strokes, 69,180 individuals were hospitalized, and 10,866 died (2.1/100,000). We found no significant regression coefficient for the implementation or suspension of the program regarding hospitalizations and deaths. 38,207 children of up to 14 years old were hospitalized with asthma, and 25 of them died (0.007/100,000). The coefficients show a monthly increase of 0.05 deaths/100,000 people (p = 0.01) in the post-inspection period. We found no correlation between the measured concentrations of the pollutants PM2.5 and CO – in a monitoring station, in the central region of the municipality – and the implementation or suspension of the inspection. CONCLUSIONS No evidence confirms that the program had a measurable beneficial impact on morbidity and mortality due to respiratory and circulatory diseases.
  • Increase in fall-related hospitalization, mortality, and lethality among older adults in Brazil Original Articles

    Stolt, Lígia Raquel Ortiz Gomes; Kolisch, Daniel Vieira; Tanaka, Clarice; Cardoso, Maria Regina Alves; Schmitt, Ana Carolina Basso

    Abstract in Portuguese:

    RESUMO OBJETIVO Estimar as tendências de internação, mortalidade e letalidade por quedas em idosos no Brasil e regiões. MÉTODOS Estudo descritivo realizado a partir de dados do Sistema de Informações Hospitalares do Sistema Único de Saúde. Foram incluídos os registros de todos os idosos, a partir de 60 anos, internados por quedas acidentais entre janeiro de 1998 e novembro de 2015 em todas regiões do Brasil. Foram selecionados os códigos E885, E886, E880, E884, E888 e W01, W03, W10, W17, W18 da Classificação Internacional de Doenças (CID), 9ª e 10ª revisão respectivamente, e calculadas as taxas de internação e mortalidade por quedas por 100.000 habitantes, além da letalidade. Para cálculo de tendências, usou-se o procedimento de Prais-Winsten de autorregressão para análise de séries temporais. RESULTADOS Foram realizadas 1.192.829 internações por quedas no período, ocorreram 54.673 desfechos fatais, e a letalidade foi de 4,5%. As taxas de internação apresentaram tendências crescentes, com sazonalidade, no Brasil e nas regiões Nordeste, Centro-Oeste e Sul (taxas de crescimento de 11%, 44%, 13% e 14%, respectivamente). No Norte, a taxa de internação foi decrescente, e no Sudeste foi estacionária (taxas de crescimento: 48% e 3%). CONCLUSÕES Houve tendência crescente de internações, mortalidade e letalidade por quedas em idosos entre 1998 e 2015 no Brasil, com picos sazonais no segundo e terceiro trimestres. É necessário aprimorar tanto a assistência hospitalar quanto incentivar programas de prevenção de quedas em idosos, visto que estamos em plena transição demográfica.

    Abstract in English:

    ABSTRACT OBJECTIVE To estimate the trends of fall-related hospitalization, mortality, and lethality among older adults in Brazil and regions. METHODS This is a descriptive study based on data from the Hospital Information System of the Brazilian Unified Health System. We included records of every older adult, aged 60 years or older, hospitalized for accidental fall from January, 1998 to November, 2015 in all Brazilian regions. We selected the codes E885, E886, E880, E884, E884 from the International Classification of Diseases, 9th revision, and W01, W03, W10, W17, W18 from the 10th revision, and calculated fall-related hospitalization and mortality rates per 100,000 inhabitants, as well as lethality. To estimate trends, we applied the Prais-Winsten regression for time series analysis. RESULTS During the period, 1,192,829 fall-related hospitalizations occurred, among which 54,673 had a fatal outcome; lethality was 4.5%. Hospitalization rates showed upward trends, with seasonality, in Brazil (11%), and in the Northeast (44%), Midwest (13%), and South regions (14%). The North showed a decreasing hospitalization rate (48%), and the Southeast a stationary one (3%). CONCLUSIONS In Brazil, fall-related hospitalizations, mortality, and lethality among older adults showed an upward trend from 1998 to 2015, with seasonal peaks in the second and third quarters. Considering we are in plain demographic transition, to improve hospital healthcare and encourage falls prevention programs among older adults is essential.
  • Effectiveness of adherence to a renal health program in a health network in Peru Original Articles

    Bravo-Zúñiga, Jessica; Saldarriaga, Enrique M.; Chávez-Gómez, Ricardo; Gálvez-Inga, Jungmei; Valdivia-Vega, Renzo; Villavicencio-Carranza, Mirko; Espejo-Sotelo, José; Rosas, Carola Medina-Sal y; Suarez-Moreno, Víctor; Hurtado-Roca, Yamilee

    Abstract in Spanish:

    RESUMEN OBJETIVO Evaluar la efectividad de la adherencia a un programa de salud renal en la reducción de mortalidad y progresión a hemodiálisis. MÉTODOS Utilizamos una base de datos que condensaba el seguimiento de los pacientes (2013-2017), los ingresos a diálisis de los mismos y la mortalidad por todas las causas en Perú. La adherencia al programa se estableció con el cumplimiento de visitas mínimas durante su primer año de seguimiento. La efectividad de la adherencia al programa se midió en términos de debut a hemodiálisis o muerte por todas las causas. Se utilizaron curvas de Kaplan-Meier, test de diferencias en la distribución (Log-Rank test) y métodos de análisis de supervivencia. Los análisis se realizaron utilizando R estudio 3.5.0 RESULTADOS Fueron evaluados 20.354 participantes, 54,1% varones, edad media de 72,1 años, con un seguimiento medio de 2,2 años; 15.279 (75.1%) tuvieron ERC en estadios tempranos (estadio 1 al 3a). La adherencia disminuyó en un 41,0% el riesgo de terapia de reemplazo renal (HR = 0,59; IC95% 0,41–0,85) en el grupo de bajo riesgo y en un 31,0% (HR = 0,69; IC95% 0,57–0,83) la mortalidad en el grupo de alto riesgo. CONCLUSIONES La estrategia de cuidado multidisciplinario con evaluaciones estandarizadas según estadio es efectiva en reducir el ingreso a terapia de reemplazo renal cuando se identifica al paciente en estadios tempranos y en reducir la mortalidad en estadios avanzados.

    Abstract in English:

    ABSTRACT OBJECTIVE To evaluate the effectiveness of adherence to a multidisciplinary renal health program in reducing mortality and progression to hemodialysis. METHODS We used a database that included patient monitoring (2013-2017), dialysis admissions and all cause of mortality in Peru. Adherence to the program was established by meeting minimum visits during the first year of monitoring. The outcome of interest was hemodialysis admissions or all cause-mortality. Kaplan-Meier curves, Log-Rank test and competing survival analysis methods were used to estimate the differential risk between adherent and non-adherent patients. RESULTS A total of 20,354 participants was evaluated; 54.1% were male, 72.1 years old in average, 2.2 years average follow-up, and 15,279 (75.1%) belonged to the early stages (1 to 3a) of Chronic Kidney Disease. Adherence decreased the risk of renal replacement therapy in 41.0% (HR = 0.59, 95%CI 0.41–0.85) in the low-risk group and mortality in the high-risk group was 31.0% (HR = 0.69, 95%CI 0.57–0.83). CONCLUSIONS The multidisciplinary care strategy with standardized assessments by stage is effective in reducing admission to .0when the patient is identified in early stages and in reducing mortality in advanced stages.
  • Profile of general hospitals in the Unified Health System Original Articles

    Botega, Laura de Almeida; Andrade, Mônica Viegas; Guedes, Gilvan Ramalho

    Abstract in Portuguese:

    RESUMO OBJETIVO Caracterizar a organização dos hospitais gerais brasileiros que prestam serviço ao Sistema Único de Saúde por meio de indicadores que descrevem as principais dimensões do cuidado hospitalar. MÉTODOS Estudo observacional transversal para o ano de 2015, compreendendo o universo dos hospitais gerais que atendem o Sistema Único de Saúde. Os indicadores hospitalares foram construídos a partir de duas bases de dados administrativos nacionais: o Cadastro Nacional de Estabelecimento de Saúde e o Sistema de Informações Hospitalares do Sistema Único de Saúde. Os indicadores contemplam as principais dimensões associadas ao cuidado hospitalar: mix público-privado, produção, fatores de produção, desempenho, qualidade, case-mix e abrangência geográfica. A análise de classes latentes dos indicadores com implementação do bootstrapping foi utilizada para a identificação dos perfis hospitalares. RESULTADOS Foram identificados três perfis, sendo porte hospitalar a variável com grau de pertencimento mais elevado. Os hospitais pequenos apresentam baixas taxas de ocupação (21,36%) e elevada participação de internações que poderiam ter sido solucionadas com cuidado ambulatorial, além de atenderem somente a média complexidade. Recebem poucos não residentes, indicando que estão dedicados praticamente à população local. Os hospitais de médio porte se assemelham mais aos de pequeno porte: cerca de 100% dos atendimentos são de média complexidade, baixa taxa de ocupação (45,81%), elevada taxa de internações por condições sensíveis à atenção primária (17,10%) e relativa importância no atendimento de não residentes (26%). Os hospitais grandes realizam os atendimentos de alta complexidade, têm taxa de ocupação média de 64,73% e apresentam maior abrangência geográfica. CONCLUSÕES Os indicadores apontam três perfis de hospitais, caracterizados principalmente pela escala de produção. Os hospitais de pequeno porte apresentam baixa performance, sugerindo a necessidade de reorganização da oferta do cuidado hospitalar, principalmente no nível municipal. O conjunto dos indicadores propostos inclui as principais dimensões do cuidado hospitalar, fornecendo uma ferramenta que pode ser utilizada no planejamento e monitoramento contínuo da rede hospitalar do Sistema Único de Saúde.

    Abstract in English:

    ABSTRACT OBJECTIVE To characterize the organization of Brazilian general hospitals that provide services to the Unified Health System using indicators that describe the main dimensions of hospital care. METHODS A 2015 cross-sectional observational study, comprising the range of general hospitals that serve the Unified Health System. We constructed the hospital indicators from two national administrative databases: the National Registry of Health Facilities and the Hospital Information System of the Unified Health System. The indicators include the main dimensions associated with hospital care: public-private mix, production, production factors, performance, quality, case-mix and geographic coverage. Latent class analysis of indicators with bootstrapping was used to identify hospital profiles. RESULTS We identified three profiles, with hospital size being the variable with the highest degree of belonging. Small hospitals show low occupancy rates (21.36%) and high participation of hospitalizations that could have been solved with outpatient care, besides attending only medium complexity cases. They receive few non-residents, indicating that they are mainly dedicated to the local population. Medium-sized hospitals are more similar to small-sized ones: about 100% of the visits are of medium complexity, low occupancy rate (45.81%), high rate of hospitalizations for primary care sensitive conditions (17.10%) and relative importance in the healthcare provision of non-residents (26%). Large hospitals provide high complexity care, have an average occupancy rate of 64.73% and show greater geographical coverage. CONCLUSIONS The indicators point to three hospital profiles, characterized mainly by the production scale. Small hospitals show low performance, suggesting the need to reorganize hospital care provision, especially at the municipal level. The set of proposed indicators includes the main dimensions of hospital care, providing a tool that can help to plan and continuously monitor the hospital network of the Unified Health System.
  • Prevalence and factors associated with active transportation to school for adolescents Original Articles

    Camargo, Edina Maria de; Silva, Michael Pereira da; Mota, Jorge; Campos, Wagner de

    Abstract in Portuguese:

    RESUMO OBJETIVO: Verificar a prevalência e os fatores associados ao transporte ativo para a escola em adolescentes brasileiros de escolas públicas. MÉTODOS: Estudo transversal, com amostra representativa de 1.984 adolescentes (55,9% meninas). Os fatores sociodemográficos incluídos foram sexo, idade, escolaridade dos pais e nível socioeconômico. Os fatores psicossociais incluídos foram apoio social dos pais e dos amigos para a atividade física. Foi considerado transporte ativo o ato de caminhar, pedalar ou usar skate no deslocamento para a escola. Modelos de regressão logística binária verificaram a associação dos fatores sociodemográficos e psicossociais ao transporte ativo para a escola adotando p < 0,05. RESULTADOS: A prevalência de transporte ativo para a escola foi de 37,7% (16,2% meninos e 21,5% meninas). Para meninos, o apoio social dos pais ao praticar atividade física junto (RC = 1,57; IC95% 1,09–2,25), transportar para a atividade física (RC = 1,56; IC95% 1,04–2,32) e comentar que o adolescente faz a atividade física bem (RC = 1,73; IC95% 1,08–2,76), assim como o apoio dos amigos ao praticar junto (RC = 2,23; IC95% 1,35–3,69), foram associados ao transporte ativo. Para meninas, a idade (RC = 1,43; IC95% 1,06–1,92) e ter amigos que praticam atividade física junto (RC = 1,48; IC95% 1,04–2,10) aumentaram as chances de transporte ativo para a escola. CONCLUSÃO: A idade e o apoio social para a prática de atividade física foram associados ao transporte ativo para a escola. Pais que praticam junto, transportam e comentam sobre a atividade aumentaram as chances para adolescentes meninos. O apoio social dos amigos para a atividade física aumentou as chances para ambos os sexos.

    Abstract in English:

    ABSTRACT OBJECTIVE: To verify the prevalence and factors associated with active transportation to school (ATS) among Brazilian adolescents attending public schools. METHODS: Crossectional study with a representative sample of 1,984 adolescents (55.9% girls). Sociodemographic variables included were: gender, age, parental schooling, and socioeconomic status. Psychosocial factors included were: social support from parents and friends for physical activity. Walking, cycling, or skateboarding to school were considered models of active transportation. Binary logistic regression models verified sociodemographic and psychosocial factors association with ATS, adopting p < 0.05. RESULTS: The prevalence of active transportation to school was 37.7% (16.2% boys and 21.5% girls). For boys, ATS was associated with: social support from parents in practicing physical activity together as a family (OR = 1.57; 95%CI 1.09–2.25), giving them rides (OR = 1.56; 95%CI 1.04–2.32), and remarking their good performance on it (OR = 1.73; CI95 1.08–2.76); as well as the social support from friends in practicing physical activity together (OR = 2.23; 95%CI 1.35–3.69). For girls, the likelihood of using ATS increased with age (OR = 1.43; 95%CI 1.06–1.92) and having friends who practice physical activity together with them (OR = 1.48, 95%CI 1.04–2.10). CONCLUSION: Age and social support for physical activity were associated with ATS. Parents who practice together, give rides, and remark on physical activities increase the likelihood of adolescent boys using ATS. Social support from friends to physical activity increased the likelihood of both genders using ATS.
  • Choosing a hospital assistance ship to fight the covid-19 pandemic Original Articles

    Costa, Igor Pinheiro de Araújo; Maêda, Sérgio Mitihiro do Nascimento; Teixeira, Luiz Frederico Horácio de Souza de Barros; Gomes, Carlos Francisco Simões; Santos, Marcos dos

    Abstract in Portuguese:

    RESUMO OBJETIVO: Aplicar o método multicritério THOR 2 para selecionar o navio de assistência hospitalar (NAsH) da Marinha do Brasil mais indicado para apoiar o combate à pandemia de covid-19. MÉTODOS: Para a estruturação e modelagem do problema, foram usados os três primeiros estágios da Soft Systems Methodology. Já para a avaliação e ordenação das alternativas, foi utilizado o método de análise multicritério Thor 2, comparando quatro classes de NAsH à luz de seus critérios operativos e hospitalares: “Dr. Montenegro”, “Soares Meirelles”, “Oswaldo Cruz” e “Tenente Maximiano”. O navio escolhido apoiaria o sistema hospitalar do Amazonas, que apresenta número cada vez maior de casos de covid-19. RESULTADOS: Após a aplicação dos métodos, foi possível analisar três cenários distintos de ordenação das alternativas, o que permitiu uma análise de sensibilidade robusta, conferindo maior transparência e confiabilidade ao processo decisório. O NAsH “Oswaldo Cruz” foi selecionado para ser empregado no combate à pandemia. CONCLUSÕES: Este trabalho traz valiosa contribuição para academia e sociedade, uma vez que representa a aplicação de um método de auxílio à decisão multicritério no estado da arte para contribuir com a solução de um problema real que afeta milhões de pessoas no Brasil e no mundo.

    Abstract in English:

    ABSTRACT OBJECTIVE: To apply the THOR 2 multi-criteria support system to select the Brazilian navy's most suitable hospital care vessel (NAsH) to support the fight against the covid-19 pandemic. METHODS: We used the first three stages of the Soft Systems Methodology for structuring and modeling of the problem. For the evaluation and ordering of alternatives, we used the Thor 2 multi-criteria support system, comparing four classes of NAsH in the light of their operational and hospital criteria: “Dr. Montenegro,” “Soares Meirelles,” “Oswaldo Cruz” and “Tenente Maximiano.” The chosen ship would support the amazon hospital system, which has an increasing number of cases of covid-19. RESULTS: After the application of the methods, we analyzed three distinct scenarios of ordering the alternatives, which allowed a robust sensitivity analysis, conferring greater transparency and reliability to the decision-making process. The NAsH “Oswaldo Cruz” was selected to be used in the fight against the pandemic. CONCLUSIONS: This study brings valuable contribution to academia and society, since it represents the application of a multi-criteria decision-aid method in the state of the art to contribute to the solution of a real problem that affects millions of people in Brazil and worldwide.
  • A methodology for apportioning federal SUS resources: the health needs index Original Articles

    Mendes, Áquilas; Leite, Marcel Guedes; Carnut, Leonardo

    Abstract in Portuguese:

    RESUMO OBJETIVO Apresentar o desenvolvimento de uma metodologia de rateio dos recursos da União para os estados no Sistema Único de Saúde, baseada em necessidades de saúde medidas pelas dimensões demográfica, socioeconômica, epidemiológica e geográfica. MÉTODOS A proposta de metodologia de rateio prioriza o eixo necessidades de saúde, baseado na Lei nº 141/2012. Adota-se um proxy de necessidades que dimensiona desigualdades relativas entre condições demográficas, epidemiológicas, socioeconômicas e geográficas das populações dos estados brasileiros para o ano de 2015. Primeiramente, utiliza-se um ajuste para que as populações dos 27 estados sejam corrigidas pela necessidade relativa referente a idade e sexo. Para o cálculo do eixo necessidades de saúde, recorreu-se às técnicas multivariadas de análise de componentes principais e fatorial e, com base na população ajustada pelo fator de correção populacional por idade e sexo para cada estado, aplicou-se o índice de necessidades de saúde. Posteriormente, aplicamos esse índice para simular recursos que deveriam ser repassados pelo Ministério da Saúde aos estados em 2015. RESULTADOS Como metodologicamente decidiu-se pela transferência de um valor per capita único para todos os entes federados, a proposta exige a correção populacional. Assim, na análise por necessidades de saúde, os estados que tiveram sua população corrigida por um fator superior à média nacional, por terem necessidade relativa maior, foram: Maranhão, Piauí, Alagoas, Paraíba, Ceará, Pará, Bahia, Acre, Pernambuco, Rio Grande do Norte, Sergipe, Amazonas, Tocantins e Roraima. No caso da simulação agregando todos os blocos de financiamento, sem reduzir os recursos já distribuídos aos demais estados em 2015, seriam necessários R$ 4,6 bilhões de recursos adicionais. CONCLUSÕES A proposta preenche a ausência de estudos que apresentem simulações quantitativas de distribuição de recursos federais, no âmbito do Sistema Único de Saúde, para os demais entes federados, baseada nos critérios de rateio definidos pela Lei nº 141/2012, de forma a contribuir na redução das desigualdades de saúde e mitigar os efeitos da crise econômica.

    Abstract in English:

    ABSTRACT OBJECTIVE To present a methodology for apportioning Union resources to the federative units (FU – 26 states and one federal district) within the Brazilian Unified Health System (SUS) based on health needs measured by demographic, socioeconomic, epidemiological and geographical dimensions. METHODS The apportionment methodology proposal prioritizes the health needs axis, based on Law 141/2012. We adopted a proxy of needs that measures relative inequalities between, socioeconomic, geographic demographic and epidemiological conditions of the populations of the Brazilian Federative Units (FU) for 2015. We first used an adjustment so that the populations of the 27 FU are corrected by their relative needs regarding age and gender. To calculate the health needs axis, the multivariate techniques factorial analysis and principal components were used, and, based on such correction, we applied the health needs index. Subsequently, this index was applied to simulate the resources that should be transferred by the Ministry of Health to states in 2015. RESULTS As we made the methodological choice of transferring a single per capita amount to all states, so the proposal required population correction. Thus, in the analysis of health needs, the FUs that had their population corrected by a factor higher than the national average because of their greater relative need, were the states of: Maranhão, Piauí, Alagoas, Paraíba, Ceará, Pará, Bahia, Acre, Pernambuco, Rio Grande do Norte, Sergipe, Amazonas, Tocantins and Roraima. For the simulation aggregating all the financing blocks, without reducing the resources already distributed to the remaining states in 2015, indicated the additional need of R$ 4.6 billion. CONCLUSIONS The proposal addresses the absence of studies presenting quantitative simulations of federal resources distribution within the scope of SUS to the FUs, based on the apportionment criteria defined by Law 141/2012, in order to contribute to the reduction health inequalities and mitigate the effects of the economic crisis.
  • Knowledge translation in the reality of Brazilian public health Comments

    Andrade, Keitty Regina Cordeiro de; Pereira, Maurício Gomes

    Abstract in Portuguese:

    RESUMO O termo tradução do conhecimento tem sido utilizado para descrever o processo de aplicar os resultados de pesquisa no mundo real, com o intuito de potencializar a qualidade e a eficácia dos serviços e cuidados de saúde. O objetivo deste artigo é discutir a incorporação da tradução do conhecimento na saúde pública do Brasil. No artigo, aborda-se as atividades básicas da tradução do conhecimento e elenca-se desafios e perspectivas no cenário brasileiro. O Brasil começou a caminhar no entendimento do processo de traduzir o conhecimento científico para a prática. Investir em estudos pilotos para adaptar intervenções efetivas, assim rotuladas em outros países, para o cenário brasileiro pode ser uma alternativa. Aumentar a capacitação de pesquisadores brasileiros no delineamento e avaliação de estudos de implementação é relevante para a melhoria deste campo no País.

    Abstract in English:

    ABSTRACT The term knowledge translation has been used to describe the process of applying research results to the real world, in order to enhance the quality and effectiveness of health care and services. The aim of this article is to discuss the incorporation of knowledge translation in the Brazilian public health. The article addresses the basic activities of knowledge translation and lists challenges and perspectives in Brazilian scenario. Brazil began to move towards understanding the process of translating scientific knowledge into practice. Investing in pilot studies to adapt the so-called effective interventions to the Brazilian scenario may be an alternative. Increasing the qualification of Brazilian researchers in the design and evaluation of implementation studies is relevant to improve this field in the country.
  • Neoliberalism in Latin America: effects on health system reforms Review

    Göttems, Leila Bernarda Donato; Mollo, Maria de Lourdes Rollemberg

    Abstract in Portuguese:

    RESUMO OBJETIVO Analisar as recomendações dos organismos internacionais pautadas no Consenso de Washington para as reformas dos sistemas de saúde de países selecionados da América Latina e Caribe nas décadas de 1980 e 1990 e investigar os efeitos da lógica concorrencial de mercado sobre a ação pública nos sistema de saúde. MÉTODOS Análise comparada de características das reformas dos sistemas de saúde realizadas nas décadas de 1980 e 1990, presentes até o momento no Brasil, Argentina, Chile, Colômbia, México e Peru. Os dados foram coletados por análise documental e revisão de literatura. Os sistemas foram descritos quanto às características de: copagamento, mecanismos de privatização, descentralização, fragmentação do sistema, integração das fontes de financiamento e cobertura da população (universal ou segmentada). RESULTADOS As reformas foram implementadas de forma variada, aprofundando desigualdades nos sistemas de prestação de serviços de saúde. As mudanças, ao serem relacionadas à ideia neoliberal de transformar a ação pública na direção da lógica privada, apontam para o predomínio das regras da concorrência e da redução dos custos econômicos em todos os países analisados, contrariando a lógica dos sistemas universais de saúde. CONCLUSÃO A redução dos custos econômicos, a fragmentação dos sistemas e as desigualdades na prestação de serviços de saúde, entre outros, poderão significar outros custos futuros decorrentes da baixa proteção à saúde da população. É imprescindível uma contrarreforma contundente e multidimensional, que retome a saúde como direito de todos, em um sistema solidário que possa levar à redução das desigualdades e a uma sociedade mais democrática.

    Abstract in English:

    ABSTRACT OBJECTIVE To analyze the recommendations of international organizations based on the Washington Consensus on health system reforms of selected countries in Latin America and the Caribbean in the 1980s and 1990s and to investigate the effects of the competitive market logic on public action in the health system. METHODS Comparative analysis of the characteristics of health system reforms conducted in the 1980s and 1990s, still seen in Brazil, Argentina, Chile, Colombia, Mexico and Peru. Data were collected by documental analysis and literature review. The systems were described based on the characteristics of: co-payment, privatization mechanisms, decentralization, fragmentation of the system, integration of funding sources and coverage of the population (universal or segmented). RESULTS The reforms were implemented differently, worsening inequalities in health service delivery systems. Changes related to the neoliberal idea of transforming public action in the direction of private logic point to the predominance of competition rules and the reduction in economic costs in all countries analyzed, contrary to the logic of universal health systems. CONCLUSION The reduction in economic costs, the fragmentation of systems and inequalities in the provision of health services, among others, may mean other future costs resulting from low protection to the population’s health. A striking and multidimensional counter-reform is essential to make health a right of all again, in a solidarity system that can lead to the reduction in inequalities and a more democratic society.
  • Purchases from family agriculture for school feeding in Brazilian capitals Original Articles

    Dias, Patricia Camacho; Barbosa, Isis Ribeiro de Oliveira; Barbosa, Roseane Moreira Sampaio; Ferreira, Daniele Mendonça; Soares, Kamilla Carla Bertu; Soares, Daniele da Silva Bastos; Henriques, Patrícia; Burlandy, Luciene

    Abstract in Portuguese:

    RESUMO OBJETIVO Analisar como o perfil de compra de alimentos da agricultura familiar no âmbito do Programa Nacional de Alimentação Escolar se relaciona com indicadores socioeconômicos e demográficos nas capitais brasileiras. MÉTODOS Este estudo transversal e descritivo foi baseado em dados secundários de 2016 e 2017 do governo brasileiro. Foram utilizados dados demográficos e socioeconômicos, o valor do recurso repassado pelo governo federal, o percentual utilizado para compras de alimentos da agricultura familiar e as chamadas públicas disponíveis. RESULTADOS As capitais no maior quartil de índice de desenvolvimento humano e de recursos repassados pelo governo federal utilizaram menos de 30% do recurso para a compra de gêneros da agricultura familiar em 2016. Todas as capitais da região Norte utilizaram acima de 30%, enquanto as regiões Sul e Sudeste não atenderam à legislação. Destaca-se a presença majoritária de alimentos in natura nas chamadas públicas analisadas. CONCLUSÕES A execução dessa política pública ocorre de forma desigual nas capitais brasileiras, com maior dificuldade naquelas supostamente com melhor estrutura institucional e maior volume de recursos destinados ao Programa Nacional de Alimentação Escolar, contudo, o programa mantém seu potencial para a promoção da alimentação adequada e saudável nas escolas, em razão da qualidade dos alimentos incluídos nas chamadas públicas.

    Abstract in English:

    ABSTRACT OBJECTIVE To analyze how the profile of food purchases from family farming under the National School Feeding Program (PNAE) is related to socioeconomic and demographic indicators in Brazilian capitals. METHODS This cross-sectional and descriptive study was based on secondary data from 2016 and 2017 from the Brazilian government. We used demographic and socioeconomic data, as well as the amount of federal funding; the percentage used purchases of food from family farming and the public call notices. RESULTS The capitals in the largest quartile of HDI and funding by the federal government used less than 30% of the resource for the purchase of crops from family farming in 2016. All capitals of the Northern region used more than 30%, while the Southern and Southeastern regions did not comply with the legislation. We highlight that most analyzed food items were in natura. CONCLUSIONS The implementation of this public policy occurs unequally in Brazilian capitals, with greater difficulty in those supposedly with better institutional structure and higher volume of resources destined to the National School Feeding Program. The program, however, maintains its potential for the promotion of adequate and healthy food in schools, due to the quality of food included in public calls.
  • Food processing and cardiometabolic risk factors: a systematic review Review

    Santos, Francine Silva dos; Dias, Mariane da Silva; Mintem, Gicele Costa; Oliveira, Isabel Oliveira de; Gigante, Denise Petrucci

    Abstract in Portuguese:

    RESUMO OBJETIVO Revisar sistematicamente as evidências da associação entre consumo de alimentos de acordo com o processamento e fatores cardiometabólicos em adultos e idosos. MÉTODOS Dois avaliadores independentes analisaram as bases de dados eletrônicas PubMed, Web of Science e Lilacs até dezembro de 2018. Os seguintes termos foram utilizados: (convenience foods OR food processing OR highly-processed OR industrialized foods OR minimally-processed OR prepared foods OR processed foods OR ultra-processed OR ultraprocessed OR ultra processed OR unprocessed) AND (metabolic syndrome OR hypertension OR blood pressure OR diabetes mellitus OR glucose OR glycaemia OR insulin OR cholesterol OR triglycerides OR blood lipids OR overweight OR obesity) AND (adult OR adults OR adulthood OR aged OR elderly OR old). Nos estudos incluídos foram avaliadas as qualidades metodológica e de evidência, além de extraídas informações para a síntese qualitativa. RESULTADOS Dos 6.423 estudos identificados após a remoção das duplicatas, onze preencheram os critérios de elegibilidade. A principal classificação de alimentos utilizada foi a Nova. O consumo de alimentos ultraprocessados foi positivamente associado com excesso de peso e obesidade, hipertensão arterial e síndrome metabólica. Todos os artigos incluídos preencheram mais de 50% dos critérios de qualidade metodológica. A qualidade de evidência foi considerada moderada para o desfecho excesso de peso e obesidade e fraca para hipertensão arterial e síndrome metabólica. CONCLUSÕES A classificação de alimentos Nova se destaca na área da epidemiologia nutricional ao avaliar os efeitos do processamento de alimentos sobre desfechos em saúde. Embora seja necessária prudência na interpretação, os resultados indicam que o consumo de alimentos ultraprocessados pode ter impacto desfavorável sobre a saúde dos indivíduos.

    Abstract in English:

    ABSTRACT OBJECTIVE To systematically review the evidence for the association between food consumption according to processing and cardiometabolic factors in adults and/or the elderly. METHOD Two independent evaluators analyzed the electronic databases PubMed, Web of Science and Lilacs until December 2018. We used the following terms: (convenience foods OR food processing OR highly-processed OR industrialized foods OR minimally-processed OR prepared foods OR processed foods OR ultra-processed OR ultraprocessed OR ultra processed OR unprocessed) AND (metabolic syndrome OR hypertension OR blood pressure OR diabetes mellitus OR glucose OR glycaemia OR insulin OR cholesterol OR triglycerides OR blood lipids OR overweight OR obesity) AND (adult OR adults OR adulthood OR aged OR elderly OR old). We assessed methodological and evidence qualities, and also extracted information for the qualitative synthesis from the selected studies. RESULTS Of the 6,423 studies identified after removing duplicates, eleven met the eligibility criteria. The main food classification we used was Nova. The consumption of ultra-processed foods was positively associated with overweight and obesity, high blood pressure and metabolic syndrome. All articles included met more than 50% of the methodological quality criteria. The quality of evidence was considered moderate for the outcome overweight and obesity and weak for hypertension and metabolic syndrome. CONCLUSIONS The Nova food classification stands out in the area of nutritional epidemiology when assessing the effects of food processing on health outcomes. Although caution is required in the interpretation, the results indicated that the consumption of ultra-processed foods can have an unfavorable impact in the health of individuals.
  • Social distancing patterns in nine municipalities of Rio Grande do Sul, Brazil: the Epicovid19/RS study Original Articles

    Barros, Aluisio J D; Victora, Cesar G; Menezes, Ana M B; Horta, Bernardo L; Hartwig, Fernando; Victora, Gabriel; Pellanda, Lúcia C; Dellagostin, Odir A; Struchiner, Claudio J; Burattini, Marcelo N; Gonçalves, Marcelo R; Possuelo, Lia G; Weber, Liliana P; Estima, Sonara Lucia; Jacques, Nadège; Härter, Jenifer; Silva, Shana G; Frizzo, Matias; Lima, Rosangela C; Barros, Fernando C; Silveira, Mariângela F; Hallal, Pedro C

    Abstract in Portuguese:

    RESUMO OBJETIVO Descrever práticas de distanciamento social em nove municípios do Rio Grande do Sul por sexo, idade, escolaridade e cidade. MÉTODOS Foram realizados dois estudos transversais sequenciais representativos da população urbana nos municípios de Canoas, Caxias do Sul, Ijuí, Passo Fundo, Pelotas, Porto Alegre, Santa Cruz do Sul, Santa Maria e Uruguaiana com o intuito de estimar a prevalência populacional de Covid-19. Foi aplicado questionário contendo três perguntas sobre distanciamento social, cujas práticas foram submetidas a análises descritivas por subgrupos. Os dados foram comparados por testes qui-quadrado. RESULTADOS Em termos de grau de distanciamento social, 25,8% dos entrevistados relataram estar praticamente isolados e 41,1% indicam praticar bastante distanciamento. Relataram ficar em casa o tempo todo 20,1% dos entrevistados, e 44,5% informam que saem apenas para atividades essenciais. Mais da metade dos domicílios não recebe visitas de não moradores. O grupo que relatou menos distanciamento social foi o de adultos entre 20 e 59 anos, enquanto mais de 80% dos entrevistados com 60 anos ou mais relataram estar praticamente isolados ou fazendo bastante distanciamento. As mulheres relataram fazer mais distanciamento que os homens, e os grupos de maior escolaridade foram os que relataram sair diariamente para atividades regulares com mais frequência. CONCLUSÕES Os grupos mais jovens e mais idosos estão mais protegidos pelo distanciamento social, mas há grupos bastante expostos, o que pode ser um limitador importante no controle da progressão da epidemia de Covid-19.

    Abstract in English:

    ABSTRACT OBJECTIVE To describe social distancing practices in nine municipalities of the state of Rio Grande do Sul, Brazil, stratified by gender, age, and educational attainment. METHODS Two sequential cross-sectional studies were conducted in the municipalities of Canoas, Caxias do Sul, Ijuí, Passo Fundo, Pelotas, Porto Alegre, Santa Cruz do Sul, Santa Maria, and Uruguaiana to estimate the population prevalence of COVID-19. The study was designed to be representative of the urban population of these municipalities. A questionnaire including three questions about social distancing was also administered to the participants. Here, we present descriptive analyses of social distancing practices by subgroups and use chi-square tests for comparisons. RESULTS In terms of degree of social distancing, 25.8% of the interviewees reported being essentially isolated and 41.1% reported being quite isolated. 20.1% of respondents reported staying at home all the time, while 44.5% left only for essential activities. More than half of households reported receiving no visits from non-residents. Adults aged 20 to 59 reported the least social distancing, while more than 80% of participants aged 60 years or older reported being essentially isolated or quite isolated. Women reported more stringent distancing than men. Groups with higher educational attainment reported going out for daily activities more frequently. CONCLUSIONS The extremes of age are more protected by social distancing, but some groups remain highly exposed. This can be an important limiting factor in controlling progression of the COVID-19 pandemic.
  • Factors associated with low birthweight: a case-control study in a city of Minas Gerais Original Articles

    Defilipo, Érica Cesário; Chagas, Paula Silva de Carvalho; Peraro-Nascimento, Andreia; Ribeiro, Luiz Cláudio

    Abstract in Portuguese:

    RESUMO OBJETIVO Analisar os fatores socioeconômicos, demográficos, ambientais, reprodutivos, comportamentais, de assistência à saúde, doenças maternas e, sobretudo, o possível impacto do desastre ambiental ocorrido em Mariana, pela exposição pré-natal a diferentes fontes de água para consumo humano, associados ao baixo peso ao nascer em nascidos vivos a termo no Hospital Municipal de Governador Valadares, Minas Gerais. MÉTODOS Estudo caso-controle, realizado com nascidos vivos no Hospital Municipal de Governador Valadares, no período de maio de 2017 a julho de 2018. O grupo caso foi composto por nascidos vivos a termo e baixo peso ao nascer e o grupo controle, por nascidos vivos a termo e com peso adequado, pareados por sexo e data de nascimento. Para cada caso foram selecionados dois controles. A coleta de dados foi realizada por meio de entrevista com as puérperas e informações complementares foram obtidas pela análise do cartão de pré-natal e prontuários. Para análise dos dados, foi realizada regressão logística. RESULTADOS Participaram do estudo 65 nascidos vivos pertencentes ao grupo caso e 130 ao grupo controle. Após a análise ajustada para os demais fatores em estudo, verificou-se que os riscos mais elevados de baixo peso ao nascer estão associados aos primeiros filhos (RC = 2,033; IC95% = 1,047–3,948; p = 0,036) e aos nascidos vivos cujas mães utilizaram cigarro durante a gestação (RC = 2,850; IC95% = 1,013–8,021; p = 0,047) e consumiram a água fornecida pelos serviços de abastecimento dos municípios atingidos pelos rejeitos provenientes do rompimento da barragem de Fundão (RC = 2,444; IC95% = 1,203–4,965; p = 0,013). CONCLUSÕES A água consumida na gestação, primiparidade e tabagismo materno apresentaram associação com baixo peso ao nascer na população estudada. Reforça-se a importância de estudos epidemiológicos, que avaliem a qualidade da água e seus efeitos adversos na saúde, assim como maior controle no pré-natal das gestantes que terão o primeiro filho e maior apoio das políticas contra o tabagismo, especialmente durante a gravidez.

    Abstract in English:

    ABSTRACT OBJECTIVE To analyze the many factors regarding socioeconomic and healthcare-related variables linked to maternal diseases and the possible impact of the environmental disaster of Mariana, given the prenatal exposure to different water sources for human consumption that were associated with low birthweight in full-term live births in the Municipal Hospital of Governador Valadares, Minas Gerais. METHODS Case-control study, carried out with live births at the Municipal Hospital of Governador Valadares, from May 2017 to July 2018. The case group consisted of full-term live births and low birthweight, and the control group consisted of full-term live births with adequate weight, matched by gender and date of birth. For each case, two controls were selected. Data collection was performed through interviews with the puerperal women, and complementary information was obtained by analyzing the prenatal card and medical records. For data analysis, logistic regression was performed. RESULTS The study included 65 live births from the case group and 130 from the control group. After the analysis was adjusted for other factors under study, we found that the higher risks of low birthweight are associated with the first childbirth (OR = 2.033; 95%CI = 1.047–3.948; p = 0.036), smoking during pregnancy (OR = 2.850; 95%CI = 1.013–8.021; p = 0.047) and consumption of water supplied by the municipalities affected by the tailings from the Fundão dam failure (RC = 2.444; 95%CI = 1.203–4.965; p = 0.013). CONCLUSIONS The variables “water consumed during pregnancy,” “previous pregnancies” and “maternal smoking” were associated with low birthweight in the population studied. The importance of epidemiological studies that assess water quality and its adverse health effects is reinforced, as well as greater prenatal control of first-time pregnant women and greater support of policies against smoking, especially during pregnancy.
  • Seroprevalence of anti-SARS-CoV-2 among blood donors in Rio de Janeiro, Brazil Original Articles

    Amorim Filho, Luiz; Szwarcwald, Célia Landmann; Mateos, Sheila de Oliveira Garcia; Leon, Antonio Carlos Monteiro Ponce de; Medronho, Roberto de Andrade; Veloso, Valdiléa Gonçalves; Lopes, Josiane Iole França; Porto, Luis Cristovão de Moraes Sobrino; Chieppe, Alexandre; Werneck, Guilherme Loureiro

    Abstract in English:

    ABSTRACT OBJECTIVE To estimate the seroprevalence of antibodies to SARS-CoV-2 among blood donors in the state of Rio de Janeiro, Brazil. METHODS Data were collected on 2,857 blood donors from April 14 to 27, 2020. This study reports crude prevalence of antibodies to SARS-CoV-2, population weighted prevalence for the state, and prevalence adjusted for test sensitivity and specificity. Logistic regression models were used to establish the correlates of SARS-CoV-2 prevalence. For the analysis, we considered collection period and site, sociodemographic characteristics, and place of residence. RESULTS The proportion of positive tests for SARS-Cov-2, without any adjustment, was 4.0% (95%CI 3.3–4.7%), and the weighted prevalence was 3.8% (95%CI 3.1–4.5%). We found lower estimates after adjusting for test sensitivity and specificity: 3.6% (95%CI 2.7–4.4%) for the non-weighted prevalence, and 3.3% (95%CI 2.6–4.1%) for the weighted prevalence. Collection period was the variable most significantly associated with crude prevalence: the later the period, the higher the prevalence. Regarding sociodemographic characteristics, the younger the blood donor, the higher the prevalence, and the lower the education level, the higher the odds of testing positive for SARS-Cov-2 antibody. We found similar results for weighted prevalence. CONCLUSIONS Our findings comply with some basic premises: the increasing trend over time, as the epidemic curve in the state is still on the rise; and the higher prevalence among both the youngest, for moving around more than older age groups, and the less educated, for encountering more difficulties in following social distancing recommendations. Despite the study limitations, we may infer that Rio de Janeiro is far from reaching the required levels of herd immunity against SARS-CoV-2.
  • Primum non nocere – Are chloroquine and hydroxychloroquine safe prophylactic/treatment options for SARS-CoV-2 (covid-19)? Comments

    Biguetti, Claudia; Marrelli, Mauro Toledo; Brotto, Marco

    Abstract in English:

    ABSTRACT Chloroquine (CQ) and its analog hydroxychloroquine (HCQ) were recently included in several clinical trials as potential prophylactic and therapeutic options for SARS-COV-2 infection/covid-19. However, drug effectiveness in preventing, treating, or slowing the progression of the disease is still unknown. Despite some initial promising in vitro results, rigorous pre-clinical animal studies and randomized clinical trials have not been performed yet. On the other hand, while the potential effectiveness of CQ/HCQ is, at best, hypothetical, their side effects are factual and most worrisome, particularly when considering vulnerable groups of patients being treated with these drugs. in this comment, we briefly explain the possible mechanisms of action of CQ/HCQ for treating other diseases, possible actions against covid-19, and their potent side effects, in order to reinforce the necessity of evaluating the benefit-risk balance when widely prescribing these drugs for SARS-COV-2 infection/covid-19. We conclude by strongly recommending against their indiscriminate use.
  • Factors associated with tuberculosis in persons deprived of liberty in Espírito Santo Original Articles

    Macedo, Laylla Ribeiro; Maciel, Ethel Leonor Noia; Struchiner, Claudio Jose

    Abstract in Portuguese:

    RESUMO OBJETIVOS Calcular a taxa de casos diagnosticados com tuberculose por unidades prisionais do Espírito Santo, apresentar as características individuais, clínicas e institucionais dos casos na população privada de liberdade (PPL) do ES e analisar a associação entre essas características e o encerramento do tratamento da tuberculose nessa população. MÉTODOS A população de estudo foram os casos de tuberculose na PPL do ES de 2014 a 2016. Realizou-se o cálculo de taxa, a análise descritiva e a regressão logística hierarquizada considerando os níveis individual, clínico e institucional. RESULTADOS A taxa de casos diagnosticados por unidade prisional no estado variou de 0 a 17,3 casos por 1.000 presos. Do total de casos notificados, 218 (72,6%) se curaram, 21 (7,0%) abandonaram o tratamento, 1 (0,3%) morreu por tuberculose, 2 (0,7%) morreram por outras causas, 56 (18,7%) transferiram o local de tratamento e 2 (0,7%) desenvolveram tuberculose drogarresistente. A análise ajustada mostrou que o tratamento supervisionado é um fator protetor para o insucesso (RC = 0,29; IC95% 0,01–0,76). CONCLUSÕES O estudo apontou a importância do conhecimento do desfecho do tratamento da TB na PPL visando à implementação de ações para a redução do insucesso, bem como a contribuição do tratamento supervisionado nesse processo.

    Abstract in English:

    ABSTRACT OBJECTIVES To calculate the rate of tuberculosis cases per prison unit in Espírito Santo; present the individual, clinical, and institutional characteristics of the cases in persons deprived of liberty (PPL); and analyze the association between these characteristics and treatment outcome in this population. METHODS The study included cases of tuberculosis in the PPL of Espírito Santo from 2014 to 2016. Rate calculation, descriptive analysis and hierarchical logistic regression were performed considering the individual, clinical and institutional levels. RESULTS The rate of diagnosed cases per prison unit in the state ranged from 0 to 17.3 cases per 1,000 inmates. Of all reported cases, 218 (72.6%) healed, 21 (7.0%) dropped out, 1 (0.3%) died of tuberculosis, 2 (0.7%) died from other causes, 56 (18.7%) transferred the treatment site and 2 (0.7%) developed drug-resistant tuberculosis. The adjusted analysis showed that supervised treatment ensures success (CR = 0.29; 95%CI 0.01–0.76). CONCLUSIONS The study highlighted the importance of knowing the TB treatment outcome in the PPL to implement measures to reduce failure, and the contribution of supervised treatment in this process.
  • Interventions in overcrowding of emergency departments: an overview of systematic reviews Review

    Bittencourt, Roberto José; Stevanato, Angelo de Medeiros; Bragança, Carolina Thomé N. M.; Gottems, Leila Bernarda Donato; O’Dwyer, Gisele

    Abstract in English:

    ABSTRACT OBJECTIVE To present an overview of systematic reviews on throughput interventions to solve the overcrowding of emergency departments. METHODS Electronic searches for reviews published between 2007 and 2018 were made on PubMed, Cochrane Library, EMBASE, Health Systems Evidence, CINAHL, SciELO, LILACS, Google Scholar and the CAPES periodicals portal. Data of the included studies was extracted into a pre-formatted sheet and their methodological quality was assessed using AMSTAR 2 tool. Eventually, 15 systematic reviews were included for the narrative synthesis. RESULTS The interventions were grouped into four categories: (1) strengthening of the triage service; (2) strengthening of the ED’s team; (3) creation of new care zones; (4) change in ED’s work processes. All studies observed positive effect on patient’s length of stay, expect for one, which had positive effect on other indicators. According to AMSTAR 2 criteria, eight revisions were considered of high or moderate methodological quality and seven, low or critically low quality. There was a clear improvement in the quality of the studies, with an improvement in focus and methodology after two decades of systematic studies on the subject. CONCLUSIONS Despite some limitations, the evidence presented on this overview can be considered the cutting edge of current scientific knowledge on the topic.
  • Occupation and maternal mortality in Brazil Original Articles

    Feitosa-Assis, Ana Isabela; Santana, Vilma Sousa

    Abstract in Portuguese:

    RESUMO OBJETIVO Estimar a razão de mortalidade materna segundo a ocupação no Brasil. MÉTODOS Trata-se de estudo de mortalidade realizado com dados nacionais do Sistema de Informação sobre Mortalidade (SIM) e do Sistema de Informação sobre Nascidos Vivos (Sinasc) no ano de 2015. Foram estimadas as razões de mortalidade materna de acordo com a ocupação registrada em declarações de óbito, utilizando a Classificação Brasileira de Ocupações, versão 2002. RESULTADOS Foram encontrados 1.738 registros de óbitos maternos, correspondendo a uma razão de mortalidade materna de 57,6/100.000 nascidos vivos. Esse índice variou entre as categorias ocupacionais, sendo maior entre as trabalhadoras dos serviços e da agropecuária, particularmente para as empregadas domésticas (123,2/100.000 nascidos vivos), seguidas pelas trabalhadoras agropecuárias em geral (88,3/100.000 nascidos vivos). Também apresentaram elevada razão de mortalidade materna as manicures e técnicas de enfermagem. A ocupação materna não foi informada em 17,0% dos casos do SIM e em 13,2% do Sinasc. Foram encontrados registros inconsistentes, como “dona de casa”, o mais frequente no SIM (35,5%) e no Sinasc (39,1%). CONCLUSÕES A razão de mortalidade materna difere de acordo com a ocupação, sugerindo uma contribuição do trabalho, o que requer pesquisas adicionais para identificar os fatores de risco ocupacionais. Fatores socioeconômicos estão intimamente relacionados à ocupação, e sua combinação com exposições no trabalho e acesso a serviços de saúde precisa ser abordada.

    Abstract in English:

    ABSTRACT OBJECTIVE To estimate maternal mortality ratio according to occupation in Brazil. METHODS This is a mortality study conducted with national data from the Mortality Information System (SIM) and the Live Birth Information System (SINASC) in 2015. Maternal mortality ratios were estimated according to the occupation recorded in death certificates, using the Brazilian Classification of Occupation (CBO), version 2002. RESULTS A total of 1,738 maternal deaths records were found, corresponding to a maternal mortality ratio of 57.6/100,000 live births. It varied among occupational groups, with higher estimates among service and agricultural workers, particularly for domestic workers (123.2/100,000 live births), followed by general agricultural workers (88.3/100,000 live births). Manicurists and nursing technicians also presented high maternal mortality ratio. Maternal occupation was not reported in 17.0% of SIM registers and in 13.2% of SINASC data. Inconsistent records of occupation were found.“Housewife” prevailed in SIM (35.5%) and SINASC (39.1%). CONCLUSIONS Maternal mortality ratio differs by occupation, suggesting a work contribution, which requires further research focusing occupational risk factors. Socioeconomic factors are closely related to occupation, and their combination with work exposures and the poor access to health services need to be also addressed.
  • Healthcare telemonitoring and business dynamics: challenges and opportunities for SUS Original Articles

    Paula, Antonio da Cruz; Maldonado, José Manuel Santos de Varge; Gadelha, Carlos Augusto Grabois

    Abstract in Portuguese:

    RESUMO OBJETIVO Apontar desafios e oportunidades para o Sistema Único de Saúde (SUS) com o uso do telemonitoramento para enfrentar o aumento crescente dos custos com as doenças crônicas não transmissíveis, a partir do seu panorama geral no Brasil, dinâmica empresarial e reaplicação de dados de estudos americanos. MÉTODOS Este trabalho se enquadra na abordagem quali-quantitativa com pesquisa do tipo exploratória, e o trabalho de campo se concentrou na análise do mercado nacional a partir das empresas privadas, pois não se identificaram experiências ou estudos relacionados a esse tema no SUS. Para análise do panorama e da dinâmica do mercado, investigou-se a oferta a partir dos produtos e serviços disponíveis e a demanda por meio dos hospitais de referência, bem como as dez maiores empresas de planos de saúde privados. Para subsidiar a discussão central deste estudo, analisou-se a redução de custos com as internações hospitalares pelo SUS decorrentes das doenças crônicas não transmissíveis mais impactadas pelo telemonitoramento (IDCST), utilizando-se dados do Datasus e de alguns estudos americanos da base de dados MEDLINE/PubMed. RESULTADOS Embora em fase embrionária, os agentes empresariais se posicionam na busca por novas oportunidades de negócios, enquanto na saúde coletiva não há aparentemente iniciativas públicas para o uso do telemonitoramento. A reaplicação dos dados estadunidenses implicaria uma redução significativa nos gastos com IDCST pelo SUS, sem considerar outros benefícios, tais como a redução nos atendimentos nas salas de emergência, internações agudas, reinternações e tempo de cuidados domiciliares, entre outros, que apontam para ganhos econômicos ainda superiores com o uso do telemonitoramento. CONCLUSÕES O desenvolvimento de um grande projeto para a redução das IDCST a partir dessa tecnologia tem potencial para avançar em uma rede integral de atenção básica, contribuir para uma maior dinamização da base produtiva e inovativa nacional e induzir inovações em toda a cadeia dessa indústria emergente.

    Abstract in English:

    ABSTRACT OBJECTIVE To point out challenges and opportunities for the Brazilian Unified Health System (SUS) with the use of telemonitoring to face the increasing costs of non-communicable chronic diseases, based on its general panorama in Brazil, business dynamics and reapplication of data from American studies. METHODS Quali-quantitative approach with exploratory research. The field work focused on the analysis of the national market from private companies, since no experiences or studies related to this theme were identified in the SUS. To analyze the panorama and market dynamics, we investigated the offer of this technology based on the products and services available and their demand by reference hospitals the ten largest private health plan companies. To support the central discussion, we analyzed the reduction of costs with hospital admissions by the SUS due to chronic non-communicable diseases sensitive to telemonitoring (HCDST), using data from Datasus and some American studies from the MEDLINE/PubMed database. RESULTS Although in the embryonic phase, business agents search for new business opportunities, whereas public initiatives for the use of telemonitoring in collective health seem inexistent. The reapplication of U.S. data would reduce spending on HCDST and provide benefits, such as the reduction in emergency room care, acute hospitalizations, readmissions and home care time, among others, which point to even greater economic gains. CONCLUSIONS The development of a major project to reduce HCDST using this technology has the potential to advance in a comprehensive network of primary care, contribute to a greater dynamism of the national productive and innovative base and induce innovations along the chain of this emerging industry.
  • Incidence, persistence and risk factors of fear of falling in older adults: cohort study (2008–2013) in Rio de Janeiro, Brazil Original Articles

    Drummond, Flávia Moura Malini; Lourenço, Roberto Alves; Lopes, Claudia de Souza

    Abstract in English:

    ABSTRACT OBJECTIVE To evaluate the incidence and persistence of fear of falling in older adults and the clinical/functional, psychosocial and lifestyle-related risk factors. METHODS A longitudinal study with 393 community-dwelling older adults aged 65 years and over (110 men/ 283 women) resident in the North Zone of the city of Rio de Janeiro, Brazil. The fear of falling was assessed by the Falls Efficacy Scale-I-BR. The explanatory variables assessed were: number of comorbidities and medicines, history of falls, fracture from falling, use of walking aids, functional dependence in basic and instrumental activities of daily living, hearing and visual impairment, hand grip strength, walking speed, self-rated health, body mass index, depressive symptoms, cognitive impairment, living alone and activity level. Incidence, persistence and risk factors were estimated. Multivariate analysis was performed using Poisson Regression, obtaining relative risks (RR) and corresponding to 95% confidence intervals. RESULTS Among the 393 participants, fear of falling occurred in 33.5% and was persistent in 71.3%. Incidence was found to associate with using seven or more medicines and reporting worse activity level than the prior year. Risk factors for persistent fear were: using seven or more medicines, a history of one or two falls, reduced walking speed, hearing impairment, cognitive impairment, depressive symptoms and poor or very poor self-rated health. CONCLUSION Fear of falling is a frequent and persistent condition. Many factors related to persistent fear showed no association with the incidence of fear, emphasizing the need for focused strategies to reduce risk factors that may be associated with the chronification of fear of falling.
  • Mortality from gastroschisis in the state of Rio de Janeiro: a 10-year series Original Articles

    Barreiros, Camilla Ferreira Catarino; Gomes, Maria Auxiliadora de Souza Mendes; Gomes Júnior, Saint Clair dos Santos

    Abstract in Portuguese:

    RESUMO OBJETIVO Analisar a mortalidade e fatores associados em uma série de nascimentos com gastrosquise no estado do Rio de Janeiro em 10 anos (2005 a 2014). MÉTODO Estudo de coorte retrospectiva, no qual foram relacionadas as bases de dados do Sistema de Informação sobre Nascidos Vivos e do Sistema de Informação sobre Mortalidade por linkage probabilístico. A base de dados final foi construída em duas etapas, que consistiram em: preparo das duas bases de dados iniciais e estabelecimento de relações entre elas. RESULTADOS Os recém-nascidos pré-termo e os com baixo peso ao nascer tiveram maior chance de óbito, com significância estatística (p = 0,03 e p = 0,006, respectivamente). Em relação ao local de nascimento, embora a frequência de óbito tenha sido maior nas maternidades do que em hospitais gerais (p = 0,04; OR = 0,5; IC95% 0,3–1,0), foi observado que uma unidade caracterizada como hospital geral apresentou uma frequência alta de nascimentos (61,2%) e, na análise comparativa da chance de óbito dessa unidade com as demais, encontrou-se uma chance de morrer 7,5 maior em hospitais gerais e 3,2 maior em maternidades, com significância estatística (p < 0,001). Além disso, nascer em unidades de terapia intensiva tipo II aumentou a chance de óbito em 3,9 vezes em comparação com as do tipo III (p < 0,001). CONCLUSÃO Este estudo dá subsídios para a discussão de duas possíveis estratégias no tratamento de recém-nascidos com gastrosquise. A primeira seria a centralização do cuidado em unidades terciárias, possibilitando que o cuidado à malformação seja analisado de forma mais minuciosa e padronizada. A segunda, e talvez mais factível, seria a elaboração de diretrizes clínicas que padronizem o cuidado imediato aos bebês com gastrosquise nascidos fora de centros terciários, bem como a padronização do transporte deles até a chegada ao centro terciário.

    Abstract in English:

    ABSTRACT OBJECTIVE To analyze mortality and associated factors in a series of gastroschisis at birth in the state of Rio de Janeiro in a 10-year period (2005 to 2014). METHOD A retrospective cohort study, which related the databases of the Live Births Information System and the Mortality Information System by probabilistic linkage. Final database was constructed in two stages: preparation of the two initial databases and establishment of relationships between them. RESULTS Preterm newborns and those with low birthweight had higher risk of death, with statistical significance (p = 0.03 and p = 0.006, respectively). Regarding place of birth, although death frequency was higher in maternity units than in general hospitals (p = 0.04; OR = 0.5; 95%CI 0.3–1.0), it was observed that a unit characterized as a general hospital had a high birth frequency (61.2%). Furthermore, the comparative analysis of the risk of death between this unit and others showed a 7.5 higher risk of death in general hospitals and 3.2 higher in maternity units, with statistical significance (p < 0.001). Moreover, births in level II intensive care units had 3.9 times more risk of death compared with level III (p < 0.001). CONCLUSION This study foments the discussion of two possible strategies in the treatment of gastroschisis in newborns. First, the centralization of care in tertiary units, enabling malformation care to be analyzed in a more detailed and standardized manner. Second, and perhaps more feasible, the elaboration of clinical guidelines to standardize immediate care for gastroschisis in babies born outside tertiary centers, as well as the standardization of their transportation until arrival at the tertiary center.
  • Infrastructure and work process in primary health care: PMAQ in Ceará Original Articles

    Vieira-Meyer, Anya Pimentel Gomes Fernandes; Morais, Ana Patrícia Pereira; Guimarães, José Maria Ximenes; Campelo, Isabella Lima Barbosa; Vieira, Neiva Francenely Cunha; Machado, Maria de Fátima Antero Sousa; Nogueira, Paula Sacha Frota; Nuto, Sharmênia de Araújo Soares; Freitas, Roberto Wagner Júnior Freire de

    Abstract in Portuguese:

    RESUMO OBJETIVO Analisar a qualidade da infraestrutura e do processo de trabalho da Estratégia Saúde da Família nos municípios do Ceará entre 2012 e 2014. MÉTODOS Estudo transversal, utilizando dados secundários da avaliação externa do 1º (2012) e 2º (2014) ciclo do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica no Ceará. Vinte indicadores compostos foram utilizados para averiguar a qualidade da infraestrutura e do processo de trabalho. RESULTADOS Dados de 183 (99,4%) dos 184 municípios foram avaliados nos dois ciclos. Avaliaram-se 1.441 equipes para infraestrutura e 800 equipes para processo de trabalho. Dentre os 20 indicadores compostos avaliados, houve melhoria em 18, porém de forma não homogênea, variando de 0,0 a 413,5%. Observou-se que quanto menor o valor inicial do indicador, maior a variação na qualidade entre 2012 e 2014. Os indicadores da infraestrutura e do processo de trabalho foram influenciados pela região de saúde e porte populacional do município, sendo mais evidente a influência nas variáveis de processo de trabalho. CONCLUSÕES Identificou-se que melhorias da qualidade referentes à infraestrutura e ao processo de trabalho ocorreram no período de implantação do programa no estado do Ceará de forma equitativa, sendo influenciadas pelo porte populacional e pela região, demonstrando a influência do contexto na implementação de políticas públicas dessa natureza.

    Abstract in English:

    ABSTRACT OBJECTIVE To analyze the quality of the infrastructure and work process of the Family Health Strategy in the municipalities of Ceará between 2012 and 2014. METHODS Cross-sectional study, using secondary data from the external evaluation of the 1st (2012) and 2nd (2014) cycle of the National Program for Improvement of Access and Quality of Primary Care in Ceará. A total of 20 composite indicators were used to verify the quality of infrastructure and work process. RESULTS Data from 183 (99.4%) of the 184 municipalities of Ceará were collected in both cycles. A total of 1,441 teams were evaluated for the infrastructure and 800 for the work process. Among the 20 composite indicators evaluated, 18 presented an improvement, but in a non-homogeneous way, ranging between 0.0 and 413.5%. We observed that the lower the initial value of the indicator, the greater the variation in quality between 2012 and 2014. The indicators of infrastructure and work process were influenced by the regional health system and population size of the municipality, being more evident the influence on the variables of the work process. CONCLUSIONS We identified that quality improvements related to infrastructure and work process occurred in the period of implementation of the program in the state of Ceará in an equitable manner, being influenced by population size and regional health system, showing the influence of the context in the implementation of public policies of this nature.
  • Socioeconomic factors and inequality in the distribution of physicians and nurses in Mexico Original Articles

    Montañez-Hernández, Julio César; Alcalde-Rabanal, Jacqueline; Reyes-Morales, Hortensia

    Abstract in Spanish:

    RESUMEN OBJETIVO Describir los recursos humanos en salud y analizar la desigualdad en su distribución en México. MÉTODOS Estudio transversal basado en la Encuesta Nacional de Ocupación y Empleo del cuarto trimestre de 2018 en México. Se consideraron como recursos humanos en salud médicos y enfermeras con licenciatura, y personal de enfermería auxiliar/técnica con estudios concluidos. Se agrupó a los estados por grado de marginación y se estimó densidades de recursos humanos en salud por 1.000 habitantes, Índices de Disimilitud e Índices de Concentración (IC) como medidas de desigualdad en la distribución. RESULTADOS La densidad de recursos humanos en salud fue de 4,6 por 1.000 habitantes; se observó heterogeneidad entre los estados con que van 2,3 hasta 10,5 por 1.000 habitantes. La desigualdad fue mayor en los estados con muy bajo grado de marginación (IC = 0,4) que en los estados de muy alto grado (IC = 0,1), y fue mayor la desigualdad en la distribución de los médicos (IC = 0,5) que en las enfermeras profesionales (IC = 0,3) entre los estados. Para que todos los estados tuvieran una densidad igual a la nacional de 4,6, se tendrían que distribuir alrededor de 12,6% de los recursos humanos en salud entre los estados que estuvieron por debajo de la densidad nacional. Adicionalmente, 17 estados tuvieron una densidad superior al umbral de 4,5 por 1.000 habitantes propuesto en la Estrategia Global en Recursos Humanos para la Salud. Eso implica un déficit de casi 60 mil recursos humanos en salud entre los 15 estados por debajo del umbral. CONCLUSIONES En México existe desigualdad en la distribución de recursos humanos en salud, diferenciada en los estados. Mecanismos gubernamentales a través de una política de recursos humanos podrían incentivar el equilibrio en el mercado de laboral de los médicos y enfermeras.

    Abstract in English:

    ABSTRACT OBJECTIVE To describe the human resources for health and analyze the inequality in its distribution in Mexico. METHODS Cross-sectional study based on the National Occupation and Employment Survey (ENOE in Spanish) for the fourth quarter of 2018 in Mexico. Graduated physicians and nurses, and auxiliary/technician nurses with completed studies were considered as human resources for health. States were grouped by degree of marginalization. Densities of human resources for health per 1,000 inhabitants, Index of Dissimilarity (DI) and Concentration Indices (CI) were estimated as measures of unequal distribution. RESULTS The density of human resources for health was 4.6 per 1,000 inhabitants. We found heterogeneity among states with densities from 2.3 to 10.5 per 1,000 inhabitants. Inequality was higher in the states with a very low degree of marginalization (CI = 0.4) than those with high marginalization (CI = 0.1), and the inequality in the distribution of physicians (CI = 0.5) was greater than in graduated nurses (CI = 0.3) among states. In addition, 17 states showed a density above the threshold of 4.5 per 1,000 inhabitants proposed in the Global Strategy on Human Resources for Health. That implies a deficit of nearly 60,000 human resources for health among the 15 states below the threshold. For all states, to reach a density equal to the national density of 4.6, about 12.6% of human health resources would have to be distributed among states that were below national density. CONCLUSIONS In Mexico, there is inequality in the distribution of human resources for health, with state differences. Government mechanisms could support the balance in the labor market of physicians and nurses through a human resources policy.
  • Liberties, rights, public policies and water fluoridation Comments

    Souza Neto, Antonio Carlos de; Frazão, Paulo

    Abstract in Portuguese:

    RESUMO OBJETIVO Discutir os conceitos negativo e positivo de liberdade e postular sua relação de interdependência e complementariedade na avaliação da política pública intersetorial, tomando como caso a fluoretação da água. MÉTODO Descrevem-se os alcances e limites relativos à distinção formulada por Isaiah Berlin nos anos 1950, demonstrando sua validade para enfrentar os efeitos nocivos decorrentes tanto de uma economia de mercado sem controle quanto de um regime político autocrático. RESULTADOS Reconhece-se que são igualmente cruciais tanto os direitos que protegem os cidadãos contra um Estado poderoso quanto os direitos que protegem o Estado contra os cidadãos poderosos. CONCLUSÃO Argumenta-se que, em um contexto de equilíbrio entre a liberdade negativa e positiva, a política regulatória tem duplo sentido, e deve buscar um balanço entre o estabelecimento de regras necessárias para a proteção do público e de limites além dos quais as regras não devem violar os direitos dos indivíduos.

    Abstract in English:

    ABSTRACT OBJECTIVE To discuss the negative and positive concepts of liberty and postulate its interdependent and complementary relationship in the evaluation of public policy intersectoral actions, taking water fluoridation as a case. METHOD To describe scopes and limits regarding 1950s Isaiah Berlin’s distinction, showing its validity in facing the harmful effects of an uncontrolled market economy and an autocratic political regime. RESULTS Both the rights that protect citizens against a powerful state and the rights that protect the state against powerful citizens were equally acknowledged as crucial. CONCLUSION We argued that, in a context in which negative and positive liberties are balanced, regulatory policies have double meaning. Thus, there should be a balance between the establishment of necessary rules for social protection and limits for them not to violate individuals’ rights.
  • A brief-review of the risk factors for covid-19 severity Brief Communication

    Rod, J.E.; Oviedo-Trespalacios, Oscar; Cortes-Ramirez, Javier

    Abstract in English:

    ABSTRACT The World Health Organization has emphasized that one of the most important questions to address regarding the covid-19 pandemic is to understand risk factors for disease severity. We conducted a brief review that synthesizes the available evidence and provides a judgment on the consistency of the association between risk factors and a composite end-point of severe-fatal covid-19. Additionally, we also conducted a comparability analysis of risk factors across 17 studies. We found evidence supporting a total of 60 predictors for disease severity, of which seven were deemed of high consistency, 40 of medium and 13 of low. Among the factors with high consistency of association, we found age, C-reactive protein, D-dimer, albumin, body temperature, SOFA score and diabetes. The results suggest that diabetes might be the most consistent comorbidity predicting disease severity and that future research should carefully consider the comparability of reporting cases, factors, and outcomes along the different stages of the natural history of covid-19.
  • Does Vitamin D play a role in the management of Covid-19 in Brazil? Comments

    Ribeiro, Helena; Santana, Keila Valente de Souza de; Oliver, Sofia Lizarralde; Rondó, Patricia Helen de Carvalho; Mendes, Marcela Moraes; Charlton, Karen; Lanham-New, Susan

    Abstract in English:

    ABSTRACT The study discusses the possible role of adequate vitamin D status in plasma or serum for preventing acute respiratory infections during the Covid-19 pandemic. Our arguments respond to an article, published in Italy, that describes the high prevalence of hypovitaminosis D in older Italian women and raises the possible preventive and therapeutic role of optimal vitamin D levels. Based on literature review, we highlight the findings regarding the protective role of vitamin D for infectious diseases of the respiratory system. However, randomized controlled trials are currently lacking. Adequate vitamin D status is obtained from sun exposure and foods rich in vitamin D. Studies in Brazil have shown that hypovitaminosis D is quite common in spite of high insolation. Authors recommend ecological, epidemiological and randomized controlled trials studies to verify this hypothesis.
  • Neighborhood environmental factors associated with leisure walking in adolescents Original Articles

    Dias, Arieli Fernandes; Gaya, Anelise Reis; Santos, Maria Paula; Brand, Caroline; Pizarro, Andreia Nogueira; Fochesatto, Camila Felin; Mendes, Thiago Monteiro; Mota, Jorge; Gaya, Adroaldo Cezar Araujo

    Abstract in English:

    ABSTRACT OBJECTIVE To verify the associations of leisure walking with perceived and objective measures of neighborhood environmental factors stratified by gender and socioeconomic status (SES) in Brazilian adolescents. METHODS Cross-sectional study with a random sample of 1,130 high school students (47.3% girls; aged 14 to 20 years old) from Porto Alegre, Brazil. Leisure walking and SES were self-reported by the adolescents. Perceived environmental factors were assessed through Neighborhood Environment Walkability Scale for Youth (NEWS-Y). Objective measures were evaluated using Geographic Information Systems, with road network calculated around the adolescent’s residential address, using 0.5km and 1.0km buffers. Data collection was carried out in 2017 and generalized linear regression models were used. RESULTS Leisure walking was positively associated with access to services (0.5 km buffers [Odds ratio (OR) = 2.22] 1.0 km buffers [OR = 2.17]) and lower distance to parks and squares (0.5 km [OR=2.80] 1.0 km [OR = 2.73]) in girls from low SES. Residential density (0.5 km [OR = 1.57] 1.0 km [OR = 1.54]) and walkability index (0.5 km [OR = 1.17] 1.0 km [OR = 1.20]) were associated with leisure walking in girls from middle SES. Boys from low SES showed an inverse association between crime safety and leisure walking (0.5 km [OR = 0.59] 1.0 km [OR = 0.63]). Neighborhood recreation facilities was positively associated with leisure walking in middle SES (0.5 km [OR = 1.55] 1.0 km [OR = 1.60]). Land use mix (0.5 km [OR = 1.81] 1.0 km [OR = 1.81]), neighborhood recreation facilities (0.5 km [OR = 2.32] 1.0 km [OR = 2.28]) and places for walking (0.5 km [OR=2.07] 1.0 km [OR=2.22]) were positively associated with leisure walking in high SES. CONCLUSION Environmental factors (objectively and subjectively measured) and leisure walking show association in boys and girls of different SES.
  • Validity studies of the scale of positive and negative perceptions about alcohol effects Original Articles

    Almeida, Leandro S.; Casanova, Joana R.; Fernández, María Fernanda Páramo; Reppold, Caroline Tozzi; Gonzalez, Maria Soledad Rodriguez

    Abstract in Portuguese:

    RESUMO OBJETIVO Considerando a relação entre as taxas de uso de álcool e as percepções dos estudantes sobre os efeitos desse consumo, descrever o processo de elaboração e validação da Escala de Percepções sobre o Consumo de Álcool em Estudantes do Ensino Superior em uma amostra portuguesa. MÉTODOS Participaram do estudo de validade 531 estudantes portugueses do primeiro ano do ensino superior que responderam ao instrumento, composto por cinco itens que expressam percepções positivas e cinco itens que expressam percepções negativas sobre os efeitos do consumo de álcool. RESULTADOS Evidências de validade de conteúdo, de estrutura interna e baseadas em variáveis externas foram obtidas. Os resultados da análise fatorial confirmam a distribuição das percepções positivas e negativas por dois fatores diferenciados em acordo com o modelo teórico de partida. Índices adequados de consistência interna foram obtidos para cada dimensão. Os dados obtidos mostraram correlações esperadas entre as percepções e os comportamentos de consumo dos estudantes, indicando evidências de validade de critério da escala. Em acréscimo, o estudo indicou haver padrões de consumo diferenciados entre os sexos, registando-se maior consumo de álcool nas residências e nos restaurantes ou cafés por parte dos homens, além de similaridade entre os dois sexos no padrão de consumo em festas e bares ou discotecas. CONCLUSÃO Os dados obtidos evidenciam a validade do instrumento. Na discussão dos dados, o artigo apresenta considerações sobre a responsabilidade das instituições de ensino superior na prevenção e redução das taxas de consumo entre a sua população estudantil.

    Abstract in English:

    ABSTRACT OBJECTIVE To describe the process of elaboration and validation of the Scale of Perceptions about Alcohol Consumption in Higher Education Students in a Portuguese sample, considering the relationship between alcohol use rates and students’ perceptions about the effects of this consumption. METHODS The validation study included 531 Portuguese college freshmen who answered the instrument, which is composed of five items that express positive perceptions and five items that express negative perceptions about the effects of alcohol consumption. RESULTS Evidence of content validity, internal structure and external variables were obtained. The results of the factor analysis confirm the distribution of positive and negative perceptions by two different factors according to the theoretical model. Adequate internal consistency indexes were obtained for each dimension. The data obtained showed expected correlations between the perceptions and consumption behaviors of the students, indicating evidence of criterion validity of the scale. Moreover, the study showed that different consumption patterns between men and women, with higher alcohol consumption in the students’ households and restaurants or cafés by male students, in addition to the similarity in the consumption pattern between the two genders in parties and bars or nightclubs. CONCLUSION The data obtained show the validity of the instrument. In the discussion, the article presents considerations about the responsibility of higher education institutions in the prevention and reduction in consumption rates among their students.
  • Latin American interventions in children and adolescents’ sedentary behavior: a systematic review Review

    Ribeiro, Evelyn Helena Corgosinho; Guerra, Paulo Henrique; Oliveira, Ana Carolina de; Silva, Kelly Samara da; Santos, Priscila; Santos, Rute; Okely, Anthony; Florindo, Alex Antonio

    Abstract in English:

    ABSTRACT OBJECTIVE To identify and evaluate the effects of community-based interventions on the sedentary behavior (SB) of Latin American children and adolescents. METHODS A systematic review on community-based trials to reduce and/or control SB in Latin American countries (Prospero: CRD42017072157). Five databases (PubMed, Web of Science, Scopus, SciELO and Lilacs) and a reference lists were searched. RESULTS Ten intervention studies met the eligibility criteria and composed the descriptive synthesis. These studies were conducted in Brazil (n=5), Mexico (n=3), Ecuador (n=1) and Colombia (n=1). Most interventions were implemented in schools (n=8) by educational components, such as meetings, lessons, and seminars, on health-related subjects (n=6). Only two studies adopted specific strategies to reduce/control SB; others focused on increasing physical activity and/or improving diet. Only one study used an accelerometer to measure SB. Seven studies investigated recreational screen time. Eight studies showed statistically significant effects on SB reduction (80%). CONCLUSIONS Latin America community-based interventions reduced children and adolescents’ SB. Further studies should: define SB as a primary outcome and implement strategies to reduce such behaviour; focus in different SBs and settings, other than recreational screen time or at-home sitting time; and use objective tools together with questionnaires to measure sedentary behaviour in.
  • Illicit drug use among students of a university in Southern Brazil Original Articles

    Houvèssou, Gbènankpon Mathias; Bierhals, Isabel Oliveira; Flesch, Betina Daniele; Silveira, Mariângela Freitas da

    Abstract in English:

    ABSTRACT OBJECTIVE To describe drug consumption and the co-occurrence use of more than one illegal drug as well as associated factors in freshmen at a public university in Southern Brazil. METHODS Cross-sectional study with census of students entering undergraduate courses in 2017. A total of 1,788 university students answered questions about illicit drug use. For analysis, ordinal logistic regression was used. RESULTS Marijuana was the most consumed drug (lifetime: 42.1%; 30-day use: 22.7%), followed by hallucinogens (lifetime: 13.1%, 30-day use: 2.8%). Rates for lifetime use of 0, 1 and 2 or more drugs were 56.2%, 23.3% and 20.4%, respectively, and were associated with men (OR = 2.2; 95%CI:1.4–3.5), being at least 23 years old (OR = 2.7; 95%CI: 1.4–5.1), under 18 years old first experimentation with drugs (OR = 2.3; 95%CI: 1.3–3.9) and living with friends (OR = 2.0; 95%CI: 1.2–3.4). Rates for 30-day use of 0, 1 and 2 or more drugs were 76.8%; 18.1% and 5.1%, respectively, and were associated with being single, separated or widowed (OR = 3.2; 95%CI: 1.4–7.0), lower socioeconomic classes (OR = 0.3; 95%CI: 0.1–1.1; p = 0.001), under 18 years old first experimentation with drugs (OR = 1.8; 95%CI: 1.1–2.9) and living with friends (OR = 1.8 95%CI: 1.2–2.8). CONCLUSION Results indicate that students are at greater risk of illicit drug-related health problems. Thus, a better understanding of this consumption should be pursued, as well as the development of a prevention plan.
  • Food advertisements on television and eating habits in adolescents: a school-based study Original Articles

    Delfino, Leandro Dragueta; Tebar, William Rodrigues; Silva, Diego Augusto Santos; Gil, Fernanda Caroline Staquecini; Mota, Jorge; Christofaro, Diego Giulliano Destro

    Abstract in English:

    ABSTRACT OBJECTIVE To analyze the association of television food advertisements with eating habits in Brazilian adolescents. METHODS The sample was composed of 1,011 adolescents, aged from 10–17 years. The influence of television food advertisements on eating habits, as well as food consumption and socioeconomic variables were assessed through questionnaires. A binary logistic regression was performed to assess the magnitude of the associations, adjusted for gender, age, socioeconomic status, and parental schooling. RESULTS Of the sample, 83.3% (n = 843) reported food consumption while watching TV. Adolescents who do not consume food while watching TV had a higher weekly consumption of fruits (3.98, SD = 2.0 versus 3.39, SD = 2.1) and vegetables (4.1, SD = 2.2 versus 3.4, SD = 2.3). Adolescents that consume food while watching TV had higher weekly consumption of fried foods (3.1, SD = 2.0 versus 2.3, SD = 1.7), sweets (4.1, SD = 2.1 versus 3.3, SD = 2.1), soft drinks (3.2, SD = 2.1 versus 2.2, SD = 1.9), and snacks (2.3, SD = 2.0 versus 1.6, SD = 1.7). For 73,8% of the sample, food advertisements induce product consumerism, most commonly sweets and fast foods. Buying or asking to buy food after seeing it on the television was associated with fried foods (OR = 1.36, 95%CI = 1.03– 1.79), sweets (OR = 1.69, 95%CI = 1.30–2.18), and snacks (OR = 1.57, 95%CI = 1.12–2.22). CONCLUSION Food advertisements were associated with greater consumption of fried foods, sweets, and snacks in adolescents, even after adjusting for confounding factors.
  • Diabetes and covid-19: more than the sum of two morbidities Comments

    Pititto, Bianca de Almeida; Ferreira, Sandra Roberta G.

    Abstract in English:

    ABSTRACT The coronavirus disease 2019 (covid-19) pandemic has caused a public health emergency worldwide. Risk, severity and mortality of the disease have been associated with non-communicable chronic diseases, such as diabetes mellitus. Accumulated evidence has caused great concern in countries with high prevalence of this morbidity, such as Brazil. This text shows the picture of diabetes in Brazil, followed by epidemiological data and explanatory hypothesis for the association between diabetes and covid-19. We emphasized how the burden of these two morbidities in a middle-income country has aggravated this pandemic scenario. The comprehension of this association and biological plausibility may help face this pandemic and future challenges.
  • Erratum: Scoping review of studies on food marketing in Latin America: Summary of existing evidence and research gaps Erratum

  • Covid-19 and the pandemic of fear: reflections on mental health Letters to the Editor

    Silva, Dandara Almeida Reis da; Pimentel, Rodrigo Fernandes Weyll; Merces, Magno Conceição das
  • Adults at high-risk of severe coronavirus disease-2019 (Covid-19) in Brazil Original Articles

    Rezende, Leandro F. M.; Thome, Beatriz; Schveitzer, Mariana Cabral; Souza-Júnior, Paulo Roberto Borges de; Szwarcwald, Célia Landmann

    Abstract in English:

    ABSTRACT OBJECTIVE To estimate the proportion and total number of the general adult population who may be at higher risk of severe Covid-19 in Brazil. METHODS We included 51,770 participants from a nationally representative, household-based health survey (PNS) conducted in Brazil. We estimated the proportion and number of adults (≥ 18 years) at risk of severe Covid-19 by sex, educational level, race/ethnicity, and state based on the presence of one or more of the following risk factors: age ≥ 65 years or medical diagnosis of cardiovascular disease, diabetes, hypertension, chronic respiratory disease, cancer, stroke, chronic kidney disease and moderate to severe asthma, smoking status, and obesity. RESULTS Adults at risk of severe Covid-19 in Brazil varied from 34.0% (53 million) to 54.5% (86 million) nationwide. Less-educated adults present a 2-fold higher prevalence of risk factors compared to university graduated. We found no differences by sex and race/ethnicity. São Paulo, Rio de Janeiro, Minas Gerais, and Rio Grande do Sul were the most vulnerable states in absolute and relative terms of adults at risk. CONCLUSIONS Proportion and total number of adults at risk of severe Covid-19 are high in Brazil, with wide variation across states and adult subgroups. These findings should be considered while designing and implementing prevention measures in Brazil. We argue that these results support broad social isolation measures, particularly when testing capacity for SARS-CoV-2 is limited.
  • International Classification of Functioning in professional rehabilitation: instruments for assessing work disability Review

    Luna, Juliana Scholtão; Monteiro, Gina Torres Rego; Koifman, Rosalina Jorge; Bergmann, Anke

    Abstract in Portuguese:

    RESUMO OBJETIVO Revisar os principais instrumentos de avaliação funcional e situação de saúde citados na literatura para avaliar trabalhadores brasileiros e verificar a compatibilidade de seus itens com o core set para reabilitação profissional. MÉTODOS Foi realizada uma revisão da literatura nas principais bases de dados em busca de artigos que utilizaram instrumentos de avaliação em populações de trabalhadores entre 2007 e 2017. Posteriormente foram recuperados os conteúdos dos instrumentos identificados e dois avaliadores analisaram seus itens para verificar a compatibilidade com as categorias do core set da Classificação Internacional de Funcionalidade para reabilitação profissional. O coeficiente kappa de Cohen foi utilizado para avaliar a concordância entre os avaliadores. RESULTADOS Foram selecionados cinco instrumentos específicos e oito genéricos que avaliaram a funcionalidade de trabalhadores. A análise dos itens do total de instrumentos permitiu o preenchimento de 58 categorias (64,5%) do core set com o mínimo de sobreposição: 13 (76,5%) do componente funções corporais, 29 (72,5%) do componente de atividades e participação e 16 (49%) de fatores ambientais. CONCLUSÕES A associação de vários instrumentos requer tempo e dificulta o uso da classificação. A elaboração de instrumentos com associação direta às suas categorias se faz essencial para operacionalizá-la.

    Abstract in English:

    ABSTRACT OBJECTIVE To review the main instruments of functional assessment and health status cited in the literature to evaluate Brazilian workers and verify the compatibility of their items with the core set for professional rehabilitation. METHODS A review of the literature was conducted in the main databases in search of articles that used assessment instruments in populations of workers between 2007 and 2017. Subsequently, the contents of the identified instruments were retrieved, and two evaluators analyzed their items to verify the compatibility with the categories of the core set of the International Classification of Functioning for professional rehabilitation. Cohen’s kappa coefficient was used to evaluate the agreement between the evaluators. RESULTS Five specific and eight generic instruments were selected to evaluate the functioning of workers. The analysis of the items of the total instruments allowed the definition of 58 categories (64.5%) of the core set with minimal overlap: 13 (76.5%) of the body functions component, 29 (72.5%) of the activities and participation component and 16 (49%) environmental factors. CONCLUSIONS The association of several instruments requires time and makes it difficult to use the classification. The development of instruments with direct association with its categories is essential to operationalize it.
  • Systematic review: Symptoms of parental depression and anxiety and offspring overweight Review

    Marco, Paula Lobo; Valério, Inaê Dutra; Zanatti, Christian Loret de Mola; Gonçalves, Helen

    Abstract in Portuguese:

    RESUMO OBJETIVO Avaliar a literatura existente acerca da associação entre depressão e ansiedade dos pais e sua influência no excesso de peso dos filhos durante a infância, identificando possíveis mecanismos envolvidos nessa associação. MÉTODOS Foi realizada uma busca na literatura, de forma sistemática, nas bases de dados PubMed, PsycINFO e SciELO, usando os descritores: (maternal OR mother* OR parent* OR paternal OR father) AND (“common mental disorder” OR “mental health” OR “mental disorder” OR “depressive disorder” OR depress* OR anxiety OR “anxiety disorder”) AND (child* OR pediatric OR offspring) AND (overweight OR obes* OR “body mass index” OR BMI). Foram encontrados 1.187 artigos após seleção por pares. RESULTADOS Foram selecionados 16 artigos que atingiram os critérios para inclusão na revisão. A maioria investigou sintomas depressivos e somente três, sintomas ansiosos maternos. Os estudos avaliados mostraram resultados sugestivos de associação positiva entre sintomas de depressão materna e maior risco de excesso de peso nos filhos. Os resultados divergiram de acordo com a cronicidade dos sintomas depressivos (depressão episódica ou recorrente) e renda do país investigado (alta ou média renda). Foram identificados mecanismos que passam pela qualidade da parentalidade, afetando comportamentos relacionados à atividade física e alimentação da criança, como mediadores da associação. CONCLUSÕES Concluímos que há evidências de uma relação positiva entre a ocorrência de sintomas maternos de depressão e ansiedade e o excesso de peso dos filhos. Ressalta-se a necessidade de uma melhor compreensão do impacto do momento de ocorrência dos sintomas depressivos e dos fatores contextuais envolvidos nessa relação para que possam ser implementadas estratégias de intervenção eficazes.

    Abstract in English:

    ABSTRACT OBJECTIVE To evaluate the existing literature on the association between parents’ depression and anxiety and their influence on their children’s weight during childhood, identifying possible mechanisms involved in this association. METHODS A systematic search of the literature was conducted in the PubMed, PsycINFO and SciELO databases, using the following descriptors: (maternal OR mother* OR parent* OR paternal OR father) AND (“common mental disorder” OR “mental health” OR “mental disorder” OR “depressive disorder” OR depress* OR anxiety OR “anxiety disorder”) AND (child* OR pediatric OR offspring) AND (overweight OR obes* OR “body mass index” OR BMI). A total of 1,187 articles were found after peer selection. RESULTS In total, 16 articles that met the inclusion criteria were selected for the review. Most of them investigated depressive symptoms and only three, symptoms of maternal anxiety. The evaluated studies suggested a positive association between symptoms of maternal depression and higher risk of childhood obesity. The results diverged according to the chronicity of depressive symptoms (episodic or recurrent depression) and income of the investigated country (high or middle income). Mechanisms were identified passing by quality of parenthood, affecting behaviors related to physical activity and child-feeding, as mediators of the association. CONCLUSIONS We conclude there is evidence of a positive relationship between the occurrence of maternal symptoms of depression and anxiety and childhood obesity. It is emphasized the need for a better understanding on the effect of depressive symptoms and the contextual factors involved in this relationship so that effective intervention strategies can be implemented.
  • Health belief model for coronavirus infection risk determinants Original Articles

    Costa, Marcelo Fernandes

    Abstract in Portuguese:

    RESUMO OBJETIVO Neste estudo buscamos utilizar as vantagens de uma escala de razão por ancoragem verbal para medidas da percepção de risco de contágio pelo novo coronavírus, causador da covid-19, em um questionário baseado no modelo de crença em saúde, assim como avaliar sua validade e reprodutibilidade. MÉTODO Utilizamos o modelo de crença em saúde, o qual explora quatro dimensões: percepção individual de susceptibilidade percebida (cinco questões), severidade percebida (cinco questões), benefícios percebidos (cinco questões) e barreiras percebidas (cinco questões). Adicionalmente, incluímos uma quinta dimensão, a qual denominamos motivação pró-saúde (quatro questões). As questões definiram um questionário eletrônico que foi divulgado por redes sociais pelo período de uma semana. As respostas foram valores quantitativos de representações subjetivas, obtidas por meio de uma escala psicofísica de razão com ancoragem verbal (CentiMax ® ). O tempo médio total de preenchimento foi de 12 minutos (desvio-padrão = 1,6). RESULTADOS Obtivemos 277 respostas completas ao formulário. Uma foi excluída por se tratar de participante com menos de 18 anos de idade. Medidas de reprodutibilidade foram significantes para 22 das 24 questões de nosso questionário (α de Cronbach = 0,883). A validade convergente foi atestada pelo coeficiente de correlação de Spearman-Brown split half (r = 0,882). Diferenças significantes entre grupos foram encontradas mais intensamente nas dimensões susceptibilidade percebida e severidade percebida, e menos intensamente para benefícios percebidos e barreiras percebidas. CONCLUSÃO Nosso questionário baseado no modelo de crença em saúde utilizando medidas quantitativas permitiu evidenciar as crenças populares sobre os riscos de contágio por covid-19. A vantagem de nossa abordagem é a possibilidade de se identificar os perfis de crença individuais para cada dimensão do questionário de forma rápida, direta e quantitativa, podendo ser uma grande aliada em processos de comunicação e educação em saúde pública.

    Abstract in English:

    ABSTRACT OBJECTIVE To use the advantages of a ratio scale with verbal anchors in order to measure the risk perception in the novel coronavirus infection, which causes covid-19, in a health belief model-based questionnaire, as well as its validity and reproducibility. METHOD We used the health belief model, which explores four dimensions: perceived susceptibility (five questions), perceived severity (five questions), perceived benefits (five questions), and perceived barriers (five questions). Additionally, we included a fifth dimension, called pro-health motivation (four questions). The questions composed an electronic questionnaire disseminated by social networks for an one-week period. Answers were quantitative values of subjective representations, obtained by a psychophysically constructed scale with verbal anchors ratio (CentiMax ® ). Mean time for total filling was 12 minutes (standard deviation = 1.6). RESULTS We obtained 277 complete responses to the form. One was excluded because it belonged to a participant under 18 years old. Reproducibility measures were significant for 22 of the 24 questions in our questionnaire (Cronbach’s α = 0.883). Convergent validity was attested by Spearman-Brown’s split half reliability coefficient (r = 0.882). Significant differences among groups were more intense in perceived susceptibility and severity dimensions, and less in perceived benefits and barriers. CONCLUSION Our health belief model-based questionnaire using quantitative measures enabled the confirmation of popular beliefs about covid-19 infection risks. The advantage in our approach lays in the possibility of quickly, directly and quantitatively identifying individual belief profiles for each dimension in the questionnaire, serving as a great ally for communication processes and public health education.
  • Brazilian cohorts with potential for life-course studies: a scoping review Review

    Araujo, Waleska Regina Machado; Santos, Iná S.; Menezes Filho, Naercio Aquino; Souza, Maria Thereza Costa Coelho de; Cunha, Antonio Jose Ledo Alves da; Matijasevich, Alicia

    Abstract in Portuguese:

    RESUMO OBJETIVO Identificar as coortes brasileiras iniciadas no período pré-natal ou no nascimento, descrever suas características e as variáveis exploradas, além de mapear as coortes com potencial para se estudar os determinantes precoces de saúde e doença e o risco de adoecer em etapas posteriores do ciclo vital. MÉTODOS Realizou-se uma revisão de escopo. A busca dos artigos foi realizada nas bases de dados PubMed e Biblioteca Virtual em Saúde em 16 de junho de 2018. Os descritores utilizados foram [(((“Child” OR “Child, Preschool” OR “Infant” OR “Infant, Newborn”) AND (“Cohort Studies” OR “Longitudinal Studies”)) AND “Brazil”)]. Os critérios de inclusão foram coortes brasileiras que iniciaram a linha de base no período pré-natal ou no nascimento e com pelo menos dois acompanhamentos com os participantes. Foram excluídas as coortes cujos acompanhamentos foram restritos ao primeiro ano de vida, as que não abordaram aspectos biológicos, comportamentais e psicossociais e também aquelas com coleta de informações em um único estágio do ciclo vital. RESULTADOS A etapa de busca identificou 5.010 artigos. Foram selecionadas 18 coortes para a síntese descritiva. A mediana do número de participantes na linha de base foi 2.000 indivíduos e a mediana de idade no último acompanhamento foi 9 anos. A perda amostral no último acompanhamento variou de 9,2 a 87,5%. A maioria das coortes realizou acompanhamentos em duas fases do ciclo vital (período perinatal e infância). A região Sul contemplou o maior número de coortes. As principais variáveis coletadas foram sociodemográficas e ambientais da família, aspectos de morbidade, práticas alimentares e estilo de vida dos participantes. CONCLUSÕES Recomenda-se a continuidade dessas coortes, a abordagem de diferentes contextos sociais e a realização de acompanhamentos com os participantes em diferentes fases do ciclo vital para o fortalecimento e ampliação das análises de epidemiologia do ciclo vital no Brasil.

    Abstract in English:

    ABSTRACT OBJECTIVE To identify the Brazilian cohorts that started either in the prenatal period or at birth, to describe their characteristics and the explored variables, and to map the cohorts with potential for studies on early determinants on health and the risk of falling ill on later stages of the life cycle. METHODS A scoping review was carried out. The articles were searched in the electronic databases PubMed and Virtual Health Library (VHL). The descriptors used were [(((“Child” OR “Child, Preschool” OR “Infant” OR “Infant, Newborn”) AND (Cohort Studies” OR “Longitudinal Studies”)) AND “Brazil”)]. The inclusion criteria were Brazilian cohorts that started the baseline in the prenatal period or at birth and with at least two follow-ups with the participants. In order to meet the concept of LCE, we excluded those cohorts whose follow-ups were restricted to the first year of life, as well as those that did not address biological, behavioral and psychosocial aspects, and cohorts with data collection of a single stage of the life cycle. RESULTS The search step identified 5,010 articles. Eighteen cohorts were selected for descriptive synthesis. The median number of baseline participants was 2,000 individuals and the median age at the last follow-up was 9 years. Sample loss at the last follow-up ranged from 9.2 to 87.5%. Most cohorts monitored two phases of the life cycle (the perinatal period and childhood). The Southern region had the highest number of cohorts. The main variables collected were sociodemographic and environmental aspects of the family, morbidity aspects, nutritional practices and lifestyle. CONCLUSIONS We recommend the continuity of these cohorts, the approach to different social contexts and the performance of follow-ups with participants in different phases of the life cycle for the strengthening and expansion of life course epidemiology analyses in Brazil.
  • Evaluation of newborn hearing screening program Original Articles

    Marinho, Ana Carolina Alves; Pereira, Edirlene Cordeiro de Souza; Torres, Kleyse Kerlyne Costa; Miranda, Andreza Monforte; Ledesma, Alleluia Lima Losno

    Abstract in Portuguese:

    RESUMO OBJETIVO Avaliar o Programa de Triagem Auditiva Neonatal do Hospital Regional de Sobradinho, no período de janeiro de 2016 a dezembro de 2017, segundo os parâmetros do Comitê Multiprofissional em Saúde Auditiva e as recomendações do Joint Committee on Infant Hearing (JCIH), bem como descrever a prevalência dos indicadores de risco para deficiência auditiva na população estudada e seu impacto no respectivo programa. MÉTODO Trata-se de um estudo quantitativo, transversal e retrospectivo no qual foram analisados criteriosamente livros de registros dos neonatos triados. Foi estabelecida a prevalência de “passa” e “falha” no teste e reteste, o percentual de comparecimento para reteste e de encaminhamento para diagnóstico audiológico. Foram descritos os indicadores de risco para deficiência auditiva, bem como sua influência nos índices de “passa” e “falha”. Foi realizada análise estatística inferencial utilizando o teste do qui-quadrado e o teste de Anderson-Darling, com índice de confiabilidade de 5%. RESULTADOS Foram triados 3.981 neonatos, 2.963 (74,4%) dos quais sem indicadores de risco e 1.018 (25,6%) com, sendo a prematuridade o mais frequente (51,6%). No teste, 166 (4,2%) falharam e 118 (71,1%) compareceram para o reteste. O índice de encaminhamento para diagnóstico foi de 0,3%. CONCLUSÃO O programa atingiu os índices recomendados pelo Joint Committee on Infant Hearing e pelo Comitê Multiprofissional em Saúde Auditiva quanto à porcentagem de encaminhamento para diagnóstico. O indicador de risco mais prevalente na população foi a prematuridade.

    Abstract in English:

    ABSTRACT OBJECTIVE To evaluate Newborn Hearing Screening Program of Hospital Regional de Sobradinho, from January 2016 to December 2017, according to Multiprofessional Committee on Auditory Health parameters and Joint Committee on Infant Hearing (JCIH) recommendations, as well as to describe the prevalence of risk factors for hearing loss within the study population and their impact on the respective program. METHOD This is a quantitative, cross-sectional and retrospective study that carefully analyzed registration books of screened newborns. It was established the prevalence of “pass” and “fail” in test and retest, retest percentage of attendance and referral for audiological diagnosis. Risk factors for hearing loss were described, as well as their influence on “pass” and “fail” rates. Inferential statistical analysis was performed using chi-square test and Anderson-Darling test, with 5% reliability index. RESULTS A total of 3,981 newborns were screened; 2,963 (74.4%) presented no risk factors whereas 1,018 (25.6%) did, prematurity being the most frequent (51.6%). In the test, 166 (4.2%) failed and 118 (71.1%) attended the retest. The referral rate for diagnosis was 0.3%. CONCLUSION Regarding the percentage of referral for diagnosis, the program reached indexes recommended by the Joint Committee on Infant Hearing and Multiprofessional Committee on Auditory Health. The most prevalent risk factor within the population was prematurity.
  • Are laws restricting soft drinks sales in Brazilian schools able to lower their availability? Original Articles

    Azeredo, Catarina Machado; Leite, Maria Alvim; Rauber, Fernanda; Ricardo, Camila Zancheta; Levy, Renata Bertazzi

    Abstract in English:

    ABSTRACT OBJECTIVE To describe students protected by laws and exposed to soft drinks sales and assess whether forbidding laws are associated with lower availability of these beverages. METHODS We identified laws forbidding non-government administered cafeterias or sales of soft drinks in schools in the 27 Brazilian state capitals. Data on soft drinks sales were obtained from Pesquisa Nacional de Saúde do Escolar 2015 (PeNSE – National Survey of School Health 2015), for a representative sample of 9th graders from public and private schools. Students were attributed with the status of their school regarding the law and sale of soft drinks. Co-variables were school status (public or private), school size, geographic regions, mother’s educational level, score of goods and services. We performed multivariate analyses using Poisson regression. RESULTS The total of 23 laws forbidding sales of soft drinks covered 63.0% of capitals, comprising 56.9% of students. Law coverage was higher among students from more developed regions (67.6%) and in public schools (60.6%), compared with those from less developed regions (38.0%) and private schools (45.8%). Soft drinks were available for 33.9% of students. Students attending public schools in less developed regions had the lowest availability of soft drinks, regardless of law coverage (14.8%; 12.0%); while students attending private schools in these regions had a high availability, regardless of law coverage (82.1%; 73.4%). Restrictive laws were associated with lower sales of soft drinks in more developed regions, and restrictions had a greater association with the availability of soft drinks in public schools (PR = 0.25; 95%CI = 0.15-0.41), compared with private schools (PR = 0.48; 95%CI = 0.35-0.66). CONCLUSION Laws restricting soft drinks in schools were associated with fewer sales in more developed regions. Private schools were less compliant with the law than public schools. A broadly enforced national law could reduce the availability of soft drinks in schools.
  • Risky sexual behavior and associated factors in undergraduate students in a city in Southern Brazil Original Articles

    Gräf, Débora Dalmas; Mesenburg, Marilia Arndt; Fassa, Anaclaudia Gastal

    Abstract in Portuguese:

    RESUMO OBJETIVO Descrever o comportamento sexual de ingressantes universitários de acordo com características demográficas, econômicas, psicossociais e comportamentais, e avaliar a prevalência de comportamento sexual de risco e seus fatores associados. MÉTODOS Estudo de delineamento transversal, do tipo censo, com universitários maiores de 18 anos, de 80 cursos de graduação da Universidade Federal de Pelotas (UFPel), no RS, que ingressaram no primeiro semestre de 2017 e que permaneceram matriculados no segundo semestre. Avaliou-se o comportamento sexual de risco entre os estudantes que relataram já ter tido relações sexuais alguma vez na vida, considerado quando relatado mais de um parceiro sexual nos últimos três meses e não ter utilizado preservativo na última relação. RESULTADOS A prevalência de comportamento sexual de risco foi de 9% (IC95% 7,6–10,5). Estudantes do sexo masculino apresentaram mais comportamento de risco do que estudantes do sexo feminino, com prevalência de 10,8% e 7,5%, respectivamente. Dos universitários, 45% não utilizaram preservativo na última relação e 24% tiveram dois parceiros ou mais nos últimos três meses. Os aplicativos de celular para fins sexuais nos últimos três meses foram utilizados por 23% dos estudantes. O comportamento sexual de risco esteve associado com sexo, idade da primeira relação sexual, frequência de consumo de bebidas alcoólicas, consumo de substâncias psicoativas antes da última relação e uso de aplicativos de celular para fins sexuais. CONCLUSÃO Embora se espere que os universitários sejam uma população informada, a prevalência de comportamento sexual de risco foi importante, indicando a necessidade de ampliação do investimento público em ações de educação sexual e conscientização.

    Abstract in English:

    ABSTRACT OBJECTIVE To describe the sexual behavior of freshmen undergraduate students according to demographic, economic, psychosocial and behavioral characteristics, and evaluate the prevalence of risky sexual behavior and its associated factors. METHODS A cross-sectional study of the census type with undergraduate students over 18 years old of 80 undergraduate courses of the Universidade Federal de Pelotas (UFPel), in Rio Grande do Sul (RS), who entered in the first semester of 2017 and remained enrolled in the second semester. Undergraduate students who reported having had sex were evaluated. We considered as risky sexual behavior having more than one sexual partner within the last three months and not having used condoms in the last sexual intercourse. RESULTS The prevalence of risky sexual behavior was 9% (95%CI 7.6–10.5). Men presented more risky behavior than women, with a prevalence of 10.8% and 7.5%, respectively. Of the undergraduate students, 45% did not use condoms in the last sexual intercourse, and 24% had two partners or more within three months before the survey. Smartphone applications for sexual purposes were used by 23% of students within three months before the survey. Risky sexual behavior was associated with gender, age at first sexual intercourse, frequency of alcohol consumption, consumption of psychoactive substances before the last sexual intercourse and use of smartphone applications for sexual purposes. CONCLUSION Although undergraduate students are expected to be an informed population, the prevalence of risky sexual behavior was important, indicating the need to expand public investment in sexual education and awareness actions.
  • Consequences of Chronic Non-Cancer Pain in adulthood. Scoping Review. Review

    Cáceres-Matos, Rocío; Gil-García, Eugenia; Barrientos-Trigo, Sergio; Porcel-Gálvez, Ana María; Cabrera-León, Andrés

    Abstract in Spanish:

    RESUMEN OBJETIVO Examinar y mapear las consecuencias del dolor crónico en la edad adulta. MÉTODO Se incluyeron documentos que abordaban las repercusiones del dolor crónico en las esferas psicológica y social de las personas que lo padecen, publicados en español e inglés entre los años 2013–2018. Aquellos que abordaban tratamientos farmacológicos, dolor crónico derivado de intervenciones quirúrgicas o que no tenían acceso a texto completo fueron excluidos. Finalmente, se incluyeron 28 documentos de los 485 revisados. RESULTADOS Los estudios muestran que el dolor se relaciona con altas tasas de limitación en las actividades de la vida diaria, alteraciones del sueño y trastornos del espectro ansiedad-depresión. Las personas con dolor experimentan más problemas para rendir en la jornada laboral y mantener relaciones sociales. Con respecto a la familia, el dolor crónico se ha asociado con un peor funcionamiento familiar. CONCLUSIONES Esta revisión pone de manifiesto que las limitaciones en la capacidad para realizar actividades de la vida diaria, el sueño, la salud psicológica, los recursos sociales y laborales y el funcionamiento familiar son líneas de interés en los trabajos publicados. Sin embargo, se detectan lagunas de conocimiento en áreas como la influencia de haber padecido dolor en la infancia o adolescencia, las consecuencias por incumplimiento de la jornada laboral y las desigualdades de género.

    Abstract in English:

    ABSTRACT OBJECTIVE To examine and map the consequences of chronic pain in adulthood. METHOD Documents addressing the impact of chronic pain on the psychological and social spheres of people suffering from chronic pain, published in Spanish and English between 2013 and 2018, were included. Those who addressed pharmacological treatments, chronic pain resulting from surgical interventions or who did not have access to the full text were excluded. Finally, 28 documents from the 485 reviewed were included RESULTS Studies show that pain is related to high rates of limitation in daily activities, sleep disorders and anxiety-depression spectrum disorders. People in pain have more problems to get the workday done and to maintain social relationships. Chronic pain is also associated with worse family functioning. CONCLUSIONS This review shows that limitations in the ability to perform activities of daily living, sleep, psychological health, social and work resources and family functioning are lines of interest in published articles. However, knowledge gaps are detected in areas such as the influence of having suffered pain in childhood or adolescence, the consequences of non-fulfillment of working hours and gender inequalities.
  • Translating transmissibility measures into recommendations for coronavirus prevention Comments

    Diaz-Quijano, Fredi Alexander; Rodriguez-Morales, Alfonso Javier; Waldman, Eliseu Alves

    Abstract in English:

    ABSTRACT The rapid increase in clinical cases of the new coronavirus disease, COVID-19, suggests high transmissibility. However, the estimates of the basic reproductive number reported in the literature vary widely. Considering this, we drew the function of contact-rate reduction required to control the transmission from both detectable and undetectable sources. Based on this, we offer a set of recommendations for symptomatic and asymptomatic populations during the current pandemic. Understanding the dynamics of transmission is essential to support government decisions and improve the community’s adherence to preventive measures.
  • Pattern evolution of antidepressants and benzodiazepines use in a cohort Original Articles

    Alcantara, Geisy de Carvalho; Coutinho, Evandro Silva Freire; Faerstein, Eduardo

    Abstract in English:

    ABSTRACT OBJECTIVE In recent decades there has been an increase in the use of antidepressants (AD) and a decrease in the use of benzodiazepines (BDZ). Prevalence, cumulative incidence, and factors associated with the incidence of AD and BDZ use in a Brazilian population were estimated in this article. METHODS Data were collected with a self-administered questionnaire in a cohort of employees from a university in Rio de Janeiro. The prevalence of the use of AD and BDZ was calculated for 1999 (4,030), 2001 (3,574), 2006-07 (3,058), and 2012 (2,933). The cumulative incidences of the use of AD and BDZ between 1999 and 2007 were estimated by the Poisson models with robust variance estimates. RESULTS In 1999, the prevalence of the use of AD and BDZ were 1.4% (95%CI: 1.1–1.8) and 4.7% (95%CI: 4.1–5.4), respectively; in 2012, they were 5.4% (95%CI: 5.5–6.2) and 6.8% (95%CI: 6.0–7.8). The incidence of use, between 1999 and 2007, was 4.9% (95%CI: 4.2–5.7) for AD and 8.3% (95%CI: 7.3–9.3) for BDZ. The incidences of AD and BDZ use were higher among women and participants with a positive General Health Questionnaire. CONCLUSION In this population, the increase in the use of AD was not accompanied by a decrease in the use of BDZ, showing the prescriptions for psychotropic medication do not follow the currently recommended guidelines for treatment of common mental health disorders.
  • Adolescent Friendly Services: quality assessment with simulated users Original Articles

    Pastrana-Sámano, Rosalila; Heredia-Pi, Ileana Beatriz; Olvera-García, Marisela; Ibáñez-Cuevas, Midiam; Castro, Filipa De; Hernández, Aremis Villalobos; Torres-Pereda, Maria del Pilar

    Abstract in Spanish:

    RESUMEN OBJETIVO Evaluar la calidad de los servicios de salud amigables para adolescentes. MÉTODOS Evaluación cualitativa utilizando la técnica de usuario simulado en clínicas de primer nivel de los Servicios de Salud de Morelos, México durante 2018. Se seleccionaron aleatoriamente 10 de 17 establecimientos con servicios amigables no exclusivos para adolescentes. Se incluyó adicionalmente un centro con servicios amigables exclusivo para adolescentes como submuestra de tipo intensivo. Cuatro adolescentes fungieron como usuarios simulados interpretando diferentes casos de consulta en las clínicas. Se realizaron 43 entrevistas semiestructuradas de salida y se hicieron dos grupos nominales para evaluar la calidad percibida a partir de la percepción de amigabilidad y la experiencia de los adolescentes. Se realizó análisis temático de los datos obtenidos. RESULTADOS La actitud del personal destacó como un elemento clave para la experiencia de los adolescentes. Se encontraron fallas como la existencia de barreras burocráticas para el acceso, falta de señalamientos en las clínicas, falta de privacidad y confidencialidad, fallas en la exploración física durante la consulta y falta de seguimiento de los motivos de consulta. La clínica exclusiva para adolescentes ofreció servicios amigables más adecuados en comparación con las clínicas no exclusivas. CONCLUSIÓN Aunque en la mayoría de los establecimientos visitados el servicio es accesible, aun distan de cumplir con las características de amigabilidad de acuerdo con las recomendaciones internacionales. La clínica exclusiva para adolescentes destacó al contar con mecanismos mejor estructurados que pueden ser implementados en clínicas no exclusivas para mejorar el proceso de atención.

    Abstract in English:

    ABSTRACT OBJECTIVE To assess the quality of adolescent friendly health services. METHODS Qualitative assessment using the simulated user technique in first level clinics of Health Services of Morelos, Mexico, during 2018. Ten out of 17 facilities with non-exclusive adolescent friendly services were randomly selected. An additional facility with exclusive adolescent friendly services was included as an intensive subsample. Four adolescents served as simulated users interpreting different cases in the clinics. The total of 43 semi-structured exit interviews were conducted, and two nominal groups were made to assess the perceived quality from the adolescents’ perception of friendliness and experience. Thematic analysis of the data obtained was performed. RESULTS Staff attitude was highlighted as a key element in the adolescents’ experience. Failures were found, such as the existence of bureaucratic barriers to access, lack of signage in clinics, lack of privacy and confidentiality, failure of physical examination during the appointment and lack of monitoring of the reasons for appointment. The exclusive clinic for adolescents offered more appropriate friendly services compared with nonexclusive clinics. CONCLUSION Although the service is accessible in most of the clinics visited, it is still far from being friendly according to international recommendations. The exclusive clinic for adolescents stood out for having better structured mechanisms that can be implemented in nonexclusive clinics to improve the care process.
  • Regular dental care in preschoolers in rural Southern Brazil Original Articles

    Camerini, Adriana Vieira; Silva, Alexandre Emidio Ribeiro; Prietsch, Silvio Omar Macedo; Meucci, Rodrigo Dalke; Soares, Mariane Pergher; Belarmino, Vanusa; Fernandes, Fabiana da Silva

    Abstract in Portuguese:

    RESUMO OBJETIVO Avaliar se fatores relacionados à orientação prévia da mãe sobre saúde bucal dos seus filhos e a frequência escolar das crianças influenciam o atendimento odontológico regular de pré-escolares moradores da área rural de um município do Sul do Brasil. MÉTODOS Um estudo de base populacional foi conduzido com 264 crianças menores de cinco anos e suas mães. Dados socioeconômicos e comportamentais foram coletados por meio de questionário e as crianças foram submetidas a exames de saúde bucal. O desfecho foi o uso regular de serviços odontológicos. As variáveis de exposição principais foram o atendimento infantil em creches ou escolas e orientação materna sobre a saúde bucal da criança. A análise de regressão de Poisson com ajuste robusto de variância foi utilizada para estimar as razões de prevalência e intervalos de confiança de 95%. RESULTADOS A prevalência de uso regular foi 11,4% (IC95% 7,5–15,2). Na análise ajustada o uso regular de serviços foi associado à criança frequentar creche/escola (RP = 2,44; IC95% 1,38–4,34) e a mãe ter recebido orientação de saúde bucal (RP = 4,13; IC95% 1,77–9,61), mesmo com controle para variáveis socioeconômicas, maternas e da criança. CONCLUSÃO Quando as mães recebem informações prévias sobre os cuidados com a saúde bucal infantil e as crianças frequentam escolas ou creches, aumenta a probabilidade de consultas odontológicas regulares em pré-escolares residentes em localidades rurais.

    Abstract in English:

    ABSTRACT OBJECTIVE To evaluate if factors related to the mother’s previous guidance on her children’s dental health and the school attendance of children influence the regular dental care of preschoolers living in the rural area of a municipality in Southern Brazil. METHODS A population-based study was conducted with 264 children under five years of age and their mothers. Socioeconomic and behavioral data were collected using a questionnaire, and the children were subjected to dental health tests. The outcome was the regular use of dental services. The main exposure variables were children’s care in daycare centers or schools and maternal guidance on the child’s dental health. Poisson regression analysis with robust variance adjustment was used to estimate prevalence ratios, considering a 95% confidence interval. RESULTS The prevalence of regular use was 11.4% (95%CI 7.5–15.2). In the adjusted analysis, the regular use of services was associated with the child attending day care center/school (PR = 2.44; 95%CI 1.38–4.34), and the mother received dental health guidance (PR = 4.13; 95%CI 1.77–9.61), even with control for socioeconomic, maternal and child variables. CONCLUSION When mothers receive previous information on child dental health care and children attend schools or daycare centers, the likelihood of regular dental appointments in preschoolers living in rural locations increases.
  • Robust older adults in primary care: factors associated with successful aging Original Articles

    Maia, Luciana Colares; Colares, Thomaz de Figueiredo Braga; Moraes, Edgar Nunes de; Costa, Simone de Melo; Caldeira, Antônio Prates

    Abstract in Portuguese:

    RESUMO OBJETIVO Estimar a prevalência de robustez entre idosos assistidos na atenção primária à saúde e identificar fatores de envelhecimento bem-sucedido. MÉTODOS Trata-se de pesquisa transversal, realizada com idosos no norte de Minas Gerais, Brasil. Foram utilizados dois questionários para coleta de dados: Brazilian Older Americans Resources and Services Multidimensional Function Assessment Questionnaire (BOMFAQ) e Índice de Vulnerabilidade Clínico-Funcional (IVCF-20). As razões de prevalências ajustadas foram obtidas por análise de regressão de Poisson múltipla com variância robusta. A análise estatística foi realizada para os idosos em geral (60 a 107 anos) e estratificada por idade: de 60 a 79 anos e 80 anos ou mais. RESULTADOS Participaram 1.750 idosos, com idade de 60 a 107 anos, sendo 48,7% robustos. Idosos de 60 a 79 anos (n = 1.421) e 80 anos ou mais (n = 329) apresentaram prevalência de robustez de 55,4% e 19,3%, respectivamente. Associaram-se ao envelhecimento bem-sucedido: autopercepção positiva da saúde, dançar, fazer caminhada, não ter comprometimento cognitivo, ausência de sintomas depressivos e de polipatologia, além de independência para atividades de vida diária. Após ajuste por idade, destacam-se para robustez entre 60 a 79 anos a ausência de polipatologia e a independência para atividades de vida diária; naqueles com 80 anos e mais, a independência para atividades de vida diária e a prática de dança apresentaram maior força de associação. CONCLUSÃO A prevalência de idosos robustos na atenção primária pode ser considerada satisfatória para os idosos em geral, mas reduz com a idade e se associa com a ausência de doenças e incapacidades. Esses resultados denotam a necessidade de redesenhar o sistema de atenção à saúde, com foco na promoção e prevenção da vulnerabilidade clínico-funcional.

    Abstract in English:

    ABSTRACT OBJECTIVE To estimate the prevalence of robustness among older adults assisted in primary health care and identify factors in successful aging. METHODS This is a cross-sectional study conducted with older adults in Northern Minas Gerais, Brazil. Two questionnaires were used for data collection: the Brazilian Older Americans Resources and Services Multidimensional Function Assessment Questionnaire (BOMFAQ) and the Clinical-Functional Vulnerability Index IVCF-20). The adjusted prevalence ratios were obtained by robust Poisson regression. Statistical analysis was performed for older adults in general (60 to 107 years) and stratified by age: from 60 to 79 years and 80 years or more. RESULTS A total of 1,750 older adults aged 60 to 107 years participated; between them, 48.7% were robust. Older adults aged 60 to 79 years (n = 1,421) and 80 years or more (n = 329) had a prevalence of robustness of 55.4% and 19.3%, respectively. Some factors associated with successful aging were: positive self-perception of health, dancing habits, walking habits, absence of cognitive impairment, absence of depressive symptoms and polypathology, as well as daily life independence. After adjustment by age, the absence of polypathology and independence for activities of daily living stand out for robustness between 60 and 79 years; in those aged 80 years and over, independence for activities of daily living and dance practice presented greater strength of association. CONCLUSION The prevalence of robust older adults in primary care is considered satisfactory for the older population in general but decreases with age and is associated with the absence of diseases and disabilities. These results denote the need to redesign the health care system, focusing on promoting and preventing clinical-functional vulnerability.
  • Community-Based Rehabilitation (CBR) in primary care centers in Chile Original Articles

    Besoain-Saldaña, Álvaro; Sanhueza, Jame Rebolledo; Hizaut, Mónica Manríquez; Rojas, Valentina Cortínez; Ortega, Gabriela Huepe; Aliaga-Castillo, Verónica

    Abstract in Spanish:

    RESUMEN OBJETIVO Describir el estado de implementación de la Rehabilitación Basada en la Comunidad en Chile. MÉTODOS Estudio cuantitativo, transversal y descriptivo. El universo estuvo conformado por los 66 centros comunitarios de rehabilitación de la Región Metropolitana de Chile que implementaron la Rehabilitación Basada en la Comunidad hasta diciembre de 2016. El muestreo tuvo intención censal, por lo que se contactaron todos los centros comunitarios. Se aplicó un cuestionario autoadministrado diseñado con base a la matriz de Rehabilitación Basada en la Comunidad definida por la Organización Mundial de la Salud. El cuestionario fue respondido on-line por los coordinadores de la estrategia en sus respectivos centros. El análisis de datos se realizó utilizando estadígrafos descriptivos. RESULTADOS Se identificó un nivel heterogéneo de implementación de la Rehabilitación Basada en la Comunidad, específicamente en cuanto a los componentes de la matriz descrita por la Organización Mundial de la Salud. El componente más implementado fue Salud; los componentes Social, Subsistencia y Fortalecimiento fueron medianamente implementados; y el componente Educación fue el menos implementado. CONCLUSIÓN La implementación de la Rehabilitación Basada en la Comunidad se basa principalmente en el componente Salud. Se requiere aumentar el nivel de implementación de los otros componentes de la matriz, así como de estrategias interdisciplinarias e intersectoriales para lograr una mayor inclusión social de las personas con discapacidad.

    Abstract in English:

    ABSTRACT OBJECTIVE To describe the implementation status of the Community-Based Rehabilitation in Chile. METHODS Quantitative, transversal and descriptive study. The scope was constituted by the 66 community-based rehabilitation centers in the Chilean Metropolitan Region that implemented Community-Based Rehabilitation until December 2016. The sampling was based on a census method, so all the community centers were contacted. A self-administered questionnaire designed based on the Community-Based Rehabilitation matrix defined by the World Health Organization was applied. The questionnaire was answered on-line by the coordinators of the strategy in their respective centers. The data analysis was performed using descriptive statistics. RESULTS A heterogeneous level of implementation of Community-Based Rehabilitation was identified, specifically in terms of the components of the matrix described by the World Health Organization. The most implemented component was Health; the Social, Livelihood and Empowerment components were moderately implemented; and the Education component was the least implemented. CONCLUSION The implementation of Community-Based Rehabilitation is mainly based on the Health component. The level implementation of the other components of the matrix needs to be increased, as well as interdisciplinary and intersectoral strategies to achieve greater social inclusion of people with disabilities.
  • Outbreak investigation in cargo ship in times of COVID-19 crisis, Port of Santos, Brazil Brief Communication

    Fernandes, Eder Gatti; Santos, Janice da Silva; Sato, Helena Keico

    Abstract in Portuguese:

    RESUMO Em fevereiro de 2020, um navio de carga vindo da China atracou no Porto de Santos com relato de tripulantes com quadro febril e respiratório. Uma equipe foi mobilizada para verificar a existência de casos suspeitos de COVID-19 dentro da embarcação e definir a liberação da embarcação no porto. Todos os 25 tripulantes foram entrevistados e não foram encontrados casos suspeitos. Então a embarcação foi liberada para atividades no porto. A investigação resultou da aplicação do plano de contingência diante de uma emergência de saúde pública de importância internacional e houve a colaboração de diversas entidades de vigilância.

    Abstract in English:

    ABSTRACT In February 2020, a Chinese cargo ship docked at the Port of Santos with reports of crew members with a feverish and respiratory condition. A team was gathered to verify the existence of suspected cases of COVID-19 inside the vessel and define its clearance. All 25 crew members were interviewed, and no suspected cases were found. The vessel was then cleared for port activities. The investigation resulted from the implementation of the contingency plan to face a public health emergency of international importance and several surveillance entities cooperated.
  • Suicidal ideation and associated factors among high school adolescents Original Articles

    Sousa, Cyntia Meneses de Sá; Mascarenhas, Márcio Dênis Medeiros; Gomes, Keila Rejane Oliveira; Rodrigues, Malvina Thaís Pacheco; Miranda, Cássio Eduardo Soares; Frota, Karoline de Macêdo Gonçalves

    Abstract in Portuguese:

    RESUMO OBJETIVO Analisar a prevalência de ideação suicida e fatores associados em adolescentes escolares. MÉTODOS Estudo transversal de base escolar com 674 estudantes de escolas públicas e privadas em Teresina, Piauí, em 2016. Realizou-se análise bivariada com o teste do qui-quadrado e análise múltipla pelo modelo de regressão de Poisson para estimar as razões de prevalência (RP) e intervalos de confiança de 95% (IC95%). RESULTADOS Os participantes do estudo foram em sua maioria estudantes do sexo feminino (56,7%), negros (77,4%), que moravam com os pais (85%), cujas mães apresentavam escolaridade maior ou igual a 8 anos de estudo (68,8%), com renda familiar maior que um salário mínimo (58,3%), praticantes de alguma religião (86,8%) e procedentes de escola pública (64,7%). A prevalência de ideação suicida foi de 7,9%. Maior frequência de ideação suicida foi relatada entre estudantes do sexo feminino (10,2%). Ideação suicida foi associada estatisticamente aos alunos que referiram não residir com os pais (RP ajustada = 2,27; IC95% 1,26–4,10; p < 0,05) e àqueles que informaram ter sofrido violência sexual por outros alunos, professores ou funcionários da escola (RP ajustada = 3,40; IC95% 1,80–6,44; p < 0,05), entre os quais a prevalência de ideação suicida foi mais de três vezes a observada entre aqueles que não referiram esse tipo de violência. CONCLUSÃO A prevalência de ideação suicida em adolescentes escolares foi associada ao sexo feminino, não residir com os pais e ter sido vítima de violência sexual na escola. Recomenda-se alertar a comunidade escolar e profissionais de saúde para identificarem sinais do comportamento suicida, em especial naqueles com suspeita ou comprovação da ocorrência de violência sexual na escola.

    Abstract in English:

    ABSTRACT OBJECTIVE To analyze the prevalence of suicidal ideation and its associated factors in school adolescents. METHODS Cross-sectional school-based study with 674 students from public and private schools in Teresina, Piauí, in 2016. Bivariate analysis was performed with the chi-square test and multiple analysis by the Poisson regression model to estimate prevalence ratios (PR) and 95% confidence intervals (95%CI). RESULTS The study participants were mostly female (56.7%), black (77.4%), who lived with their parents (85%), whose mothers had schooling greater than or equal to 8 years of schooling (68.8%), with family income greater than a minimum wage (58.3%), practitioners of some religion (86.8%) and coming from public school (64.7%). The prevalence of suicidal ideation was 7.9%. Higher frequency of suicidal ideation was reported among female students (10.2%). Suicidal ideation was statistically associated with students who reported not living with their parents (adjusted PR = 2.27; 95%CI 1.26–4.10; p < 0.05) and those who reported having suffered sexual violence by other students, teachers or school staff (adjusted PR = 3.40; 95%CI 1.80–6.44; p < 0.05), among which the prevalence of suicidal ideation was more than three times that observed among those who did not mention this type of violence. CONCLUSION The prevalence of suicidal ideation in school adolescents was associated with female students, who did not live with parents and have been victim of sexual violence at school. We recommend advising the school community and health professionals to identify signs of suicidal behavior, especially in those with suspicion or proof of the occurrence of sexual violence at school.
  • Characteristics of primary care and rates of pediatric hospitalizations in Brazil Original Articles

    Lisboa, Lívia Anniele Sousa; Queiroz, Rejane Christine de Sousa; Thomaz, Erika Bárbara Abreu Fonseca; Silva, Núbia Cristina da; Rocha, Thiago Augusto Hernandes; Vissoci, João Ricardo Nickenig; Staton, Catherine Ann; Lein, Adriana; Simões, Vanda Maria Ferreira; Thumé, Elaine; Facchini, Luiz Augusto

    Abstract in English:

    ABSTRACT OBJECTIVE To evaluate the association among characteristics of primary health care center (PHCC) with hospitalizations for primary care sensitive conditions (PCSC) in Brazil. METHOD In this study, a cross-sectional ecological study was performed. This study analyzed the 27 capitals of Brazil’s federative units. Data were aggregated from the following open access databases: National Program for Access and Quality Improvement in Primary Care, the Hospital Information System of Brazilian Unified Health System and Annual Population Census conducted by the Brazilian Institute of Geography and Statistics. Associations were estimated among characteristics of primary care with the number of three PCSC as the leading causes of hospitalization in children under-5 population in Brazil: asthma, diarrhea, and pneumonia. RESULTS In general, PHCC showed limited structural adequacy (37.3%) for pediatric care in Brazil. The capitals in South and Southeast regions had the best structure whereas the North and Northeast had the worst. Fewer PCSC hospitalizations were significantly associated with PHCC which presented appropriate equipment (RR: 0.98; 95%CI: 0.97–0.99), structural conditions (RR: 0.98; 95%CI: 0.97–0.99), and signage/identification of professionals and facilities (RR: 0.98; 95%CI: 0.97–0.99). Higher PCSC hospitalizations were significantly associated with PHCC with more physicians (RR: 1.23, 95%CI: 1.02–1.48), it forms (RR: 1.01, 95%CI: 1.01–1.02), and more medications (RR: 1.02, 95%CI: 1.01–1.03) CONCLUSION Infrastructural adequacy of PHCC was associated with less PCSC hospitalizations, while availability medical professional and medications were associated with higher PCSC hospitalizations.
  • Association between cigarette use and adolescents’ behavior Original Articles

    Cruz, Jamile Francelino; Lisboa, Jonathan Lopes de; Zarzar, Patricia Maria Pereira de Araújo; Santos, Carolina da Franca Bandeira Ferreira; Valença, Paula Andréa de Melo; Menezes, Valdenice Aparecida de; Colares, Viviane

    Abstract in English:

    ABSTRACT OBJECTIVE To determine the prevalence of cigarette use among adolescents and to identify associated health risk behaviors. METHODS This is a cross-sectional study with a representative sample, composed of 1059 adolescents between 13 and 19 years old, enrolled in primary and secondary public schools of Olinda, Pernambuco, in 2014. Information was obtained through self-administered questionnaires (validated version of YRBS 2007). Cigarette experimentation was defined as smoking at least once in life. Adolescents who smoked at least one day within 30 days prior to the survey were considered current smokers. Most students were female and 16 years old or older. RESULTS Almost 30% used it in life and about 10% smoked within the 30 days before the survey. Suicidal ideation (PR = 1.51, 95%CI 1.25–1.82), alcohol use (PR = 1.41, 95%CI 1.03–1.92), marijuana (PR = 1.64, 95%CI 1.37–1.96), excessive alcohol consumption (PR = 1.57, 95%CI 1.15–2.16) and sexual experience (PR = 1.78, 95%CI 1.43–2.21) have increased the risk of using cigarettes. Feelings of sadness (PR = 1.70, 95%CI 1.22–2.36), alcohol use (PR=2.40, 95%CI 1.12–5.12), excessive alcohol consumption (PR = 2.5, 95% CI 1.24–5.38), marijuana (PR = 2.31, 95%CI.57–3.39) and cocaine (PR = 1.99, 95%CI.32–3.01) increased the risk of cigarette use within the 30 days before the survey. CONCLUSIONS Cigarette use among adolescents from Olinda was high, being considered higher than the national prevalence. Possible factors associated with cigarette use were drug use (alcohol, marijuana, and cocaine) and behaviors related to sexual experience, feelings of sadness and suicidal ideation.
  • Socioeconomic status and family functioning influence oral health literacy among adolescents Original Articles

    Lopes, Roanny Torres; Neves, Érick Tássio Barbosa; Dutra, Laio da Costa; Gomes, Monalisa Cesarino; Paiva, Saul Martins; Abreu, Mauro Henrique Nogueira Guimarães de; Ferreira, Fernanda Morais; Granville-Garcia, Ana Flávia

    Abstract in English:

    ABSTRACT OBJECTIVE Evaluate socio-demographic, family and behavioral factors associated with oral health literacy (OHL) in adolescents. METHODS Cross-sectional study conducted with adolescents aged 15 to 19 years in Campina Grande, Brazil. Parents/guardians answered a questionnaire addressing socio-demographic data. The adolescents answered validated instruments on family cohesion and adaptability (family adaptability and cohesion evaluation scale), drug use (alcohol, smoking and substance involvement screening test), type of dental service used for last appointment and OHL (Brazilian version of the Rapid Estimate of Oral Health Literacy in Dentistry). Two dentists were trained to evaluate OHL (K = 0.87–0.88). Descriptive analysis was performed, followed by Poisson regression analysis (α = 5%). A directed acyclic graph was used to select independent variables in the study. RESULTS The following variables remained associated with better OHL: high mother’s schooling level (RR = 1.07; 95%CI: 1.03–1.12), high income (RR = 1.04; 95%CI: 1.01–1.09), white ethnicity/skin color (RR = 1.05; 95%CI: 1.01–1.10), married parents (RR = 1.04; 95%CI: 1.01–1.09), “enmeshed” family cohesion (RR = 1.21; 95%CI: 1.12–1.30), “structured” (RR = 1.06; 95%CI: 1.01–1.12) or “rigid” (RR = 1.11; 95%CI: 1.04–1.19) family adaptability, having more than five residents in the home (RR = 1.07; 95%CI: 1.01–1.14) and having used a private dental service during the last appointment (RR = 1.08; 95%CI: 1.03–1.13). CONCLUSION Family functioning and socio-demographic factors influence the level of oral health literacy among adolescents.
  • Development of an instrument to measure the cultural competence of health care workers Original Articles

    Pedrero, Victor; Bernales, Margarita; Chepo, Macarena; Manzi, Jorge; Pérez, Miguel; Fernández, Paulina

    Abstract in Spanish:

    RESUMEN OBJETIVO Validar un instrumento de medición de competencia cultural en trabajadores de salud de Chile. MÉTODOS Utilizando el modelo teórico de Sue y Sue, se diseñó un instrumento de medición el cual fue evaluado por trabajadores de salud y expertos. Este instrumento se aplicó a una muestra diversa de 483 proveedores de salud, durante 2018 en Santiago de Chile. Se realizó análisis factorial exploratorio, confirmatorio, estimación de confiabilidad y análisis de sesgo de medición. Se estimó el nivel de competencia cultural alcanzado por los profesionales. RESULTADOS El instrumento final contó con 14 ítems los cuales se agruparon en tres dimensiones: sensibilidad a los propios prejuicios, conocimiento cultural y habilidades para trabajar en entornos culturalmente diversos. Esta herramienta mostró buen ajuste en los modelos factoriales, adecuada confiabilidad y ausencia de evidencias de sesgo de medición. Los trabajadores de salud evaluados exhibieron un bajo nivel de sensibilidad a los propios prejuicios en comparación con las otras dimensiones evaluadas. CONCLUSIONE La Escala de Medición de Competencia Cultural en trabajadores de salud (EMCC-14) es una herramienta confiable, con soporte inicial para su validez, que puede usarse en el contexto Chileno. Además, los resultados de este estudio podrían guiar algunas posibles intervenciones en el sector de la salud para fortalecer el nivel de competencia cultural.

    Abstract in English:

    ABSTRACT OBJECTIVE To validate an instrument measuring the cultural competence in health care workers from Chile. METHODS Using Sue & Sue’s theoretical model of cultural competence, we designed a scale, which was assessed by health care workers and experts. Subsequently, the scale was applied to a sample of 483 different health care workers, during 2018 in Santiago de Chile. The analysis included: exploratory and confirmatory factor analysis, estimation of reliability, and analysis of measurement bias. Finally, the level of cultural competence was calculated for every professional who participated in this study. RESULTS The final scale include 14 items that are grouped into three dimensions concordant with the theoretical model: sensitivity to own prejudices, cultural knowledge, and skills to work in culturally diverse environments. This scale showed good fit in factor models, adequate reliability and lack of evidence of measurement bias. Regarding the performance of health care workers, sensitivity showed a lower level compared with the other dimensions evaluated. CONCLUSION The scale for measuring the level of cultural competence in health care workers (EMCC-14) is a reliable instrument, with initial support for its validity, which can be used in the Chilean context. Additionally, the results of this study could guide some possible interventions in the health sector to strengthen the level of cultural competence.
  • Years of life lost by CNCD attributed to occupational hazards in Brazil: GBD 2016 study Original Articles

    Assunção, Ada Ávila; França, Elisabeth Barboza

    Abstract in Portuguese:

    RESUMO OBJETIVO Avaliar anos de vida perdidos por morte prematura e por incapacidade ( disability-adjusted life years – DALY) em decorrência de doenças crônicas não transmissíveis atribuíveis a fatores de risco ocupacionais e comparar a posição desses fatores no ranking dos riscos para doenças crônicas não transmissíveis em 1990 e 2016. MÉTODOS Os dados referentes ao indicador DALY, estimado no estudo de Carga Global de Doenças de 2016 (GBD 2016), foram analisados para doenças crônicas não transmissíveis atribuíveis a fatores de risco ocupacionais e outros selecionados no Brasil. Realizou-se análise descritiva comparando a proporção de DALY por sexo e faixa etária (15 a 49 e 50 a 69 anos), além do ranqueamento de atribuição dos fatores de risco ocupacionais em 1990 e 2016. RESULTADOS Em 2016, fatores de risco ergonômicos, agentes carcinogênicos e ruído no ambiente laboral estiveram entre os 25 que mais contribuíram para os DALY por doenças crônicas não transmissíveis na faixa etária de 15 a 49 anos. A contribuição de todos fatores de risco ocupacionais aumentou em 2016, exceto os aerodispersoides ocupacionais para os homens. Para a faixa etária de 50 a 69 anos, sobressaem os agentes carcinogênicos ocupacionais, com aumento de 26.0% para homens e 17.1% para mulheres em 2016. Comparando o ranqueamento de 1990 e 2016 dos fatores de risco avaliados, os ocupacionais ascenderam de posição, com destaque em relação aos demais. CONCLUSÕES A carga global de doenças crônicas não transmissíveis atribuídas aos fatores de risco ocupacionais têm adquirido importância crescente. Sugere-se reforçar a abordagem dos fatores de risco ocupacionais nas agendas para enfrentamento dessas doenças no Brasil.

    Abstract in English:

    ABSTRACT OBJECTIVE To assess the years of life lost due to premature death and disability-adjusted life years (DALY) as a result of chronic noncommunicable diseases attributable to occupational hazard factors, and to compare their position according to the risk ranking for chronic noncommunicable diseases in 1990 and 2016. METHODS Data for the DALY indicator, estimated from the Global Burden of Disease 2016 (GBD 2016) study, were analyzed for noncommunicable chronic diseases attributable to occupational, and other risk factors, selected in Brazil. A descriptive analysis was performed comparing the proportion of DALY by sex and age group (15 to 49 and 50 to 69 years old), as well as the ranking of occupational hazard factors in 1990 and 2016. RESULTS In 2016, ergonomic risk factors, carcinogenic agents, and noise in the workplace were among the 25 largest contributors to DALY for chronic noncommunicable diseases affecting the age group between 15 and 49 years. The contribution of all occupational hazard factors increased in 2016, except for occupational aerodispersoids affecting men. Concerning the age group between 50 and 69, occupational carcinogens stand out, with an increase of 26.0% for men, and 17.1% for women in 2016. Risk factors evaluated according to their 1990 and 2016 ranking show that occupational hazards have all scored higher on the second evaluation (2016), especially when compared with other risks. CONCLUSIONS The global burden of chronic noncommunicable diseases attributed to occupational hazard factors has become increasingly important. We suggest the strengthening of the approach of occupational hazard factors in the agendas for tackling these diseases in Brazil.
  • Relationship between anthropometric indicators and risk factors for cardiovascular disease in adults and older adults of Rio Branco, Acre Original Articles

    Loureiro, Nathalia Silva de Lima; Amaral, Thatiana Lameira Maciel; Amaral, Cledir de Araújo; Monteiro, Gina Torres Rego; Vasconcellos, Maurício Teixeira Leite de; Bortolini, Miguel Junior Sordi

    Abstract in Portuguese:

    RESUMO OBJETIVO Analisar a associação entre variáveis antropométricas e os fatores de risco cardiovascular na população de adultos e idosos de Rio Branco, Acre. MÉTODOS Estudo transversal de base populacional com 641 adultos e 957 idosos. As análises estatísticas consistiram na distribuição das variáveis antropométricas segundo os fatores de risco cardiovascular por medidas de frequência e dispersão. Foram calculadas a correlação de Pearson e razões de prevalência (RP) com seus respectivos intervalos de confiança de 95% (IC5%), empregando as rotinas do SPSS ® versão 20.0. RESULTADOS Correlações moderadas foram obtidas nos adultos homens para relação cintura-quadril e colesterol total (r = 0,486; p < 0,001) e para relação cintura-quadril e triglicerídeos (r = 0,484; p < 0,001). As maiores prevalências de hipertensão arterial e diabetes nos adultos foram observadas nos homens; já nos idosos, as prevalências de hipertensão ficaram acima de 65% em ambos os sexos. As prevalências de dislipidemia ficaram acima de 78% nos indivíduos obesos adultos e idosos. Ao analisar as associações, constatou-se maior força de associação entre hipertensão arterial e relação cintura-estatura (RP = 13,42; IC95% 12,58–14,31) e com índice de massa corporal maior que 30 kg/m 2 (RP = 6,61; IC95% 6,34–6,89) nos homens adultos. Na análise para diabetes, a relação cintura-quadril apresentou maior robustez na associação para mulheres (RP = 7,53; IC95% 6,92–8,20) e homens (RP = 9,79; IC95% 9,14–10,49). CONCLUSÃO As variáveis antropométricas são importantes preditores de risco cardiovascular; no entanto, suas avaliações devem ser feitas de forma independente, segundo sexo e grupo etário.

    Abstract in English:

    ABSTRACT OBJECTIVE To analyze the association between anthropometric variables and cardiovascular risk factors in adults and older adults of Rio Branco, Acre. METHODS A population-based cross-sectional study with 641 adults and 957 older adults was conducted. The statistical analyses consisted of the distribution of anthropometric variables according to the cardiovascular risk factors by frequency and dispersion measures. Pearson’s correlation coefficient and prevalence ratios (PR) were estimated with their respective 95% confidence intervals (95%CI) using the SPSS ® version 20.0. RESULTS Moderate correlations were obtained in adult men for waist-hip ratio and total cholesterol (r = 0.486; p < 0.001) and for waist-hip and triglyceride ratios (r = 0.484; p < 0.001). The highest prevalence of hypertension and diabetes in adults were observed in men; in the older adults, the prevalence of hypertension was above 65% in both sexes. The prevalence of dyslipidemia was above 78% in obese adults and older adults. When analyzing the associations, a higher strength of association was found between arterial hypertension and waist-to-stature ratio (PR = 13.42; 95%CI 12.58–14.31) and body mass index greater than 30 kg/m 2 (PR = 6.61; 95%CI 6.34–6.89) in adult men. In the analysis of diabetes, the waist-hip ratio presented greater robustness in the association for women (PR = 7.53; 95%CI 6.92–8.20) and men (PR = 9.79; 95%CI 9.14–10.49). CONCLUSION Anthropometric variables are important predictors of cardiovascular risk; however, their assessments should be performed independently, according to sex and age group.
  • Cross-cultural adaptation of the Clear Communication Index to Brazilian Portuguese Original Articles

    Marinho, Angélica Maria Cupertino Lopes; Baur, Cynthia; Ferreira, Fernanda Morais; Borges-Oliveira, Ana Cristina; Abreu, Mauro Henrique Nogueira Guimarães de

    Abstract in English:

    ABSTRACT OBJECTIVE To perform a cross-cultural adaptation of the Clear Communication Index instrument from the Centers for Disease Control and Prevention (CDC-CCI) from English to Brazilian Portuguese. METHODS This study comprised initial discussion about the conceptual equivalence of the instrument by a committee formed by experts on health education. We performed translations, synthesis of translations, back-translations, revision by the committee, and linguistic revision. Semantic equivalence was obtained by analyzing the referential and general meaning of each item by the committee, resulting in a pre-final version of the instrument. Subsequently, thirty professionals with health sciences degrees performed a pre-test. These professionals used the pre-final version of the instrument to assess a health education material. A questionnaire was applied to evaluate the acceptability of the instrument, the understanding of each of the 20 items, as well as the individual and professional variables. We analyzed the scores attributed to the health education material, the variables related to healthcare professionals, the proportions of the acceptability of the instrument, and the comprehension of each item. RESULTS After we obtained the conceptual equivalence of the instrument, the committee of experts, the instrument’s main author, and the linguist produced the pre-final version using two translations, a synthesis of the translations, and two back-translations. A general equivalence was maintained in 15 of the 20 items (75%), four of the items were slightly altered (20%), and one item was very altered (5%). Nineteen items presented referential equivalence or near equivalence (95%). We then carried out with the pre-test, in which the professionals used the pre-final version. Two items in the domains of “risks” and “main message” were unclear and needed to be revised. CONCLUSION The process of cross-cultural adaptation of the Clear Communication Index provided an adapted version to the Brazilian Portuguese language.
  • Efficacy and safety of cryotherapy, cold cone or thermocoagulation compared to LEEP as a therapy for cervical intraepithelial neoplasia: Systematic review. Review

    Hurtado-Roca, Yamilée; Becerra-Chauca, Naysha; Malca, Magaly

    Abstract in Spanish:

    RESUMEN OBJETIVOS Evaluar la eficacia y seguridad del uso de crioterapia, cono frio o termo-coagulación en comparación con el procedimiento de escisión electroquirúrgica en asa (LEEP) para el manejo de neoplasias intraepiteliales cervicales. MÉTODOS Revisión sistemática de ensayos controlados aleatorizados en mujeres con neoplasia intraepitelial cervical en tratamiento con crioterapia, cono frio, o termo coagulación y LEEP, para estimar su eficacia y seguridad. La búsqueda se realizó en MEDLINE/PUBMED, Registro Cochrane Central de Ensayos Controlados (CENTRAL) y Scopus, hasta setiembre de 2018. RESULTADOS Se identificaron 72 estudios, ocho cumplieron los criterios de inclusión. Cono frio disminuyó el riesgo de enfermedad residual en comparación con LEEP (RR 0,54; IC del 95%, 0,30–0,96, p = 0,04). Crioterapia en comparación con LEEP incrementó el riesgo de recurrencia de enfermedad en un 86,0% (RR 1,86; IC del 95%, 1,16–2,97, p = 0,01) con un tiempo de seguimiento de seis a 24 meses, y de infecciones (RR, 1,17; IC del 95%, 1,08–1,28, p < 0,001); pero redujo el riesgo de sangrado menor en un 51,0% (RR 0,49; IC del 95%, 0,40–0,59, p ≤ 0,001). CONCLUSIONES Cono frio reduce el riesgo de enfermedad residual. Sin embargo, la crioterapia reduce el riesgo de sangrado menor en las 24 horas posteriores al tratamiento e incrementa el riesgo de recurrencia de enfermedad y de infecciones.

    Abstract in English:

    ABSTRACT OBJECTIVES To determine the efficacy and safety of the use of cryotherapy, cold knife or thermocoagulation compared to Loop Electrosurgical Excision Procedure (LEEP) for the treatment of cervical intraepithelial neoplasia. METHODS Systematic review with meta-analysis of randomized controlled trials in women with cervical intraepithelial neoplasia undergoing treatment with cryotherapy, cold knife, or thermo-coagulation compared with LEEP, to estimate its efficacy and safety. The search was conducted on MEDLINE/PUBMED, Cochrane Central Register of Controlled Trials (CENTRAL) and Scopus, until September 2018. RESULTS The total of 72 studies were identified, of which only 8 studies met the inclusion criteria. The treatment of CIN with cold knife decreases the risk of residual disease compared with LEEP (RR, 0.54, 95%CI, 0.30–0.96, p = 0.04). The management of premalignant lesions with cryotherapy, compared with LEEP, increases the risk of disease recurrence by 86% (RR, 1.86, 95%CI, 1.16–2.97, p = 0.01), increases the risk of infections (RR, 1.17, 95%CI, 1.08–1.28, p < 0.001) and reduces the risk of minor bleeding by 51% (RR, 0.49, 95%CI) %, 0.40–0.59, p ≤ 0.001). CONCLUSIONS The treatment of premalignant lesions of cervical cancer with cold knife reduces the risk of residual disease. Nevertheless, cryotherapy reduces the risk of minor bleeding in the 24 hours after treatment and increases the risk of recurrence of disease and infections.
  • The case of eculizumab: litigation and purchases by the Brazilian Ministry of Health Original Articles

    Caetano, Rosângela; Rodrigues, Paulo Henrique Almeida; Corrêa, Marilena C Villela; Villardi, Pedro; Osorio-de-Castro, Claudia Garcia Serpa

    Abstract in Portuguese:

    RESUMO OBJETIVOS O estudo examinou as aquisições de eculizumabe, um anticorpo monoclonal de alto custo utilizado no tratamento de doenças raras, pelos órgãos federais brasileiros, em termos das quantidades compradas, gastos e preços. MÉTODOS Foram analisadas compras de eculizumabe realizadas entre março de 2007 e dezembro de 2018, por meio de dados secundários extraídos do sistema de compras do governo federal (Siasg). Foram examinados o número de compras, quantidades adquiridas, número de doses diárias definidas por 1.000 habitantes por ano, gastos anuais e preços praticados. Os preços foram corrigidos pelo índice nacional de preços ao consumidor amplo para dezembro de 2018. Regressão linear foi utilizada para análises de tendência. RESULTADOS Todas as aquisições por órgãos federais foram realizadas pelo Ministério da Saúde. As compras se iniciaram em 2009, sendo efetuadas por dispensa de licitação e para atendimento de demanda judicial. Houve tendência crescente no número de compras e quantidades adquiridas ao longo do tempo. Foram realizadas 283 compras, totalizando 116.792 unidades adquiridas, 28,2% compradas em 2018. Os gastos totais contratados corrigidos somaram mais de R$ 2,44 bilhões. Após a aprovação do registro pela Agência Nacional de Vigilância Sanitária, o preço médio ponderado caiu aproximadamente 35%, para valores abaixo dos preços estabelecidos pela Câmara de Regulação do Mercado de Medicamentos. CONCLUSÃO O eculizumabe representou gastos extremamente significativos para o Ministério da Saúde no período. Todas as compras foram feitas para atendimento de demandas judiciais, fora do ambiente competitivo. Seu registro promoveu queda importante nos preços praticados. O estudo aponta a relevância do registro sanitário e da necessidade de monitoramento e auditoria permanentes das compras de medicamentos para atendimento de demandas judiciais.

    Abstract in English:

    ABSTRACT OBJECTIVES This study examined the purchases of eculizumab, a high-cost monoclonal antibody used in the treatment of rare diseases by Brazilian federal agencies, in terms of purchased quantities, expenditures, and prices. METHODS Eculizumab purchases made between March 2007 and December 2018 were analyzed, using secondary data extracted from the Federal Government Purchasing System (SIASG in Portuguese). The following aspects were assessed: number of purchases, purchased quantities, number of daily doses defined per 1,000 inhabitants per year, annual expenditures, and prices. The prices were adjusted by the National Broad Consumer Price Index for December 2018. Linear regression was used for trend analysis. RESULTS All acquisitions by federal agencies were made by the Brazilian Ministry of Health. The purchases began in 2009 with tender waiver to comply with legal demand. There was an increasing trend in the number of purchases and quantities acquired over time. Two hundred and eighty-three purchases were made, totaling 116,792 units purchased, 28.2% of them in 2018. The adjusted total expenses summed more than R$ 2.44 billion. After market approval by the Brazilian Health Regulatory Agency, the weighted average price fell approximately 35%, to values under the Medicines Market Chamber of Regulation established prices. CONCLUSION Eculizumab represented extremely significant expenditures for the Brazilian Ministry of Health during the period. All purchases were made to meet demands from lawsuits, outside the competitive environment. The market approval of eculizumab promoted an important price reduction. This study indicates the relevance of licensing and the need for permanent monitoring and auditing of drug purchases to meet legal demands.
  • Health access to immigrants: identifying gaps for social protection in health Original Articles

    Cabieses, Baltica; Oyarte, Marcela

    Abstract in Spanish:

    RESUMEN OBJETIVO Comparar el acceso y uso efectivo de servicios de salud disponibles entre migrantes internacionales y chilenos. MÉTODOS Análisis secundario de la encuesta poblacional de Caracterización Socioeconómica Nacional (CASEN), versión 2017. Se describieron indicadores de acceso al sistema de salud (tener previsión de salud) y uso efectivo de servicios de salud (necesidad sentida, consulta o cobertura, barreras y satisfacción de la necesidad) en inmigrantes y locales, autorreportados. Las brechas por condición de inmigrante se estimaron utilizando regresiones logísticas, con muestras complejas. RESULTADOS Los inmigrantes presentaron 7,5 veces más chances de no tener previsión de salud que los locales. Los inmigrantes presentaron una menor necesidad sentida que los locales, en conjunto con una mayor falta de consulta (OR: 1,7 IC95%: 1,2–2,5), cobertura (OR: 2,7 IC95%: 2,0–3,7) e insatisfacción de necesidades. La diferencia entre inmigrantes y locales no fue estadísticamente significativa en barreras de acceso a atención en salud (α = 0,005). CONCLUSIONES Persisten las desventajas en acceso y uso a servicios de salud en inmigrantes en comparación con los nacidos en Chile en contraste con información de años anteriores. Es necesario reducir las brechas entre inmigrantes y nacidos en Chile, sobre todo en cuanto a pertenencia a un sistema de salud. Esta es la primera barrera para un uso efectivo de servicios. Se sugiere generar estrategias concretas y políticas en salud que consideren un enfoque de participación social de la comunidad inmigrante y, adicionalmente, acerquen al sistema de salud a esta población.

    Abstract in English:

    ABSTRACT OBJECTIVE To compare the access to and effective use of health services available among international migrants and Chileans. METHODS Secondary analysis of the National Socioeconomic Characterization Survey (CASEN – Caracterización Socioeconómica Nacional ), version 2017. Indicators of access to the health system (having health insurance) and effective use of health services (perceived need, appointment or coverage, barriers and need satisfaction) were described in immigrants and local population, self-reported. Gaps by immigrant status were estimated using logistic regressions, with complex samples. RESULTS Immigrants were 7.5 times more likely to have no health insurance than local residents. Immigrants presented less perceived need than local residents, together with a greater lack of appointments (OR: 1.7 95%CI: 1.2–2.5), coverage (OR: 2.7 95%CI: 2.0–3.7) and unsatisfied need. The difference between immigrants and locals was not statistically significant in barriers to health care access (α = 0.005). CONCLUSIONS Disadvantages persist regarding the access to and use of health services by immigrants as opposed to Chileans compared with information from previous years. It is necessary to reduce the gaps between immigrants and people born in Chile, especially in terms of health system access. This is the first barrier to effective use of services. The generation of concrete strategies and health policies that consider an approach of social participation of the immigrant community is suggested to bring the health system closer to this population.
  • Practices and challenges on coordinating the Brazilian Unified Health System Original Articles

    Bastos, Luzia Beatriz Rodrigues; Barbosa, Maria Alves; Rosso, Claci Fátima Weirich; Oliveira, Lizete Malagoni de Almeida Cavalcante; Ferreira, Ilma Pastana; Bastos, Diniz Antonio de Sena; Paiva, Ana Cláudia Jaime de; Santos, Alex de Assis Santos dos

    Abstract in Portuguese:

    RESUMO OBJETIVO Analisar os entraves e desafios enfrentados pelos gestores e profissionais de regulação em suas práticas nas centrais reguladoras municipais. MÉTODOS Estudo descritivo exploratório com enfoque qualitativo, aplicado em quarenta gestores e profissionais de regulação, no período de setembro de 2017 e novembro de 2018, por meio de entrevista semiestruturada, resultando em duas categorias de análise: fatores limitantes e fatores facilitadores da gestão e operacionalização do setor de regulação do SUS. RESULTADOS Na análise dos enunciados, foram encontradas evidências dos seguintes fatores limitantes: falha nos critérios de encaminhamento, indisponibilidade de leitos, grande demanda, dificuldades sistêmicas em relação ao sistema de regulação, procedimentos de difícil agendamento e execução, aumento da demanda reprimida de procedimentos eletivos e dificuldades no fluxo de informações entre a atenção primária e a regulação. Na categoria de fatores facilitadores, as possibilidades mais significativas foram: ampliação da capacidade de conhecer a realidade do usuário, melhoria na atenção primária e incrementos de recursos financeiros para a saúde, capacitação e formação em saúde e reestruturação, além de reorganização dos procedimentos internos de regulação. CONCLUSÃO Os fatores limitantes da regulação demonstram a necessidade de fomentar ações que ofereçam a todos os usuários do SUS o acesso pleno aos serviços de saúde.

    Abstract in English:

    ABSTRACT OBJECTIVE To analyze the obstacles and challenges faced by managers and coordination professionals in their practices in municipal coordinating centers. METHODS An exploratory descriptive study with a qualitative focus, applied in 40 managers and coordination professionals, from September 2017 to November 2018, with semi-structured interviews, resulting in two categories of analysis: limiting factors and factors that facilitate the management and operationalization of the Brazilian Unified Health System (SUS) coordinating sector. RESULTS Analyzing the statements, we found evidence of the following limiting factors: failure in the criteria of referral, unavailability of beds, high demand, systemic difficulties in relation to the coordinating system, procedures of difficult scheduling and execution, increased repressed demand for elective procedures and difficulties in the flow of information between primary care and coordination. In the category of facilitating factors, the most significant possibilities were: expansion of the capability to know the user’s reality, improvement in primary care and increase in health financial resources, health training and education and restructuring, in addition to reorganizing internal coordinating procedures. CONCLUSION The limiting factors of coordination show the need to promote actions that offer all SUS users full access to health services.
  • AGRASS Questionnaire: Assessment of Risk Management in Health Care Original Articles

    Gama, Zenewton André da Silva; Saturno-Hernandez, Pedro Jesus; Caldas, Anna Claudia Sales Gomes; Freitas, Marise Reis de; Mendonça, Ana Elza Oliveira de; Medeiros, Carlos Alexandre de Souza; Medeiros, Wilton Rodrigues; Kessler, Oliver; Soares, Diogo Penha

    Abstract in Portuguese:

    RESUMO OBJETIVO O estudo objetiva descrever a construção e análise da validade do Questionário Avaliação da Gestão de Riscos Assistenciais em Serviços de Saúde (AGRASS). MÉTODOS Trata-se de estudo de validação de um instrumento de medida nas etapas: 1. construção do modelo conceitual e itens; 2. apreciação formal multidisciplinar; 3. grupo nominal para análise da validade com especialistas da esfera nacional; 4. desenvolvimento de softwares e estudo-piloto nacional em 62 hospitais do Brasil; 5. Delphi para análise da validade com utilizadores do questionário. Nas etapas 3 e 5, os itens foram julgados quanto à validade de face e conteúdo, utilidade e viabilidade, em uma escala Likert de 1 a 7 (ponto de corte: mediana < 6). A validade de construto e a confiabilidade foram analisadas com análise fatorial confirmatória e coeficientes α de Cronbach. RESULTADOS A versão inicial do instrumento (98 itens) foi adaptada durante as etapas 1 a 3 para a versão com 40 itens considerados relevantes, de conteúdo adequado, úteis e viáveis. O instrumento tem duas dimensões e nove subdimensões, e os itens têm opção de resposta fechada (sim ou não). Os softwares para coleta e análise automática geram indicadores, tabelas e gráficos automáticos para a instituição avaliada e conjuntos agregados. Os índices de ajuste confirmaram o modelo bidimensional de estrutura e processo (X2/gl = 1,070, RMSEA ≤ 0,05 = 0,847; TLI = 0,972), havendo confiabilidade alta para o Questionário AGRASS (α = 0,94) e a dimensão processo (α = 0,93) e aceitável para a dimensão estrutura (α = 0,70). CONCLUSÃO O Questionário AGRASS é um instrumento potencialmente útil para a vigilância e monitoramento da gestão de riscos e segurança do paciente em serviços de saúde.

    Abstract in English:

    ABSTRACT OBJECTIVE This study aims to assess the development and the validity analysis of the Assessment of Risk Management in Health Care Questionnaire (AGRASS). METHODS This is a validation study of a measurement instrument following the stages: 1) Development of conceptual model and items; 2) Formal multidisciplinary assessment; 3) Nominal group for validity analysis with national specialists; 4) Development of software and national pilot study in 62 Brazilian hospitals 5) Delphi for validity analysis with the users of the questionnaire. In stages 3 and 5, the items were judged based on face validity, content validity, and utility and viability, by a 1-7 Likert scale (cut-off point: median < 6). Accuracy and reliability of the questionnaire were analyzed with the Confirmatory Factor Analysis and the Cronbach’s alpha. RESULTS The initial version of the instrument (98 items) was adapted during stages 1 to 3 for the final version with 40 items, which were considered relevant, of adequate content, useful, and viable. The instrument has 2 dimensions and 9 subdimensions, and the items have closed-ended questions (yes or no). The software for the automatic collection and analysis generates indicators, tables, and automatic graphs for the assessed institution and aggregated data. The adjustment indices confirmed a bi-dimensional model composed of structure and process (X2/gl = 1.070, RMSEA ≤ 0.05 = 0.847, TLI = 0.972), with high reliability for the AGRASS Questionnaire (α = 0.94) and process dimension (α = 0.93), and adequate for the structural dimension (α = 0.70). CONCLUSIONS The AGRASS Questionnaire is a potentially useful instrument for the surveillance and monitoring of the risk management and patient safety in health services.
  • Structure and practices in hospitals of the Apice ON Project: a baseline study Original Articles

    Mendes, Yluska Myrna Meneses Brandão e; Rattner, Daphne

    Abstract in Portuguese:

    RESUMO OBJETIVO Este artigo descreve algumas características dos 97 hospitais de ensino participantes do Projeto de Aprimoramento e Inovação no Cuidado e Ensino em Obstetrícia e Neonatologia (Apice ON). MÉTODOS Foi adotado como linha de base o semestre anterior ao lançamento do programa, para permitir avaliar as mudanças estruturais e processuais decorrentes desse projeto. Utilizaram-se dados secundários referentes ao primeiro semestre de 2017 disponíveis no Cadastro Nacional de Estabelecimentos de Saúde (CNES), no Sistema de Informações Hospitalares e no Sistema de Informações sobre Nascidos Vivos. RESULTADOS Antes da implantação do projeto, apenas 66% dos hospitais apresentaram habilitação de Hospital Amigo da Criança, somente 3% estavam habilitados com Casa da gestante, Bebê e Puérpera e 45,4% adotavam o método canguru; 97% dispunham de sala de pré-parto e 93% de sala de parto normal separadas, sem seguir o preconizado pelo Ministério da Saúde; nove hospitais (9%) não tinham alojamento conjunto; havia poucos enfermeiros obstetras (menos de 1% dos profissionais cadastrados no CNES), e em apenas seis hospitais a proporção de partos assistidos por esse profissional foi superior a 50% dos partos vaginais, enquanto em oito hospitais esta proporção ficou entre 15 e 50%; a taxa média de cesáreas foi de 42%, variando entre 37,6% (Sudeste) e 49,1% (Nordeste); em dez dos hospitais não constava cobrança de diária de acompanhante na autorização de internação hospitalar. CONCLUSÃO O estudo fortalece a pertinência do projeto Apice ON como indutor de mudança do modelo nos hospitais de ensino e, portanto, como estratégico para a efetivação da política pública nacional representada pela Rede Cegonha.

    Abstract in English:

    ABSTRACT OBJECTIVE To describe some characteristics of the 97 teaching hospitals participating in the Projeto de Aprimoramento e Inovação no Cuidado e Ensino em Obstetrícia e Neonatologia (Apice ON—Project for Improvement and Innovation in Care and Teaching in Obstetrics and Neonatology). METHODS The semester prior to the beginning of the program was adopted as the baseline to evaluate the subsequent structural and processes changes of this project. Secondary data from the first half of 2017 were extracted from the National Registry of Health Establishments (NRHE), the Hospital Information System and the Sistema de Informações sobre Nascidos Vivos (SINASC—Live Birth Information System). RESULTS Before the implementation of the project, only 66% of the hospitals had a Baby-friendly Hospital Initiative, only 3% offered special accommodations for high-risk pregnant women, mothers and their newborns, and 45.4% hospitals adopted the skin-to-skin contact; 97% hospitals had separate rooms for pre-labor and vaginal delivery (93%), not following the recommendations of the Ministry of Health; nine hospitals (9%) had no rooming-in; there were few obstetrics nurses (less than 1% of professionals enrolled in the NRHE), and in only six hospitals the proportion of births assisted by this professional was above 50% of vaginal deliveries, while in eight this percentage ranged between 15% and 50%; the average cesarean section rate was 42%, ranging between 37.6% (Southeast) and 49.1% (Northeast); ten hospitals did not charge for companions according to inpatient hospital authorization. CONCLUSION The study strengthens the relevance of the Apice ON project as an inducer of change of the care model in teaching hospitals and, therefore, as a strategy for the implementation of the national public policy represented by the Stork Network.
  • Compliance of infant formula promotion on websites of Brazilian manufacturers and drugstores Original Articles

    Prado, Isabella Scatamacchia Cordeiro Ferraz; Rinaldi, Ana Elisa Madalena

    Abstract in English:

    ABSTRACT OBJECTIVE To verify the compliance with Law No. 11,265/2006 in the promotion strategies for infant formula in Brazilian websites of manufacturers and drugstore networks. METHODS This was a cross-sectional study conducted in 2017. We analyzed the compliance to attributes of the Law No.11,265/2006 (Law for Marketing of Foods for Infants and Toddlers, Feeding Bottles, Teats and Pacifiers) in five websites of infant formula manufacturers and nine websites of drugstore networks. The main attributes assessed were: the presence of drawings or representations of children, the presence of warning statements displayed in conspicuous and prominent spaces informing if products are intended for infants aged under or over 6 months, the adequate display of infant formulas/similar products, and the presence of pop-ups with other infant formulas or links to websites for children’s products. All compliances and non compliances verified were described in absolute and relative frequencies. RESULTS We verified that 80% of the websites of infant formula manufacturers displayed advertisements for other children’s food products. The main non compliance in infant formula manufacturer’s websites was the absence of warning statements about products intended for infants over 6 months of age. Only 33% of the drugstores’ websites complied with Law No. 11,265/2006. The main non compliances in these websites were the absence of warning statements on products intended for infants over 6 months of age (100%), the presence of pop-up advertisements for other infant foods (77%) and the presence of advertisements for other children’s food products (92%). CONCLUSION We identified non compliances with the Law No. 11,256/2006 in almost all websites of infant formula manufacturers and in all the websites of drugstore networks. Most promotion strategies were found at drugstore websites, which are the main channels for online sales.
  • Sociodemographic factors associated with the consumption of ultra-processed foods in Colombia Original Articles

    Khandpur, Neha; Cediel, Gustavo; Obando, Daniel Ayala; Jaime, Patrícia Constante; Parra, Diana C.

    Abstract in Spanish:

    RESUMEN OBJETIVO Analizar el consumo de alimentos ultraprocessados en la población colombiana según factores sociodemográficos. MÉTODOS Se usaron datos de la Encuesta Nacional de la Situación Nutricional en Colombia del año 2005. El consumo de alimentos se evaluó por medio de recordatorio 24 horas en 38.643 individuos. Los ítems alimentarios se clasificaron según el grado y extensión de procesamiento industrial usando la propuesta NOVA. RESULTADOS La contribución promedio de calorías de los alimentos ultraprocesados varió del 0,2% en el primer quintil al 41,1% en el ultimo quintil. Los mayores incrementos se dieron por el consumo de panes industrializados, snacks dulces y salados, las bebidas azucaradas, las carnes procesadas y los productos de confitería. No hubo grandes diferencias en el consumo de alimentos ultraprocesados entre hombres y mujeres. Se observaron diferencias significativas por edad, estatus socioeconómico, área de residencia y región geográfica. Los niños y adolescentes presentaron mayor ingesta de alimentos ultraprocesados, casi el doble que los participantes mayores de 50 años. Los niños consumieron significativamente mayor cantidad de snacks, productos de confitería, cereales procesados, bebidas a base de leche y postres. Mientras que los participantes mayores de 50 años consumieron menor cantidad de productos de estos subgrupos de alimentos ultraprocesados, pero tenían el consumo más alto de pan industrializado. Los habitantes urbanos, con alto estatus socioeconómico, que residían en la región de Bogotá tenían entre 1,5 a 1,7 más veces de ingesta calórica de alimentos ultraprocesados en comparación con sus contrapartes de bajo estatus socioeconómico, y sus contrapartes rurales. CONCLUSIÓN En Colombia, el pan industrializado es el alimento ultraprocesado más fácilmente asimilable en la dieta tradicional, junto con los snacks y las bebidas azucaradas. Los niños y adolescentes residentes en zonas urbanas y hogares con mayor poder adquisitivo fueron más vulnerables en el consumo de alimentos ultraprocesados.

    Abstract in English:

    ABSTRACT OBJECTIVE To analyze the consumption of ultra-processed foods in the Colombian population across sociodemographic factors. METHODS We used data from the 2005 National Survey of the Nutritional Status in Colombia. Food consumption was assessed using a 24-hour food recall in 38,643 individuals. The food items were classified according to the degree and extent of industrial processing using the NOVA classification. RESULTS The mean calorie contribution of ultra-processed foods ranged from 0.2% in the lowest quintile of consumers to 41.1% in the highest quintile of consumers. The greatest increases were due to the consumption of industrialized breads, sweet and savory snacks, sugary drinks, processed meats, and confectionery. No major differences were found in the consumption of ultra-processed foods between men and women. We observed significant differences by age, socioeconomic status, area of residence, and geographic region. Children and adolescents showed a higher intake of ultra-processed foods, almost double that of participants over 50 years of age. Children consumed significantly more snacks, confectionery products, processed cereals, milk-based drinks and desserts. Participants over 50 years consumed fewer products from these sub-groups of ultra-processed foods but had the highest consumption of industrialized bread. Individuals from urban areas, those with high socioeconomic status, participants residing in the Bogotá region had 1.5 to 1.7 times higher calorie intake from ultra-processed foods compared with those from a lower socioeconomic status and those residing in rural regions. CONCLUSION In Colombia, industrialized bread is the ultra-processed product that is most easily assimilated into the traditional diet, along with snacks and sugary drinks. Children and adolescents residing in urban areas and households with greater purchasing power have some of the highest intakes of ultra-processed foods in the country.
  • Whither social determinants of health? Comments

    Nedel, Fúlvio Borges; Bastos, João Luiz

    Abstract in Portuguese:

    RESUMO Este comentário crítico retoma o debate sobre a determinação social da saúde e da doença. Seu principal argumento é o de que, se por um lado, são desnecessárias novas pesquisas que procurem conferir maior consistência aos resultados que fundamentam essa interpretação, por outro, é escassa, nesses estudos, uma análise pautada pela noção de que a pobreza e outras formas de opressão são escolhas políticas da sociedade, que devem ser situadas historicamente. Essa noção deve orientar a pesquisa e o debate na área, sob pena de que as associações encontradas supostamente para denunciar a injustiça terminem por naturalizá-la. A pesquisa pautada por esses princípios pode superar o alcance limitado de abordagens multicausais do tipo caixa-preta, que não analisam as inter-relações entre os determinantes e pouco contribuem para a construção de sociedades saudáveis.

    Abstract in English:

    Abstract This critical commentary extends the debate on social determinants of health and disease. Its main argument is that while further studies are unnecessary to demonstrate the fundamentally social distribution of health outcomes, extant analyses rarely engage with the fact that poverty and other forms of oppression are political choices made by societies, which are both contemporaneously contingent and historically situated. This view must guide research and debate in the area so that studies intending to bring injustice to light do not end up naturalizing it. Research based on this fundamental understanding may help to overcome the narrow scope of multicausal black box approaches, which do not analyze the interrelations among determinants and make only a limited contribution to the construction of healthy societies.
  • Illegal commercial promotion of products competing with breastfeeding Original Articles

    Silva, Karine Borges da; Oliveira, Maria Inês Couto de; Boccolini, Cristiano Siqueira; Sally, Enilce de Oliveira Fonseca

    Abstract in Portuguese:

    RESUMO OBJETIVO Avaliar se a comercialização de fórmulas infantis, mamadeiras, bicos, chupetas e protetores de mamilo é realizada em cumprimento com a Norma Brasileira de Comercialização de Alimentos para Lactentes e Crianças de Primeira Infância e de Produtos de Puericultura Correlatos (NBCAL). A promoção comercial desses produtos é proibida pela Lei 11.265. MÉTODOS Estudo transversal conduzido em 2017 por meio de um censo de todas as farmácias, supermercados e lojas de departamento que comercializavam produtos abrangidos pela NBCAL na Zona Sul do Rio de Janeiro. Profissionais de saúde capacitados na NBCAL utilizaram formulário eletrônico estruturado para observação direta dos estabelecimentos e para entrevista com seus responsáveis. Foram criados seis indicadores de avaliação das práticas comerciais e realizadas análises descritivas. RESULTADOS Foram avaliados 352 estabelecimentos comerciais: 240 farmácias, 88 supermercados e 24 lojas de departamento, dos quais 88% comercializavam produtos cuja promoção é proibida pela NBCAL. Foram encontradas promoções comerciais ilegais em 20,3% daqueles que comercializavam os produtos investigados: 52 farmácias (21,9%), quatro supermercados (7,5%) e sete lojas de departamento (33,3%). As estratégias de promoção comercial mais frequentes foram os descontos (13,2%) e as exposições especiais (9,3%). Os produtos com maior prevalência de infrações à NBCAL foram as fórmulas infantis (16,0%). Foram entrevistados 309 responsáveis por estabelecimentos comerciais, 50,8% relatando não conhecer a lei. Mais de três quartos dos responsáveis relataram receber visitas nos estabelecimentos de representantes comerciais de empresas fabricantes de fórmulas infantis. CONCLUSÃO Mais de um quinto dos estabelecimentos comerciais faziam promoção comercial de fórmulas infantis para lactentes, mamadeiras e bicos, apesar de essa prática ser proibida no Brasil há trinta anos. É necessária a capacitação dos seus responsáveis. Os órgãos governamentais devem realizar fiscalização dos estabelecimentos comerciais para coibir estratégias de persuasão e indução à vendas desses produtos, garantindo às mães autonomia na decisão sobre a alimentação de seus filhos.

    Abstract in English:

    ABSTRACT OBJECTIVE To assess if the commercialization of infant formulas, baby bottles, bottle nipples, pacifiers and nipple protectors is performed in compliance with the Norma Brasileira de Comercialização de Alimentos para Lactentes e Crianças de Primeira Infância e de Produtos de Puericultura Correlatos (NBCAL – Brazilian Code of Marketing of Infant and Toddlers Food and Childcare-related products). The commercial promotion of these products is prohibited by the Law 11,265. METHOD Cross-sectional study conducted in 2017 through a census of all pharmacies, supermarkets and department stores that sold products covered by NBCAL in the South Zone of Rio de Janeiro. Health professionals trained at NBCAL used structured electronic form for direct observation of establishments and for interviews with their managers. We created indicators to evaluate commercial practices and performed descriptive analyses. RESULTS A total of 352 commercial establishments were evaluated: 240 pharmacies, 88 supermarkets and 24 department stores, of which 88% sold products whose promotion is prohibited by NBCAL. Illegal commercial promotions were found in 20.3% of the establishments that sold the products we investigated: 52 pharmacies (21.9%), four supermarkets (7.5%) and seven department stores (33.3%). The most frequent commercial promotion strategies were discounts (13.2%) and special exposures (9.3%). The products with the highest prevalence of infractions of NBCAL were infant formulas (16.0%). We interviewed 309 managers of commercial establishments; 50.8% reported unfamiliarity with the law. More than three-quarters of the managers reported having been visited at the establishments by commercial representatives of companies that produce infant formulas. CONCLUSION More than a fifth of commercial establishments promoted infant formulas, baby bottles and nipples, although this practice has been banned in Brazil for thirty years. We think it is necessary to train those managers. Government agencies must monitor commercial establishments in order to inhibit strategies of persuasion and induction to sales of these products, ensuring mothers’ autonomy in the decision on the feeding of their children.
  • Pre-frailty, frailty and associated factors in older caregivers of older adults Original Articles

    Máximo, Roberta de Oliveira; Lopes, Ingrid Cristina; Brigola, Allan Gustavo; Luchesi, Bruna Moretti; Gratão, Aline Cristina Martins; Inouye, Keika; Pavarini, Sofia Cristina Iost; Alexandre, Tiago da Silva

    Abstract in English:

    ABSTRACT INTRODUCTION Providing care to an older adult is an activity that requires considerable physical effort and can cause stress and psychological strain, which accentuate factors that trigger the cycle of frailty, especially when the caregiver is also an older adult. However, few studies have analyzed the frailty process in older caregivers. OBJECTIVES To investigate the prevalence of pre-frailty, frailty and associated factors in older caregivers of older adults. METHODS A cross-sectional study was conducted including 328 community-dwelling older caregivers. Frailty was identified using frailty phenotype. Socio-demographic, behavioral and clinical aspects, characteristics related to care and functioning were covariables in the multinomial logistic regression. RESULTS The prevalence of pre-frailty and frailty were 58.8% and 21.1%, respectively. An increased age, female sex, not having a conjugal life, depressive symptoms and pain were commonly associated with pre-frailty and frailty. Sedentary lifestyle was exclusively associated with pre-frailty, whereas living in an urban area, low income and the cognitive decline were associated with frailty. A better performance on instrumental activities of daily living reduced the chance of frailty. CONCLUSION Many factors associated with the frailty syndrome may be related to the act of providing care, which emphasizes the importance of the development of coping strategies for this population.
  • Major depressive episode among university students in Southern Brazil Original Articles

    Flesch, Betina Daniele; Houvèssou, Gbènankpon Mathias; Munhoz, Tiago Neuenfeld; Fassa, Anaclaudia Gastal

    Abstract in Portuguese:

    RESUMO INTRODUÇÃO A depressão é a principal causa de incapacidade em todo o mundo, atingindo cada vez mais os jovens. Este estudo avalia a prevalência e fatores associados ao episódio depressivo maior em universitários, com ênfase na influência do meio acadêmico, área de estudo escolhida pelo universitário e ambiente onde ele está inserido. METODOLOGIA Realizou-se um censo dos universitários ingressantes do primeiro semestre de 2017 em uma universidade do sul do Brasil. O desfecho episódio depressivo maior foi avaliado a partir do questionário Patient Health Questionnaire-9, considerado quando o indivíduo apresentava cinco ou mais sintomas depressivos por pelo menos uma semana. Sua prevalência foi estimada e os fatores associados foram examinados pela análise multivariável hierarquizada utilizando a regressão de Poisson com seleção para trás. RESULTADOS Um total de 32% (intervalo de confiança de 95% 29,9–34,2) dos universitários apresentou episódio depressivo maior, e o problema foi mais frequente entre indivíduos do sexo feminino (razão de prevalências [RP] = 1,59), de 21 a 23 anos de idade (RP = 1,24), com histórico familiar de depressão (RP = 1,27), com orientação sexual de minorias (homossexuais, RP = 1,64, e bissexuais, RP = 1,69), que moravam com amigos ou colegas (RP = 1,36), estudantes da área das ciências sociais aplicadas e humanas (RP = 1,28) e de linguística, letras e artes (RP = 1,25). O pior desempenho acadêmico (RP = 2,61), o uso abusivo de álcool (RP = 1,25) e o consumo de drogas ilícitas (RP = 1,30) também estiveram positivamente associados ao episódio depressivo maior. CONCLUSÃO Além dos aspectos individuais, familiares e comportamentais, semelhantes aos já descritos como fatores de risco para episódio depressivo maior na população em geral, aspectos acadêmicos também influenciam a ocorrência de depressão entre universitários. Considerando a alta prevalência de episódio depressivo maior e seu impacto negativo na saúde, são necessárias políticas públicas e institucionais que enfoquem a promoção da saúde e atenção à demanda de saúde mental dos estudantes.

    Abstract in English:

    ABSTRACT INTRODUCTION Depression is the leading cause of disability around the world, and it has been increasingly affecting young people. This study evaluates the prevalence and factors associated with major depression in university students, with emphasis on the influence of the academic field, chosen study area and the environment they are inserted. METHODS A census of students who entered the university in the first semester of 2017 was held at a university in Southern Brazil. The outcome of major depressive episode was evaluated using the Patient Health Questionnaire-9, considered when the individual had five or more depressive symptoms for at least one week. Its prevalence was estimated, and the associated factors were examined by the hierarchical multivariable analysis using the Poisson regression model. RESULTS A total of 32% (95% confidence interval 29.9–34.2) of university students presented a major depressive episode, and the problem was more frequent among women (prevalence ratio [PR] = 1.59); people aged 21 to 23 years (PR = 1.24); those with a family history of depression (PR = 1.27); minorities’ sexual orientation (homosexuals, PR = 1.64, and bisexuals, PR = 1.69); who lived with friends or colleagues (PR = 1.36); students in the area of applied social and human sciences (PR = 1.28), and linguistics, language and literature, and art (PR = 1.25). The worst academic performance (PR = 2.61), alcohol abuse (PR = 1.25), and illicit drug use (PR = 1.30) were also positively associated with major depressive episode. CONCLUSION In addition to individual, family, and behavioral aspects, already described as risk factors for major depressive episodes in the general population, academic aspects also influence the occurrence of depression among university students. Considering the high prevalence of major depressive episode and its negative impact on health, public and institutional policies are necessary to focus on students’ mental health promotion and care.
  • Health outcomes of the Bolsa Família program among Brazilian Amazonian children Original Articles

    Ford, Katherine J; Lourenço, Barbara Hatzlhoffer; Cobayashi, Fernanda; Cardoso, Marly Augusto

    Abstract in English:

    ABSTRACT OBJECTIVE One of the primary objectives of Brazil’s conditional cash transfer program, Bolsa Família, is to break the intergenerational transmission of poverty by improving human capital via conditionalities. In this study, we hypothesized that health indicators of Bolsa Família participants would be comparable to those of other local children who were nonparticipants after two years of follow-up in the city of Acrelândia, Acre state, Western Brazilian Amazon. METHODS Data from a population-based longitudinal study were analyzed to examine school enrollment, vaccination coverage, height and body mass index for age z-scores, and biomarkers of micronutrient deficiencies (iron and vitamin A) between Bolsa Família participants (n = 325) and nonparticipants (n = 738). RESULTS Out of 1063 children 10 years and younger included in the 2007 baseline survey, 805 had anthropometric measurements and 402 had biochemical indicators in the 2009 follow-up survey. Prevalence rate ratio (PRR) for non-enrollment in school at 4 years of age was 0.58 (95%CI: 0.34–1.02) when comparing Bolsa Família participants with nonparticipants. No difference was found for vaccination coverage, which was insufficient for most vaccine-preventable diseases. Bolsa Família participants were less likely to show a positive change in body mass index for age z-scores compared with nonparticipants (PRR = 0.81, 95%CI: 0.70–0.95), while a positive change in height for age z-scores was similar in the groups. No differences in micronutrient deficiencies were found between groups after 2 years. CONCLUSIONS Early school enrollment and consistent nutritional indicators between Bolsa Família participants and nonparticipants suggest Bolsa Família was facilitating similarities between groups over time.
  • Democracy and Health: reflections and challenges before the 16th Brazilian National Health Conference Comments

    Bispo Júnior, José Patrício; Morais, Marciglei Brito

    Abstract in Portuguese:

    RESUMO Este texto teve por objetivo analisar as características e os desafios da 16ª Conferência Nacional de Saúde a partir dos três eixos temáticos da conferência: Saúde como direito; Consolidação dos princípios do Sistema Único de Saúde (SUS); Financiamento adequado e suficiente para o SUS. Diante das iniciativas de desmonte do modelo de seguridade social e dos retrocessos das políticas de proteção social, a delimitação da saúde em sentido ampliado é fundamental para a defesa do projeto do SUS. Analisamos a proposta da Cobertura Universal de Saúde como alternativa aos sistemas universais. Apresentamos as restrições da cobertura universal e as ameaças que podem significar aos princípios do SUS. Discutimos a insuficiência do financiamento do SUS e os possíveis agravamentos diante das políticas de austeridade fiscal. É necessário o fortalecimento da participação social e o monitoramento das propostas aprovadas na conferência.

    Abstract in English:

    ABSTRACT This text aimed to analyze characteristics and challenges of the 16th Brazilian National Health Conference based on the conference three thematic axes: Health as a right; Consolidation of the Brazilian Unified Health System (SUS) principles; Adequate and enough funding for SUS. Given the initiatives to dismantle the social security model and the setbacks of social protection policies, to delimitate health in an expanded sense is essential to defend the SUS project. We analyzed the proposal of Universal Health Coverage as an alternative to universal systems. We then presented the restrictions of universal coverage and how the restrictions can threaten the SUS principles. We also discussed insufficient SUS funding and possible worsening in the face of fiscal austerity policies. To strengthen social participation and to monitor the proposals approved at the conference are necessary.
  • Resolution, access, and waiting time for specialties in different models of care Original Articles

    Mori, Natália Leite Rosa; Olbrich Neto, Jaime; Spagnuolo, Regina Stella; Juliani, Carmen Maria Casquel Monti

    Abstract in English:

    ABSTRACT OBJECTIVE This study aimed to identify the treatment demands coming from primary health care units and, based on that, the demand for referrals to medical specialties in reference services. This study is justified by the scarcity of scientific literature on the subject. METHODS This is a cross-sectional study using secondary data on the treatments and referrals made by the primary health care units, throughout 2014, in a municipality of the State of São Paulo, Brazil. The total population treated in 2014 was considered, resulting in 411,177 treatments. RESULTS Out of all treatments performed, the percentage of referrals was of 4.42%, showing that 95,58% of the problems did not need to be referred to another service. A number of 8,897 referrals were made, to 6,850 users, who were mostly women (60.74%). The mean of referrals per patient was 1.3 (min. 1 and max. 8), and 1,604 patients (23.5%) were referred at least twice. CONCLUSIONS Primary health care services have been responsible for a large number of treatments, whereas the demand for referrals has decreased, suggesting that such services have established themselves as a gateway to the health system and achieved the expected solvability, although the waiting time for some specialties is very long.
  • Access to healthcare for deaf people: a model from a middle-income country in Latin America Original Articles

    Fuentes-López, Eduardo; Fuente, Adrian

    Abstract in English:

    ABSTRACT OBJECTIVE To determine if there are existing healthcare access inequities among the deaf Chilean population when compared to the general Chilean population. METHODS Data were obtained from a population-based national survey in Chile. In total, 745 prelingually deaf individuals were identified. The number of times the person used the healthcare system was dichotomized and analyzed using a multivariate logistic regression model. RESULTS Prelingually deaf people had lower incomes, fewer years of education, and greater rates of unemployment and poverty when compared with the general population. Moreover, they visited more general practitioners, mental health specialists, and other medical specialists. On average, they attended more appointments for depression but had fewer general checkups and gynecological appointments than the general population. CONCLUSIONS Deaf people in Chile have a lower socioeconomic status than the rest of the Chilean population. The results from this study are similar to the findings reported for high-income countries, despite differences in the magnitude of the associations between being deaf and healthcare access. Further studies should be conducted to determine the health status of deaf people in Chile and other Latin American countries and what factors are associated with a significantly lower prevalence of gynecological appointments among deaf women when compared with non-deaf women.
  • Feeding practices of low birth weight Brazilian infants and associated factors Original Articles

    Ortelan, Naiá; Neri, Daniela Almeida; Benicio, Maria Helena D’Aquino

    Abstract in Portuguese:

    RESUMO OBJETIVO Caracterizar a alimentação complementar e analisar a influência de fatores individuais e contextuais sobre práticas alimentares de lactentes que nasceram com baixo peso. MÉTODOS Este estudo transversal incluiu 2.370 lactentes nascidos com baixo peso e com idade entre 6 e 12 meses incluídos na Pesquisa de Prevalência de Aleitamento Materno em Municípios Brasileiros (2008), que abrangeu as 26 capitais, o Distrito Federal e mais 37 municípios. As práticas alimentares foram avaliadas usando dois indicadores: i) diversidade alimentar, caracterizada pelo consumo dos cinco grupos alimentares: carnes, feijão, legumes e verduras, frutas e leite; ii) consumo de alimentos ultraprocessados, caracterizado pela ingestão de pelo menos um dos seguintes alimentos no dia anterior à pesquisa: refrigerante, ou suco industrializado, ou bolacha, biscoito e salgadinho. As covariáveis de interesse corresponderam às características socioeconômicas, dos lactentes, das mães e dos serviços de saúde. O fator contextual foi a “prevalência municipal de desnutrição infantil”. O efeito individualizado dos fatores de estudo sobre os desfechos foi avaliado mediante regressão de Poisson com estrutura multinível. RESULTADOS Aproximadamente 59% dos lactentes consumiram alimentos ultraprocessados, enquanto 29% apresentaram diversidade alimentar. Mães que residiam em municípios com prevalência de desnutrição infantil inferior a 10%, com maior nível de escolaridade e que trabalhavam fora de casa foram mais propensas a oferecer diversidade alimentar. O consumo de alimentos ultraprocessados foi maior entre lactentes residentes em municípios com prevalência de desnutrição infantil inferior a 10%, cujas mães eram mais jovens e multíparas. CONCLUSÕES A baixa prevalência de alimentação diversa aliada à alta prevalência do consumo de alimentos ultraprocessados caracteriza a baixa qualidade da alimentação dos lactentes brasileiros com baixo peso ao nascer. Fatores individuais e contextuais impactam a qualidade da alimentação dessa população, sugerindo a necessidade de adoção de estratégias eficazes para aumentar o consumo de alimentos in natura e minimamente processados e diminuir o consumo de alimentos ultraprocessados por esta população vulnerável.

    Abstract in English:

    ABSTRACT OBJECTIVE To characterize complementary feeding and to analyze the influence of individual and contextual factors on dietary practices of low birth weight infants. METHODS This cross-sectional study included 2,370 low birth weight infants aged 6 to 12 months included in the Breastfeeding Prevalence Survey in Brazilian Municipalities (2008), which covered the 26 state capitals, the Federal District and 37 municipalities. Dietary practices were assessed using two indicators: I) dietary diversity, characterized by the consumption of five food groups: meat, beans, vegetables, fruit and milk; II) consumption of ultra-processed foods, characterized by the ingestion of at least one of the following foods on the day prior to the survey: soda, or processed juice, or cookie, cracker and crisps. The covariates of interest were the socioeconomic characteristics of infants, mothers and health services. The contextual factor was the “municipal prevalence of child undernutrition.” The individualized effect of the study factors on outcomes was assessed by multilevel Poisson regression. RESULTS Approximately 59% of infants consumed ultra-processed foods, while 29% had diverse feeding. Mothers living in municipalities with child undernutrition prevalence below 10%, with higher education and working outside the home were more likely to offer dietary diversity. Consumption of ultra-processed foods was higher among infants living in municipalities with child undernutrition prevalence below 10%, whose mothers were younger and multiparous. CONCLUSIONS The low prevalence of diverse feeding combined with the high prevalence of ultra-processed food consumption characterizes the low quality of feeding of low birth weight Brazilian infants. Individual and contextual factors impact the feeding quality of this population, suggesting the need for effective strategies to increase the consumption of fresh and minimally processed foods and decrease the consumption of ultra-processed foods by this vulnerable population.
  • Prenatal care in the Brazilian public health services Original Articles

    Leal, Maria do Carmo; Esteves-Pereira, Ana Paula; Viellas, Elaine Fernandes; Domingues, Rosa Maria Soares Madeira; Gama, Silvana Granado Nogueira da

    Abstract in Portuguese:

    RESUMO OBJETIVO Verificar desigualdades regionais no acesso e na qualidade da atenção ao pré-natal e ao parto nos serviços públicos de saúde no Brasil e a sua associação com a saúde perinatal. MÉTODOS Nascer no Brasil foi uma pesquisa nacional de base hospitalar realizada entre 2011 e 2012, que incluiu 19.117 mulheres com pagamento público do parto. Diferenças regionais nas características sociodemográficas e obstétricas, bem como as diferenças no acesso e qualidade do pré-natal e parto foram testadas pelo teste do χ2. Foram avaliados os desfechos: prematuridade espontânea, prematuridade iniciada por intervenção obstétrica, baixo peso ao nascer, crescimento intrauterino restrito, Apgar no 5º min < 8, near miss neonatal e near miss materno. Para a análise dos desfechos perinatais associados, foram utilizadas regressões logísticas múltiplas e não condicionais, com resultados expressos em odds ratio ajustada e intervalo de confiança de 95%. RESULTADOS As desigualdades regionais ainda são evidentes no Brasil, no que diz respeito ao acesso e qualidade do atendimento pré-natal e ao parto entre as usuárias dos serviços públicos. A peregrinação para o parto se associou a todos os desfechos perinatais estudados, exceto para crescimento intrauterino restrito. As odds ratios variaram de 1,48 (IC95% 1,23–1,78) para near miss neonatal a 1,62 (IC95% 1,27–2,06) para prematuridade iniciada por intervenção obstétrica. Entre as mulheres com alguma complicação clínica ou obstétrica, a peregrinação se associou ainda mais com a prematuridade iniciada por intervenção e com Apgar no 5º min < 8, odds ratio de 1,98 (IC95% 1,49–2,65) e 2,19 (IC95% 1,31–3,68), respectivamente. A inadequação do pré-natal se associou à prematuridade espontânea em ambos os grupos de mulheres CONCLUSÃO Melhorar a qualidade do pré-natal, a coordenação e a integralidade do atendimento no momento do parto têm um impacto potencial nas taxas de prematuridade e, consequentemente, na redução das taxas de morbimortalidade infantil no país.

    Abstract in English:

    ABSTRACT OBJECTIVE To verify regional inequalities regarding access and quality of prenatal and birth care in Brazilian public health services and associated perinatal outcomes METHODS Birth in Brazil was a national hospital-based survey conducted between 2011 and 2012, which included 19,117 women with public-funded births. Regional differences in socio-demographic and obstetric characteristics, as well as differences in access and quality of prenatal and birth care were tested by the χ2 test. The following outcomes were assessed: spontaneous preterm birth, provider-initiated preterm birth, low birth weight, intrauterine growth restriction, Apgar in the 5th min < 8, neonatal and maternal near miss. Multiple and non-conditional logistic regressions were used for the analysis of the associated perinatal outcomes, with the results expressed in adjusted odds ratio and 95% confidence interval. RESULTS Regional inequalities regarding access and quality of prenatal and birth care among users of public services are still evident in Brazil. Pilgrimage for birth associated with all perinatal outcomes studied, except for intrauterine growth restriction. The odds ratios ranged between 1.48 (95%CI 1.23–1.78) for neonatal near miss and 1.62 (95%CI 1.27–2.06) for provider-initiated preterm birth. Among women with clinical or obstetric complications, pilgrimage for birth associated with provider-initiated preterm birth and with Apgar in the 5th min < 8, odds ratio of 1.98 (95%CI 1.49–2.65) and 2.19 (95%CI 1.31–3.68), respectively. Inadequacy of prenatal care associated with spontaneous preterm birth in both groups of women, with or without clinical or obstetric complications. CONCLUSION Improvements in the quality of prenatal care, appropriate coordination and comprehensive care at the time of birth have a potential to reduce prematurity rates and, consequently, infant morbidity and mortality rates in the country.
  • Impact of Seniors Centers on oral health-related quality of life of older adults Original Articles

    Machado Luz, Fernanda W.; Silva, Alexandre Emídio Ribeiro; Perroni, Ana Paula; Goettems, Marília L.; Boscato, Noéli

    Abstract in English:

    ABSTRACT OBJECTIVE This study evaluated the oral health-related quality of life (OHRQoL) of older adults participating or not in Seniors Centers (SC). METHODS Two independent samples were compared: older adults who participate in SC (n = 124) and older adults who visited Primary Healthcare Centers (PHC) and do not participate in SC (n = 164). The data collected consisted of sociodemographic (sex, age, educational level, marital status, family income) and psychosocial characteristics—Sense of Coherence (SOC), anxiety and depression using HADS, happiness—, and oral clinical evaluation—use and need of dental prosthesis and decayed (D), missing (M), or filled (F) teeth. The resulting OHRQoL was evaluated using the Oral Health Impact Profile (OHIP-14). The Mann-Whitney test was used to assess the associations between the independent variables and the OHIP-14. Poisson regression models were also used in the analyses (α=0.05). RESULTS In the PHC, of the 270 individuals invited to participate in the study, 164 (60.7%) were interviewed and clinically examined; while in the SC, of the 166 individuals invited to participate in the study, 124 (74.7%) were interviewed and clinically examined. After adjustments for sociodemographic, psychosocial and clinical factors, we found that the impact on OHRQoL was 2.8 times higher (95%CI 2.0–4.2) for older adults who did not participate in SC. CONCLUSION Older adults who participated in SC showed better perception on OHRQoL, independently of sociodemographic, psychosocial and clinical factors.
  • Assessment of Primary Health Care for rural workers exposed to pesticides Original Articles

    Silvério, Alessandra Cristina Pupin; Martins, Isarita; Nogueira, Denismar Alves; Mello, Marco Antônio Santos; Loyola, Edilaine Assunção Caetano de; Graciano, Miriam Monteiro de Castro

    Abstract in Portuguese:

    ABSTRACT OBJETIVO Avaliar os atributos da atenção primária à saúde (APS) na assistência à saúde de trabalhadores rurais; analisar condições sociodemográficas, histórico de intoxicação e internações por agrotóxicos e uso de equipamentos de proteção individual; e verificar a exposição aos praguicidas pela determinação de bioindicadores. MÉTODOS Estudo transversal, descritivo-analítico, com amostra de 1.027 trabalhadores rurais residentes em municípios pertencentes a uma superintendência regional de saúde do sul de Minas Gerais, cuja APS é regida pelo modelo da Estratégia Saúde da Família. Utilizou-se o Instrumento de Avaliação da Atenção Primária (PCATool Brasil) versão adulto e um questionário estruturado para coleta de dados socioeconômicos, histórico de intoxicação e internação por agrotóxicos e uso de equipamentos de proteção individual. Foram coletadas amostras sanguíneas para dosagem de biomarcadores de exposição a praguicidas e de sinais de sequelas renais e hepáticas. RESULTADOS A baixa escolaridade foi prevalente, bem como o contato intenso dos trabalhadores com praguicidas. O uso frequente de equipamentos de proteção individual foi maior entre os homens, assim como o histórico de intoxicação e de internações por agrotóxicos. Detectaram-se índices de 20% de intoxicação, 15% de hepatopatia e 2% de nefropatia. Os sinais de hepatotoxicidade foram mais frequentes em homens. As diferenças entre sexos foram todas estatisticamente significantes. Com relação à APS, apenas o atributo “grau de afiliação” apresentou escore elevado. Nenhum dos casos de intoxicação detectados no estudo tinha diagnóstico prévio. CONCLUSÕES A despeito de uma alta cobertura da Estratégia Saúde da Família, o risco ocupacional e suas consequências não têm sido detectados pelos serviços de saúde, que se apresentam como não orientados à atenção primária, carecendo mesmo de seus atributos essenciais. Percebe-se a necessidade de adequação imediata e efetiva das políticas públicas no que concerne à saúde do trabalhador rural, com adequada capacitação das equipes e revisão da carteira de serviços da APS ofertados.

    Abstract in English:

    ABSTRACT OBJECTIVE To evaluate the attributes of Primary Health Care (PHC) for rural workers; to analyze sociodemographic conditions, history of poisoning and hospitalizations for pesticides and use of personal protective equipment; and to verify exposure to pesticides by determining bioindicators. METHODS Cross-sectional, descriptive-analytical study with a sample of 1,027 rural workers living in municipalities belonging to a regional health department in Southern Minas Gerais, whose PHC is governed by the Family Health Strategy model. We used the adult version of the Primary Care Assessment Tool (PCATool Brazil) and a structured questionnaire to collect socioeconomic data, history of poisoning and hospitalization for pesticides and use of personal protective equipment. Blood samples were collected to measure biomarkers of pesticide exposure and signs of renal and hepatic sequelae. RESULTS Low education was prevalent, as well as the intense contact of workers with pesticides. Frequent use of personal protective equipment was higher among men, as was the history of poisoning and hospitalizations for pesticides. Rates of 20% poisoning, 15% liver disease and 2% nephropathy were detected. Signs of hepatotoxicity were more frequent in men. Gender differences were all statistically significant. Regarding PHC, only the attribute “degree of affiliation” had a high score. None of the poisoning cases detected in the study were previously diagnosed. CONCLUSIONS Despite the high coverage of the Family Health Strategy, occupational risk and its consequences have not been detected by health services, which do not seem oriented to primary care, even lacking their essential attributes. There is a need for immediate and effective adaptation of public policies regarding the health of rural workers, with adequate training of teams and review of the portfolio of PHC services offered.
  • Evaluation of comprehensive care for older adults in primary care services Original Articles

    Placideli, Nádia; Castanheira, Elen Rose Lodeiro; Dias, Adriano; Silva, Pedro Alcântara da; Carrapato, Josiane Lozigia Fernandes; Sanine, Patricia Rodrigues; Machado, Dinair Ferreira; Mendonça, Carolina Siqueira; Zarili, Thais Fernanda Tortorelli; Nunes, Luceime Olivia; Monti, José Fernando Casquel; Hartz, Zulmira Maria de Araújo; Nemes, Maria Ines Battistella

    Abstract in Portuguese:

    RESUMO OBJETIVO Avaliar o desempenho da atenção integral ao idoso em serviços de atenção primária do Sistema Único de Saúde no estado de São Paulo, Brasi lMÉTODOS Um total de 157 serviços de atenção primária de cinco regiões de saúde do centro-oeste paulista respondeu, de outubro a dezembro de 2014, o instrumento pré-validado Questionário de Avaliação e Monitoramento de Serviços de Atenção Básica 2014. Foram selecionadas 155 questões, com base nas políticas e diretrizes nacionais sobre essa temática. As respostas indicam o desempenho do serviço na atenção ao idoso, agrupadas em três domínios de análise: atenção à saúde para o envelhecimento ativo e saudável (45 indicadores, d1), atenção às doenças crônicas não transmissíveis (89 indicadores, d2) e rede de apoio na atenção ao envelhecimento (21 indicadores, d3). A medida de desempenho foi a soma de respostas positivas (valor 1) ou negativas (valor 0) para cada indicador. Os serviços foram agrupados segundo k-médias dos escores de desempenho de cada um dos domínios. Após a ponderação dos domínios (testes Z), foram estimadas as associações entre os escores de cada domínio e variáveis independentes de gestão (tipologia, planejamento e avaliação dos serviços), por meio de regressão linear simples e múltipla. RESULTADOS A atenção às doenças crônicas não transmissíveis (d2) mostrou, para todos os agrupamentos, melhor desempenho médio (55,7) do que os domínios d1 (35,4) e d3 (39,2). O desempenho do serviço na área geral de planejamento e avaliação esteve associado ao desempenho da atenção ao idoso. CONCLUSÕES Os serviços avaliados apresentaram implementação incipiente da atenção integral ao idoso. O quadro avaliativo pode contribuir para processos de melhoria da qualidade da atenção primária à saúde.

    Abstract in English:

    ABSTRACT OBJECTIVE To evaluate the performance of comprehensive care for older adults in primary care services in the Brazilian Unified Health System in the state of São Paulo, Brazil. METHODS A total of 157 primary care services from five health regions in midwestern São Paulo responded, from October to December 2014, the pre-validated 2014 questionnaire for primary care services assessment and monitoring. We selected 155 questions, based on national policies and guidelines on this theme. The responses indicate the service performance in older adults’ care, clustered into three areas of analysis: health care for active and healthy aging (45 indicators, d1), chronic noncommunicable diseases care (89 indicators, d2), and support network in aging care (21 indicators, d3). Performance was measured by the sum of positive (value 1) or negative (value 0) responses for each indicator. Services were clustered according to k-means of the performance scores of each domain. After weighting the domains (Z tests), we estimated the associations between the scores of each domain and independent management variables (typology, planning and evaluation of services), with simple and multiple linear regression. RESULTS Chronic noncommunicable diseases care (d2) showed, for all clusters, better average performance (55.7) than domains d1 (35.4) and d3 (39.2). Service performance in the general area of planning and evaluation associates with the performance of older adults’ care. CONCLUSIONS The evaluated services had incipient implementation of comprehensive care for older adults. The evaluation framework can contribute to processes to improve the quality of primary health care.
  • On-demand cesarean section: assessing trends and socioeconomic disparities Original Articles

    Carlotto, Kharen; Marmitt, Luana Patrícia; Cesar, Juraci Almeida

    Abstract in English:

    ABSTRACT OBJECTIVE: to measure prevalence, evaluate trends and identify socioeconomic differences of on-demand cesarean section in the municipality of Rio Grande (RS), extreme south of Brazil, in 2007, 2010, 2013 and 2016. METHODS: all the puerperae residing in this municipality who had cesarean deliveries in one of the only two local maternity hospitals in the period 01/01-31/12 of the aforementioned years were part of this transversal study. Puerperae were interviewed using a single, standardized questionnaire at the hospital within 48 hours after delivery. The outcome was assessed based on the mothers’ report that the cesarean section was performed according to their request. The analysis consisted of the observation of the outcome's frequency in each year and the evaluation of its prevalence throughout this period through the chi-square linear trend test. Socioeconomic inequalities were assessed based on household income and women's schooling using the Slope Index of Inequality and the Relative Index of Inequality. RESULTS: In these four years, 5,721 cesarean deliveries were recorded among mothers living in this municipality (1,309 in 2007, 1,341 in 2010, 1,626 in 2013 and 1,445 in 2016). In this period, the rate of on-demand cesarean sections increased by 107%, from 10.5% (95%CI: 8.9% -12.2%) of the deliveries in 2007 to 21.7% (95%CI: 19.5% -23.8%) in 2016. This increase was more evident among those with lower household income and schooling level. Absolute inequality also increased, especially regarding schooling, while relative inequality sharply declined when assessed by household income. CONCLUSIONS: The increased on-demand cesarean sections in the study location is unsettling, despite the decreasing gap between extreme categories as a consequence of higher levels of this procedure among women of lower income and worse schooling.
  • Common mental disorders and socioeconomic status in adolescents of ERICA Original Articles

    Ribeiro, Isabel Batista da Silva; Correa, Marcia Mara; Oliveira, Gabriela; Cade, Nágela Valadão

    Abstract in Portuguese:

    RESUMO INTRODUÇÃO: A adolescência é uma fase de grande demanda social, familiar e emocional, e a literatura tem relacionado o transtorno mental comum (TMC) com piores condições de vida. OBJETIVO: Investigar a relação entre TMC e a condição socioeconômica em adolescentes brasileiros de 12 a 17 anos. MÉTODO: Estudo seccional com os dados do Estudo de Riscos Cardiovasculares em Adolescentes (Erica). O desfecho foi o TMC e a exposição foi a condição socioeconômica avaliada por raça/cor, escolaridade materna, relação morador/cômodo, tipo de escola, existência de empregada e banheiro no domicílio e atividade laboral. Para o cálculo das prevalências, foi utilizado o modo survey e, na análise multivariada, a regressão logística com p < 5%, assim como o intervalo de confiança de 95%. RESULTADOS: A prevalência de TMC em meninas foi 23,3% e em meninos, 11,1%. As variáveis associadas ao TMC nas meninas foram ter idade entre 15 e 17 anos (OR = 1,34; 1,17–1,51), estudar em escola privada (OR = 1,13; 1,01–1,27), ter empregada doméstica (OR = 1,15; 1,00–1,34) e, como fator de proteção, o trabalho não remunerado (OR = 0,64; 0,55–0,75). Os meninos também apresentaram maior chance de TMC na faixa etária mais alta (OR = 1,42; 1,18–1,71) e quando tinham empregada (OR = 1,26; 1,02–1,57), enquanto o trabalho não remunerado diminuiu essa chance (OR = 0,79; 0,67–0,95). CONCLUSÃO: As variáveis socioeconômicas que estiveram associadas ao TMC foram sugestivas de classe econômica mais elevada, enquanto o trabalho não remunerado favoreceu a saúde mental dos adolescentes, resultados contrários à literatura sobre condição socioeconômica e TMC.

    Abstract in English:

    ABSTRACT INTRODUCTION: Adolescence is a stage of great social, family and emotional demands, and the literature has related common mental disorder (CMD) with poor living conditions. OBJECTIVE: To investigate the relationship between CMD and socioeconomic status in Brazilian adolescents aged 12 to 17 years. METHOD: This is a cross-sectional study with data from the Study of Cardiovascular Risk in Adolescents (ERICA – Estudo de Riscos Cardiovasculares em Adolescentes). The outcome was CMD and the exposure was socioeconomic status assessed by race/skin color, maternal schooling, resident/room relationship, type of school, existence of maid and bathroom at home, and work activity. For the calculation of prevalence, the survey mode was used and, in the multivariate analysis, logistic regression with p < 5%, as well as the 95% confidence interval. RESULTS: The prevalence of CMD in girls was 23.3%, and in boys, 11.1%. The variables associated with CMD in girls were age between 15 and 17 years (OR = 1.34; 1.17–1.51), studying in private school (OR = 1.13; 1.01–1.27), having a housemaid (OR = 1.15; 1.00–1.34) and, as a protective factor, unpaid work (OR = 0.64; 0.55–0.75). Boys also had a higher chance of CMD in the highest age group (OR = 1.42; 1.18–1.71) and when they had a housemaid (OR = 1.26; 1.02–1.57), whereas unpaid work decreased this chance (OR = 0.79; 0.67–0.95). CONCLUSION: Socioeconomic variables that were associated with CMD were suggestive of higher economic class, whereas unpaid work favored the mental health of adolescents, results contrary to the literature on socioeconomic status and CMD.
  • Integration in health: cooperation at triple international border Amazon Original Articles

    Santos-Melo, Giane Zupellari dos; Andrade, Selma Regina de; Meirelles, Betina Hörner Schlindwein; Ortiga, Angela Maria Blatt

    Abstract in Portuguese:

    RESUMO OBJETIVO: Descrever o alcance e as limitações das principais estratégias de cooperação em saúde, adotadas entre 2005 e 2017, no contexto da tríplice fronteira Brasil, Colômbia e Peru. MÉTODO: Estudo de caso único, explicativo, qualitativo e integrado realizado no ano de 2017, no contexto da tríplice fronteira no município de Tabatinga, Amazonas, Brasil. Como fontes de evidências foram utilizados: dados documentais, observações diretas em quatro serviços de saúde do município de Tabatinga e entrevistas com gestores da Secretaria de Estado de Saúde do Amazonas, Secretaria Municipal de Saúde de Tabatinga, Conselho Municipal de Saúde de Tabatinga e Consulado do Peru na Colômbia. Os dados foram organizados com o software MaxQDA12®. RESULTADOS: Os dados analisados demonstraram que, no período estudado, o governo federal do Brasil realizou diversos acordos de cooperação em saúde, tanto com o Peru quanto com a Colômbia, e que o governo do estado do Amazonas empreendeu estratégias para melhoria das condições de saúde da população de Tabatinga e região do Alto Solimões, as quais indiretamente alcançaram as populações dos países vizinhos, favorecendo as inter-relações entre os países da região. Quando ao governo municipal, verificou-se a existência de acordos de integração de saúde, estabelecidos informalmente, com o intuito de minimizar as adversidades da saúde local. CONCLUSÃO: As estratégias de cooperação em saúde adotadas na tríplice fronteira amazônica apresentam diferentes finalidades, benefícios e limitações. Destacam-se como benefícios a existência de acordos de cooperação em saúde entre os governos federais do Brasil, Colômbia e Peru e a presença de acordos informais de cooperação entre os governos municipais de Tabatinga (Brasil), Letícia (Colômbia) e Santa Rosa (Peru). As limitações são o desconhecimento dos gestores locais sobre os acordos de cooperação estabelecidos entre os governos federais e a falta de legitimidade dos acordos informais estabelecidos pelo governo de Tabatinga.

    Abstract in English:

    ABSTRACT OBJECTIVE: To describe the scope and limitations of the main strategies of cooperation in health, adopted between 2005 and 2017, in the context of the triple border Brazil, Colombia and Peru. METHOD: Single, explanatory, qualitative, integrated case study carried out in 2017, in the context of the triple Amazon border, Brazil, Colombia and Peru, in the city of Tabatinga, state of Amazonas, Brazil. Our sources of evidence were: documentary data; interviews with health managers of the State Health Secretariats of Amazonas and Municipal Health of Tabatinga, Municipal Health Council of Tabatinga and Consulate of Peru in Colombia; and direct observations in four health services of Tabatinga. Data were organized with MaxQDA12® software. RESULTS: Data analyzed showed that, during the study period, the Brazilian federal government made several health cooperation agreements with both Peru and Colombia and that the state government of Amazonas undertook strategies to improve the health conditions of the dwellers of Tabatinga and the region of Alto Solimões, which indirectly reached the populations of neighboring countries, supporting the interrelationships between the countries of the region. Regarding the municipal government, we verified the existence of health integration agreements, established informally, to minimize the adversities of the local health. CONCLUSION: The cooperation strategies in health adopted in the triple Amazon border have different purposes, benefits and limitations. It is noteworthy that the existence of cooperation agreements between the federal governments of Brazil, Colombia and Peru and the presence of informal cooperation agreements between the municipal governments of Tabatinga (Brazil), Leticia (Colombia) and Santa Rosa (Peru). The limitations of this study are the lack of knowledge of local managers about the cooperation agreements established between federal governments and the lack of legitimacy of the informal agreements established by the Tabatinga government.
  • Multiform invasion of life by work among basic education teachers and repercussions on health Original Articles

    Silva, Jefferson Peixoto da; Fischer, Frida Marina

    Abstract in Portuguese:

    RESUMO INTRODUÇÃO: Diversos estudos têm apontado para um cenário de precarização e adoecimento entre os professores. Entretanto, o modo como o trabalho repercute sobre a vida pessoal de professores não tem recebido significativa atenção, mesmo que lhes seja comum levar trabalho para casa. OBJETIVO: Este estudo investigou a repercussão do trabalho sobre a vida pessoal cotidiana de professores e sua implicação sobre o processo saúde-doença. MÉTODOS: Estudo qualitativo que se utilizou de entrevistas individuais semiestruturadas, complementadas por formulário de caracterização sociodemográfica. Os dados foram analisados por meio de codificação temática com auxílio do software MAXQDA 12. Participaram do estudo 29 professores de quatro escolas públicas das redes municipal e estadual dos ensinos regular e integral de São Paulo, além dos seus respectivos diretores. RESULTADOS: Os resultados indicaram que os agravos advindos do trabalho têm se projetado sobre a vida pessoal dos professores. Identificamos quatro formas principais de manifestação desse tipo de invasão: vinculação contínua com o trabalho por: frustrações sucessivas; abalo moral; pendências ininterruptas; e interferência sobre o curso privado da vida. CONCLUSÃO: O sofrimento de amplitude social e de tipo patogênico que a invasão da vida pelo trabalho produz apontou para este fenômeno como um dos elementos que podem ajudar a explicar os recorrentes quadros de adoecimento dos professores.

    Abstract in English:

    ABSTRACT INTRODUCTION: Several studies have pointed to a scenario of precariousness and illness among teachers. However, the way the profession resonates with the personal life of teachers has not received significant attention, even if it is common for them to take work home. OBJECTIVE: This study investigated the repercussion of work on the everyday life of teachers and its implication on the health-disease process. METHODS: This is a qualitative study based on individual semi-structured interviews, complemented by a form of sociodemographic characterization. Data were analyzed by thematic coding with the aid of the MAXQDA 12 software. This study included 29 teachers from four public schools of the municipal and state networks of regular and full day education of São Paulo, in addition to the principal of each school. RESULTS: The results indicated that the illnesses arising from work have been projected on the personal life of teachers. We identified four main forms of manifestation of this type of invasion: continuous link with work by successive frustrations; moral harassment; uninterrupted pending matters; and interference over the private course of life. CONCLUSION: The social and pathogenic suffering caused by the invasion of life by work pointed to this phenomenon as one of the elements that can help explain the recurrent clinical pictures of illness among teachers.
Faculdade de Saúde Pública da Universidade de São Paulo São Paulo - SP - Brazil
E-mail: revsp@org.usp.br