Abstract

Noncommunicable Diseases are an important public health issue in Brazil and worldwide. This study aimed to analyze the scientific production published by the “Journal Ciência & Saúde Coletiva” in order to shed light on its contributions for the dissemination of scientific knowledge and the debate regarding noncommunicable diseases. A bibliometric study on the publications from 1996 to 2019 related to noncommunicable diseases was carried out. A total of 458 documents that met the eligibility criteria were selected. An increasing trend in the number of publications per year was found; at some points, it coincided with political and institutional milestones in Brazil. Quantitative research papers stood out, as did studies on risk and protective factors. Public educational and research institutions led the publishing and the financing of the studies. Most authors were female. The journal has been reflecting the magnitude of the theme and its prioritization on the public agenda by promoting the debate and providing a scientific dissemination of content related to noncommunicable diseases.

Key words:
Noncommunicable diseases; Public Health; Risk factors; Scientific communication and diffusion; Bibliometrics

Introduction

Noncommunicable diseases (NCD) are an important public health issue, since they are the main cause of death in the world, in addition to causing premature mortality, disabilities, loss of quality of life, overload of the health system¹1 World Health Organization (WHO). Noncommunicable diseases progress monitor 2020. Geneva: WHO; 2020. [acessado 2020 Abr 24]. Available from: https://www.who.int/publications-detail/ncd-progress-monitor-2020^,22 Malta DC, Silva MMA, Moura L, Morais Neto OL. A implantação do Sistema de Vigilância de Doenças Crônicas Não Transmissíveis no Brasil, 2003 a 2015: alcances e desafios. Rev Bras Epidemiol 2017; 20(4):661-675., and contribute to increase spending on health care and social security³3 Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, Barros MBA. Doenças crônicas não transmissíveis e a utilização de serviços de saúde: análise da Pesquisa Nacional de Saúde no Brasil. Rev Saude Publica 2017; 51(Supl. 1):4s.^,44 Moura de AAG, Carvalho de EF, Silva NJC. Repercussão das doenças crônicas não-transmissíveis na concessão de benefícios pela previdência social. Cien Saude Colet 2007; 12(6):1661-1672..

The increase in morbidity and mortality due to these diseases is related to the effects of the epidemiological, demographic, and nutritional transition⁵5 World Health Organization (WHO). World Health Statistics 2015. Genebra: WHO; 2015 [acessado 2020 Abr 24]. Disponível em: https://apps.who.int/iris/bitstream/handle/10665/170250/9789240694439_eng.pdf?sequence=1&isAllowed=y

6 Pan American Health Organization (PAHO). The economic burden of Non-communicable Diseases in the Americas. Washington: PAHO; 2011. [acessado 2020 Abr 24]. Disponível em: https://www.paho.org/hq/dmdocuments/2011/paho-policy-brief-3-En-web1.pdf^-77 World Health Organization (WHO). Health 2020: a European policy framework supporting action across government and society for health and well-being. Geneva: WHO; 2013 [acessado 2020 Abr 24]. Disponível em: http://www.euro.who.int/__data/assets/pdf_file/0006/199536/Health2020-Short.pdf, and also to the growth of modifiable risk factors such as tobacco consumption, harmful use of alcohol, physical inactivity, and inadequate diets⁸8 World Health Organization (WHO). Global Action Plan for the Prevention and Control of NCDs 2013-2020. Geneva: WHO; 2013 [acessado 2020 Abr 24]. Disponível em: https://apps.who.int/iris/bitstream/handle/10665/94384/9789241506236_eng.pdf;jsessionid=CC05322BD984F039B84D717FF29E96D8?sequence=1. Besides these elements, the occurrence and distribution of NCDs and their risk factors¹¹11 Schmidt MI, Duncan BB, Azevedo e Silva G, Menezes AM, Monteiro CA, Barreto SM, Chor D, Menezes PR. Chronic non-communicable diseases in Brazil: burden and current challenges. Lancet 2011; 377(9781):1949-1961.^,1212 Marmot M, Bell R. Social determinants and non-communicable diseases: time for integrated action. BMJ 2019; 365(Supl. 1):kl251. are related to the effects of economic crises and austerity measures⁹9 Paes-Sousa R, Schramm JMA, Mendes LVP. Austeridade fiscal e o setor saúde: o preço do ajuste. Cien Saude Colet 2019; 24(12):4375-4384.^,1010 Malta DC, Duncan BB, Barros MBA, Katikireddi SV, Souza FM, Silva AG, Machado DB, Barreto ML. Medidas de austeridade fiscal comprometem metas de controle de doenças não transmissíveis no Brasil. Cien Saude Colet 2018; 23(10):3115-3122., and other social determinants, such as poverty. As a consequence, worse health indicators are observed in the most socially vulnerable population, and higher prevalence of risk factors for NCDs in individuals with low education and income¹³13 Stringhini S, Carmeli C, Jokela M, Avendaño M, Muennig P, Guida F, Ricceri F, d'Errico A, Barros H, Bochud M, Chadeau-Hyam M, Clavel-Chapelon F, Costa G, Delpierre C, Fraga S, Goldberg M, Giles GG, Krogh V, Kelly-Irving M, Layte R, Lasserre AM, Marmot MG, Preisig M, Shipley MJ, Vollenweider P, Zins M, Kawachi I, Steptoe A, Mackenbach JP, Vineis P, Kivimäki M, LIFEPATH consortium. Socioeconomic status and the 25 x 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1·7 million men and women. Lancet 2017; 389(10075):1229-1237.

14 Pearce N, Ebrahim S, McKee M, Lamptey P, Barreto ML, Matheson D, Walls H, Foliaki S, Miranda JJ, Chimeddamba O, Garcia-Marcos L, Haines A, Vineis P. Global prevention and control of NCDs: Limitations of the standard approach. J Public Health Policy 2015; 36(4):408-425.^-1515 Malta DC, Bernal RT, de Souza MF, Szarcwald CL, Lima MG, Barros MB. Social inequalities in the prevalence of self-reported chronic non-communicable diseases in Brazil: national health survey 2013. Int J Equity Health 2016; 15:153..

NCDs, their risk and protective factors, aspects related to treatment and strategic actions to cope with them are among the themes addressed in publications from the journal Ciência & Saúde Coletiva (C&SC), a reference in both national and global settings. Edited by the Brazilian Association of Collective Health (Abrasco), the journal was created in 1996 with the aim of disseminating high-quality health research studies to the scientific community and society in general, in Brazil and abroad. This is an important national vehicle for scientific communication of discussions, debates, research, and for the exposure of new ideas in the field of Public Health, in addition to being indexed in the main health databases.

Considering the relevance of NCDs in Brazilian and global contexts, and in the perspective of shedding light on important contributions from C&SC in this field, the present study sought to analyze the scientific production related to NCDs published throughout the journal’s 25 years of existence.

Methods

This is an exploratory and descriptive study that consisted of a bibliometric analysis of C&SC’s collection published from 1996 to 2019. Bibliometrics corresponds to a set of research methods that combines quantitative approach, statistics, and data visualization techniques¹⁶16 Vošner HB, Kokol P, Bobek S, Železnik D, Završnik J. A bibliometric retrospective of the Journal Computers in Human Behavior (1991-2015). Comput Human Behav 2016; 65:46-58., applied to the analysis and evaluation of bibliographic production. Its intention is measuring production indexes and scientific knowledge dissemination¹⁷17 Araújo CA. Bibliometria: evolução histórica e questões atuais. Em Questão 2006; 12(1):11-32..

C&SC is indexed in several databases. To retrieve the publications of interest, the database Medical Literature Analysis and Retrieval System Online (Medline) was used, via United States National Library of Medicine National Institutes of Health (PubMed), as well as Scientific Electronic Library Online (SciELO). PubMed was used as a search engine for being extremely robust and reliable and for allowing the development of a search strategy with all the terms necessary to represent the universe searched. It should be noted, however, that it was not possible to retrieve via PubMed the C&SC content published between 1996 and 2006; the publications of this period are not indexed in Medline. Therefore, the production mapping process carried out at C&SC had to be segment in three stages:

As an inclusion criterion, all types of publication (editorial, thematic articles, articles on free themes, review articles, opinion, reviews, debates and letters) were considered that would focus on: a) the four main groups of diseases prioritized by the World Health Organization in the “Global Action Plan for the Prevention and Control of NCDs 2013-2020”⁷7 World Health Organization (WHO). Health 2020: a European policy framework supporting action across government and society for health and well-being. Geneva: WHO; 2013 [acessado 2020 Abr 24]. Disponível em: http://www.euro.who.int/__data/assets/pdf_file/0006/199536/Health2020-Short.pdf and in the “Strategic Action Plan for Coping with NCDs in Brazil, 2011-2022”¹⁸18 Brasil. Ministério da Saúde (MS). Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011-2022. Brasília: MS; 2011 [acessado 2020 Abr 24]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/plano_acoes_enfrent_dcnt_2011.pdf (circulatory, cancer, chronic respiratory, and diabetes); b) its modifiable risk factors (tobacco, alcohol, physical inactivity, inadequate diet) and metabolic risk factors (obesity, high blood pressure, altered blood glucose); c) policies, programs, and actions related to NCDs, surveillance, promotion, prevention, diagnosis, care, and treatment. The exclusion criteria included publications that did not present NCDs as the main objective according with the above-mentioned dimensions of approach.

Guided by the eligibility criteria, the selection of publications was made, in both stages (manual search and through PubMed), based on title, abstract, and keywords for articles, and full text for editorial, opinion, debate, review, and letter documents. This selection was carried out by peers, the divergences were discussed and resolved by consensus between the parties and the reasons for the exclusion of publications were registered.

Data of interest for the selected publications were extracted into a spreadsheet Microsoft Office Excel (Microsoft^® 2016). The following variables were considered: publication identification number, with PubMed Unique Identifier (PMID) for those indexed in MEDLINE and Document Object Identifier (DOI) for those not indexed in this database; year of publication; language; publication section; authorship (number of authors per article and name of the authors); institutional affiliation of authors; key words; financing; thematic categories; link to access publications on the SciELO platform.

Thematic categories were guided by the dimensions of approach to NCDs mentioned in the inclusion criterion. Therefore, each publication was classified into one of those four categories: 1) Morbidity and Mortality; 2) Risk and Protective Factors; 3) Therapeutic and Care Strategies; and 4) Policies, Programs and Actions. In Morbidity and Mortality were included articles related to the four major groups of NCDs, their diagnosis and mortality rate. For Risk and Protection Factors, publications were included whose object was risk factors (behavioral, lifestyles, biological, metabolic, environmental, social, economic, and demographic inequalities) and protective factors for NCDs (healthy lifestyles, health promotion and prevention). Therapeutic and Care Strategies grouped studies with a focus on the treatment of NCDs, pharmacological research, comprehensive NCD care strategies and self-care. The Policies, Programs and Actions category included publications that addressed policies, programmatic actions for NCDs, surveillance, and monitoring.

A descriptive analysis of the data was carried out based on the survey of absolute and relative frequencies for each variable. In addition, a simple linear regression method was used to verify the occurrence of a linear trend in the number of publications from 1996 to 2019. The publication year of C&SC manuscripts was considered as an explanatory variable and the number of publications (absolute frequencies) was taken as a variable response. Temporal variations were interpreted as statistically significant when the regression coefficient of the model was different from zero for a p value less than or equal to 0.05. Statistical analyzes were performed using Microsoft Office Excel software (Microsoft^® 2016).

Clouds of keywords and authors’ institutional affiliations were created with the aid of an online data visualization tool named Infogram (https://infogram.com/). The “word cloud” or “text cloud” is a visual strategy for presenting linguistic data; it shows the frequency with which the terms appear and allows identifying the importance of a certain word in relation to the total number of words¹⁹19 Lunardi MS, Castro JMFC, Monat AS. Visualização dos resultados do Yahoo em nuvens de texto: uma aplicação construída a partir de web services. InfoDesign - Revista Brasileira de Design da Informação 2008; 5(1):21-35.. The keywords included in the selected articles were grouped according to their synonyms, the vocabulary of the Health Sciences Descriptors (DeCS), as well as terms in plural and singular and words in different languages, but with the same meaning. Besides, for a better visualization of the terms, it was decided to establish a cutoff point based on the distribution of absolute frequencies, ordered from the highest to the lowest frequency, so that the keyword cloud presented 29 terms of one total of 625, and the cloud of institutional affiliations of authors gave visibility to the 50 most recurring, out of a total of 251 institutions.

Results

Between 1996 and 2019, C&SC published 247 issues and 5,871 documents, of which 4,860 were research articles. The journal was published every six months between 1996 and 2001, every four months from 2002 to 2006, every two months between 2007 and 2010 and, starting in 2011, its periodicity began to be monthly, with the annual publication of twelve issues.

Noteworthy was the launch of a first thematic issue dedicated to NCDs in 2004. Nevertheless, chronic diseases or related topics (national surveys, surveillance, risk factors such as obesity and hypertension and related to eating behavior and lifestyle) were also a subject of interest made explicit in titles and topics covered in editorials of thematic numbers, as the reader will find in those editions: 2004 (number 4), 2010 (supplement 2), 2011 (number 1), 2013 (number 2), 2014 (numbers 1 and 6), 2015 (numbers 3, 4 and 8) , 2016 (numbers 1, 2 and 4), 2017 (number 2), 2018 (number 12) and 2019 (number 7).

In manual recovery, a total of 794 publications were initially identified; after exclusions, 25 remained. In automated retrieval, the search strategy retrieved 979 documents, of which 433 were selected based on the eligibility criteria. At the end, a total of 458 articles were included.

Table 1 presents the overview of publications according to period, journal section, number of authors, language, thematic category, and funding. When considering the 25-year time frame of Journal C&SC, the first manuscript that met the eligibility criteria of this study was published in 2002. There was a big quantitative jump of publications on NCDs in the following years.

The articles correspond to the majority of publications, making a total of 440 documents (96.0%), mostly of which used quantitative methodology (72.1%). There was a predominance of publications with 3 and 4 authors (39.7%) and public institutions represented the most prevalent institutional affiliation (86.0%). Most of the publications were written and published in Portuguese (60.9%), although a notable portion was written and published in Portuguese and English or only in English (38.0%). “Risk and Protection Factors” was the most frequent thematic category (56.1%), followed by “Morbidity and Mortality” (21.4%). Of the analyzed publications, a small percentage declared financial support (26.1%), and, from this, the national agencies for research promotion figured as the biggest financing agent (53.0%), followed by the state foundations for research support (26.5%) (Table 1).

A total of 1,529 different researchers, disregarding repetitions, was responsible for producing all 458 analyzed publications. Of these, 27 contributed in 4 or more publications, either as first author or as co-author, and they are mostly female (70.4%). The cutoff point of 4 or more publications was defined for better presentation of the data, considering the large number of authors who participated in 3 or less publications (n = 1502; data not shown). The five authors who published the most were: Malta, DC; Barros, MBA; Cotta, RMM; Barreto, SM; Christofaro, DGD. With regard to the institutional affiliation of these researchers, public institutions stand out, with federal universities being the most frequent (Table 2).

Figure 1 shows the annual number of publications according to thematic categories (A), and a timeline of the annual total of publications according to institutional frameworks in the field of NCDs (B). As previously mentioned, the first publications on NCDs were verified in C&SC from 2002. There is a predominance of publications on the theme “Morbidity and Mortality” in 2002 and 2004. As of 2008, the theme “Risk and Protective Factors” of NCDs became the most frequent, especially in the years 2015, 2018 and 2019, accounting for 30, 34 and 44 publications only in this category, respectively (Figure 1A).

The launch of C&SC’s first thematic issue was dedicated to NCDs and took place in 2004. In chronological sequence, highlights are seen in 2008, 2011, 2013, 2015, 2018 and 2019, which can be related to national and international events and actions in the scope of chronic diseases. In 2008, the “Guidelines and Recommendations for Comprehensive Care of NCDs” were listed and information on morbidity and some risk factors was included in the National Household Sample Survey (PNAD in Portuguese), as part of the Global Adult Tobacco Survey (GATS) initiative. National scenery watched in 2011 the publication of the “Plan of Strategic Actions for Coping with Non-communicable Diseases (NCDs) in Brazil, 2011-2022”, and the launch of the “Healthy Gym Program”; internationally, the General Assembly of the United Nations (UN) held, in New York, the High Level Meeting on NCDs. In 2013, the “Global Action Plan for the Prevention and Control of NCDs” was launched by the World Health Organization (WHO), while, in a national context, the Department of Non-communicable Diseases and Conditions and Health Promotion (DANTPS in Portuguese) was being created, along with the first National Health Survey (PNS in Portuguese). In 2018, the WHO launched the SAFER initiative at the Third United Nations High Level Conference on the Prevention and Control of Non-communicable Diseases, with the aim of promoting and strengthening actions to reduce harmful consumption in the alcohol (Figure 1B).

The interval between 2002 and 2019 presents a tendency for a significant increase (p < 0.05) in the number of publications on NCDs, representing an average variation of 0.0072 per year, with an adjusted R²2 Malta DC, Silva MMA, Moura L, Morais Neto OL. A implantação do Sistema de Vigilância de Doenças Crônicas Não Transmissíveis no Brasil, 2003 a 2015: alcances e desafios. Rev Bras Epidemiol 2017; 20(4):661-675. of 0.62 (data not shown).

Figure 2 shows the main keywords appearing in the analyzed publications. From a total of 458 publications, 625 keywords were identified (the sum of the frequencies corresponds to a total of 1775 keywords). The word cloud shows a cut of the 29 most frequent keywords, among which obesity (n = 61), cancer (n = 61), adolescents (n = 60), eating behavior (n = 55), smoking (n = 52), risk and protection factors (n = 47), physical activity (n = 45), hypertension (n = 45), elderly (n = 45) and non-communicable diseases (n = 41) (Figure 2).

Figure 3 shows authors’ most frequent institutional affiliations. The publications resulted 251 distinct institutional affiliations, whose sum of frequencies makes up a total of 1912 citations. The word cloud exposes a section of the 50 most frequent institutions, of which the most outstanding were Universidade Federal de Minas Gerais (UFMG) (n = 132), Oswaldo Cruz Foundation (Fiocruz in Portuguese) (n = 129), and Universidade de São Paulo (USP) (n = 118) (Figure 3).

Discussion

The study points to a continuous growth of scientific production related to NCDs in the Journal C&SC since 2002, with 2011, 2015, 2018 and 2019 being years of publication peak on the theme. Of the analyzed articles, most had a quantitative approach; in about two fifths of the publications the number of authors varied between 3 to 4 per article, and more than half were published in Portuguese. The main thematic category corresponded to “Risk and Protection Factors”. Financial support was declared in only one fifth of the studies, but among those who declared it, there was a predominance of public agents. Public institutions were also the ones that most published in the journal, with UFMG, Fiocruz and USP being the authors’ main institutional affiliations. Female researchers were the majority among those who appeared as authors in 4 or more publications. The highest volumes of publications coincided with the establishment of political and institutional frameworks at national and international levels. The keywords most frequently mentioned were obesity, cancer, adolescents, eating behavior, smoking, and risk and protective factors.

The increase in publications on NCD and its risk and protection factors in C&SC over the years may be related to the prioritization of this topic on the national and international agendas. In this perspective, it is important to highlight the inclusion of NCDs on the global agenda in 2000, when the WHO approved World Health Assembly’s Resolution 53.17 in order to support Member States in their efforts to reduce the number of morbidities, disabilities and premature mortality associated with non-communicable diseases. To this end, the creation of public policies for health promotion and prevention, as well as innovation in health care and management²⁰20 World Health Organization (WHO). Prevention and control of noncommunicable diseases. Genebra: WHO; 2000 [acessado 2020 Abr 23]. Disponível em: https://www.paho.org/bra/index.php?option=com_docman&view=download&alias=1178-resolucao-53-17-prevencao-e-controle-doencas-cronicas-nao-transmissiveis-8&category_slug=doencas-nao-transmissiveis-948&Itemid=965 guided an organization concerning the surveillance of these diseases. In the national scenario, the establishment of governmental and scientific milestones, such as the Health Surveillance Secretariat (SVS in Portuguese) in the Ministry of Health (MS in Portuguese) in 2003, was fundamental to consolidate the theme in the internal agenda. It made possible the conduction of longitudinal studies, of municipal (ISACamp, ISA-SP and others)²2 Malta DC, Silva MMA, Moura L, Morais Neto OL. A implantação do Sistema de Vigilância de Doenças Crônicas Não Transmissíveis no Brasil, 2003 a 2015: alcances e desafios. Rev Bras Epidemiol 2017; 20(4):661-675. and national population surveys (household, telephone, and school). The SVS organization chart established the General Coordination for the Surveillance of Non-communicable Diseases and Conditions (CGDANT in Portuguese), whose mission was to consolidate a surveillance and monitoring system for non-communicable diseases and conditions, implementing, then, major national surveys²2 Malta DC, Silva MMA, Moura L, Morais Neto OL. A implantação do Sistema de Vigilância de Doenças Crônicas Não Transmissíveis no Brasil, 2003 a 2015: alcances e desafios. Rev Bras Epidemiol 2017; 20(4):661-675., ²¹21 Malta DC, Cezário AC, Moura L, Morais Neto OL, Silva Junior JB. A construção da vigilância e prevenção das doenças crônicas não transmissíveis no contexto do Sistema Único de Saúde. Epidemiol Serv Saúde 2006; 15(3):47-65.^-2222 Brasil. Ministério da Saúde (MS). A vigilância, o controle e a prevenção das doenças crônicas não transmissíveis: DCNT no contexto do Sistema Único de Saúde brasileiro / Brasil. Brasília: MS; 2005 [acessado 2020 Abr 24]. Disponível em: https://www.saude.gov.br/images/pdf/2015/fevereiro/23/2.%20DCNT%20no%20contexto%20do%20SUS%202005.pdf.

These governmental milestones also coincide with the first C&SC publications, which occurred only in 2002, about six years after the journal’s launch. In the first publication, Furquin et al.²³23 Almeida MF, Barata RB, Montero CV, Silva ZP. Prevalência de doenças crônicas auto-referidas e utilização de serviços de saúde, PNAD/1998, Brasil. Cien Saude Colet 2002; 7(4):743-756. analyzed data from the IBGE’s National Household Sample Survey (PNAD/98). The article discussed the effects of Brazilian population’s aging, an increase in NCDs and a strong demand for health services. In another study, Leite et al.²⁴24 Leite IC, Schramm JMA, Gadelha AMJ, Valente JG, Campos MR, Portela MC, Hokerberg YHM, Oliveira AF, Cavalini LT, Ferreira VMB, Bittencourt SA. Comparação das informações sobre as prevalências de doenças crônicas obtidas pelo suplemento saúde da PNAD/98 e as estimadas pelo estudo Carga de Doença no Brasil. Cien Saude Colet 2002; 7(4):733-741. compared information on the prevalence of chronic diseases obtained by the health supplement of PNAD/98 and those estimated by the study “Load of Disease in Brazil”, by Beltrão and Sonoê²⁵25 Iwakami BK, Sonoê S. Comparação de informações sobre saúde das populações brasileira e norte-americana baseada em dados da PNAD/98 e NHIS/96. Cien Saude Colet 2002; 7(4):841-867., compared health information of the Brazilian population, based on data PNAD/98, and North American surveys.

In 2004, C&SC published its first thematic issue dedicated to NCDs. In the editorial, Lessa²⁶26 Lessa I. Editorial. Cien Saude Colet 2004; 9(4):828-831. discusses the importance of the topic and the delay in its inclusion in the country’s agenda; the inequalities in estimates of mortality due to NCDs, affecting more the low-income population; and the scarcity of data on morbidity. Lessa²⁷27 Lessa I. Doenças crônicas não-transmissíveis no Brasil: um desafio para a complexa tarefa da vigilância. Cien Saude Colet 2004; 9(4):931-943. also highlighted the importance of the WHO approval of the Global strategy for healthy eating, physical activity and health, as well as the initiatives of the Secretariat of Health Surveillance, of the Brazilian Ministry of Health, in the implementation of this affirmative agenda. The thematic number included analysis of Achutti and Azambuja²⁸28 Achutti A, Azambuja MIR. Doenças crônicas não-transmissíveis no Brasil: repercussões do modelo de atenção à saúde sobre a seguridade social. Cien Saude Colet 2004; 9(4):833-840. and the panelists Loureiro²⁹29 Loureiro S. Modelos assistenciais podem diminuir o impacto das DCNT na seguridade social? Cien Saude Colet 2004; 9(4):843:844., Lotufo³⁰30 Lotufo PA. Por que não vivemos uma epidemia de doenças crônicas: o exemplo das doenças cardiovasculares?. Cien Saude Colet 2004; 9(4):844-847., Teixeira³¹31 Teixeira CF. Transição epidemiológica, modelo de atenção à saúde e previdência social no Brasil: problematizando tendências e opções políticas. Cien Saude Colet 2004; 9(4):841-843., who discussed the repercussions of NCDs and the increase in pressure on social security, accompanied by their consequences for society. Still in this issue, Almeida-Filho³²32 Almeida-Filho N. Modelos de determinação social das doenças crônicas não-transmissíveis. Cien Saude Colet 2004; 9(4):865-884. reviewed the benchmarks and theoretical models for social determination of NCDs, and Lima-Costa et al.³³33 Lima-Costa MF. Estilos de vida e uso de serviços preventivos de saúde entre adultos filiados ou não a plano privado de saúde (inquérito de saúde de Belo Horizonte). Cien Saude Colet 2004; 9(4):857-864. analyzed data from a household survey carried out in Belo Horizonte and showed the differences in lifestyles and use of preventive health services among adults affiliated or not to a private health insurance, pointing out the worst indicators among those who do not have health insurance plans. Laurenti et al.³⁴34 Laurenti R, Mello Jorge MHP, Gotlieb SLD. A confiabilidade dos dados de mortalidade e morbidade por doenças crônicas não-transmissíveis. Cien Saude Colet 2004; 9(4):909-920. pointed to the NCD mortality results from the Mortality Information System (SIM in Portuguese), while Toscano³⁵35 Toscano CM. As campanhas nacionais para detecção das doenças crônicas não-transmissíveis: diabetes e hipertensão arterial. Cien Saude Colet 2004; 9(4):885-895. described the experience of population screening for diabetes. The number also presented Solla’s government report³⁶36 Franco LJ, Campos GP, Machado CA. Entrevista: O enfoque das políticas do SUS para promoção da saúde e prevenção das DCNT: do passado ao futuro. Cien Saude Colet 2004; 9(4):945-956., which addressed SUS policies for health promotion and prevention of NCDs and the challenges in training professionals. A second report described the first “Workshop on Surveillance of Non-communicable Diseases and Conditions”, held in 2004 at the Epidemiology Congress of the Brazilian Association of Collective Health (Abrasco), with the presence of specialists and the CGDANT, marking the beginning of an organization of the surveillance of NCDs in the country³⁷37 Coordenação Geral de Doenças e Agravos Não-Transmissíveis. Síntese da oficina de vigilância em doenças crônicas não-transmissíveis. Cien Saude Colet 2004; 9(4):957-962..

In the following years, new thematic numbers were published, highlighting the analysis of the first National School Health Survey (PeNSE in Portuguese) results (2010), addressing the health of adolescents³⁸38 Malta DC, Sardinha LMV, Mendes I, Barreto SM, Giatti L, Castro IRR, Moura L, Dias AJR, Crespo C. Prevalência de fatores de risco e proteção de doenças crônicas não transmissíveis em adolescentes: resultados da Pesquisa Nacional de Saúde do Escolar (PeNSE), Brasil, 2009. Cien Saude Colet 2010; 15(Supl. 2):3009-3019., exposure to smoking³⁹39 Levy RB, Castro IRR, Cardoso LO, Tavares LF, Sardinha LMV, Gomes FS, Costa AWN. Consumo e comportamento alimentar entre adolescentes brasileiros: Pesquisa Nacional de Saúde do Escolar (PeNSE), 2009. Cien Saude Colet 2010; 15(Supl. 2):3085-3097., eating behavior⁴⁰40 Castro IRR, Levy RB, Cardoso LO, Passos MD, Sardinha LMV, Tavares LF, Dutra SP, Martins A. Imagem corporal, estado nutricional e comportamento com relação ao peso entre adolescentes brasileiros. Cien Saude Colet 2010; 15(Supl. 2):3099-3108., body image⁴¹41 Hallal PC, Knuth AG, Cruz DKA, Mendes MI, Malta DC. Prática de atividade física em adolescentes brasileiros. Cien Saude Colet 2010; 15(Supl. 2):3035-3042., physical activity⁴²42 Sánchez FG, Terry JGP, Goire CT, Prevots MO, Castillo MC. Análisis de algunos indicadores bibliométricos de la Revista Información Científica de la Universidad Médica de Guantánamo. Rev Inf Cient 2018; 97(6):1088-1099.. Other supplements on food and nutrition, obesity, lifestyles, PNS results (2015), alcohol consumption and others followed.

Regarding the number of authors who signed the publications analyzed in this study, group research predominated at the expense of individual research. Other authors point out converging facts and indicate that this is a characteristic of studies in the field of health sciences⁴³43 Conner N, Provedel A, Maciel ELN. Ciência & Saúde Coletiva: análise da produção científica e redes colaborativas de pesquisa. Cien Saude Colet 2017; 22(3):987-996.

44 Sweileh WM, Al-Jabi SW, AbuTaha AS, Zyoud SH, Anayah FMA, Sawalha AF. Bibliometric analysis of worldwide scientific literature in mobile - health: 2006-2016. BMC Med Inform Decis Mak 2017; 17(1):72.^-4545 Njelesani J, Stevens M, Cleaver S, Mwambwa L, Nixon S. International research partnerships in occupational therapy: A Canadian-Zambian case study. Occup Ther In 2013; 20(2):75-84.. Group research is an expectation in funded research, given that partnerships can enhance the combination of complementary skills and knowledge⁴⁶46 Luz MT. Complexidade do campo da Saúde Coletiva: multidisciplinaridade, interdisciplinaridade, e transdisciplinaridade de saberes e práticas - análise sócio-histórica de uma trajetória paradigmática. Saude Soc 2009; 18(2):304-311., in addition to multidisciplinary speeches⁴⁷47 Garcia DCF, Gattaz CC, Gattaz NC. A Relevância do Título, do Resumo e de Palavras-chave para a Escrita de Artigos Científicos. Rev Adm Contemp 2019; 23(3):1-9..

It is also worth mentioning an approximation of the most frequent keywords with the thematic categories identified in this study. The keywords facilitate the retrieval of content, are fundamental for indexing, and act as a gateway to the text⁴⁸48 Bonita R, Magnusson R, Bovet P, Zhao D, Malta DC, Geneau R, Il S, Thankappan KR, McKee M, Hospedales J, Courten M, Capewell S, Beaglehole R, Lancet NCD Action Group. Country actions to meet UN commitments on non-communicable diseases: a stepwise approach. Lancet 2013; 381(9866):575-584., which reiterates the importance of careful selection of keywords that actually portray the theme and content covered. The keywords and thematic categories reflect the goals foreseen in the global and national plans to confront NCDs^8.19, the Sustainable Development Goals (ODS in Portuguese) and the national health research agenda, justifying the high frequency of terms such as “non-communicable diseases”, “risk factors”, “obesity”, “smoking”, “physical activity”, “food”, and “alcohol”. It should be noted that most articles refer to the risk and protection factors for NCDs, which may also reflect the consolidation of NCD surveillance in the country. Brazil organized actions to structure and operationalize a specific surveillance system for this group of diseases, in order to understand the distribution, magnitude and trend of NCDs and their risk factors, to support public policies for prevention and health promotion¹⁹19 Lunardi MS, Castro JMFC, Monat AS. Visualização dos resultados do Yahoo em nuvens de texto: uma aplicação construída a partir de web services. InfoDesign - Revista Brasileira de Design da Informação 2008; 5(1):21-35., and complementarily, to identify social, economic, and environmental determinants, establishing multi-causal chains of determination²2 Malta DC, Silva MMA, Moura L, Morais Neto OL. A implantação do Sistema de Vigilância de Doenças Crônicas Não Transmissíveis no Brasil, 2003 a 2015: alcances e desafios. Rev Bras Epidemiol 2017; 20(4):661-675.^,4949 Instituto Nacional de Câncer (INCA). Inquérito domiciliar sobre comportamentos de risco e morbidade referida de doenças e agravos não transmissíveis: Brasil, 15 capitais de Distrito Federal, 2002-2003. Rio de Janeiro: INCA; 2004 [acessado 2020 Abr 24]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/inquerito_domiciliar_comportamentos_risco_doencas_transmissiveis.pdf. In this regard, mention should be made of the implementation of some surveys in the country.

In 2003, it was conducted the first national household survey on risk behavior and reported morbidity of non-communicable diseases, setting the baseline in monitoring the main risk factors for NCDs⁵⁰50 Brasil. Ministério da Saúde (MS). Vigitel Brasil 2006: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: MS; 2007 [acessado 2020 Abr 24]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/vigitel_brasil_2006.pdf. Since 2006, the Surveillance of Risk and Protection Factors for Non-Communicable Diseases by Telephone Survey System (Vigitel in Portuguese) was implemented in all capitals of the 26 Brazilian states and in the Federal District; it monitors the frequency and distribution of NCD’s main determinants by telephone survey⁵¹51 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional por Amostra de Domicílios: tabagismo 2008. Rio de Janeiro: IBGE; 2009 [acessado 2020 Abr 24]. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv42980.pdf. In 2008, PNAD included, as part of the GATS initiative, information on morbidity and some risk factors. In Brazil, it is called: Special Smoking Survey (PETab in Portuguese)⁵²52 Brasil. Ministério da Saúde (MS). Pesquisa Nacional de Saúde do Escolar (PeNSE):o que é, para que serve, temas [página na Internet]. [acessado 2020 Abr 24]. Disponível em: https://saude.gov.br/saude-de-a-z/pense
https://saude.gov.br/saude-de-a-z/pense... . In 2009, in partnership with the Brazilian Institute of Geography and Statistics (IBGE in Portuguese) and with the support of the Ministry of Education (MEC), the PeNSE survey conducted with adolescent students was instituted. The research took place in 2009, 2012, 2015 and 2019, with the objective of subsidizing the monitoring of risk and health protection factors in schoolchildren in Brazil⁵³53 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde - PNS [página na Internet]. [acessado 2020 Abr 24]. Disponível em: https://www.ibge.gov.br/estatisticas/sociais/justica-e-seguranca/9160-pesquisa-nacional-de-saude.html?=&t=o-que-e
https://www.ibge.gov.br/estatisticas/soc... . In 2013 and 2019, the PNS was carried out by IBGE, in partnership with the Ministry of Health, being the broadest household-based survey in the country; its aim was of collecting information on the performance of the national health system with regard to access and use of available services and continuity of care, as well as on the population’s health conditions, surveillance of non-communicable diseases and the associated risk factors⁵⁴54 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de Orçamentos Familiares - POF [página na Internet]. [acessado 2020 Abr 24]. Disponível em: https://www.ibge.gov.br/estatisticas/sociais/trabalho/9050-pesquisa-de-orcamentos-familiares.html?edicao=9060&t=sobre
https://www.ibge.gov.br/estatisticas/soc... . In addition to these surveys, the Family Budget Survey (POF in Portuguese) reveals results related to the nutritional condition of the Brazilian population and the food consumption of Brazilians⁵⁵55 Brasil. Lei 8080 de 19 de Setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União 1990; 20 set..

As for the financing of the analyzed publications, it came from public agents (development agencies and government agencies) in more than 90% of the cases in which funding was declared. This is related to the fact that the Brazilian State has a legal framework and normative that guides the articulation between the sectors Health, Education and Science and Technology, as well as the national development in science, technology, and innovation in health. The promotion of research and studies in the health area is at the heart of SUS, materialized through Law N^o 8.080⁵⁶56 Tenório M, Mello GA, Viana ALD. Políticas de fomento à ciência, tecnologia e inovação em saúde no Brasil e o lugar da pesquisa clínica. Cien Saude Colet 2017; 22(5):1441-1454..

The public sector also answered for the main institutional affiliation of the authors who published in the journal. This information indicates that, despite the challenges related to scarcity of financial resources destined for public universities and research, especially in times of fiscal austerity and underfunding of science and technology, there is a mobilization in order to foster the fulfillment of the social role played by these institutions and its researchers. Scientific, technological and innovation research constitutes a fundamental element in all sectors of society, particularly in the scope and for SUS, producing significant changes in people’s lives, relationships, and work processes⁵⁷57 Departamento de Ciência e Tecnologia, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Ministério da Saúde. Pesquisa em saúde no Brasil. Rev Saude Publica 2008; 42(4):773-775.. The health field accounts for just over a third of scientific production in Brazil and there are also successful efforts and initiatives by MS⁵⁸58 Santos LMP, Souza LEPF, Serruya SJ, Guimarães RFN. O papel da pesquisa na consolidação do Sistema Único de Saúde (SUS). Cad Saude Publica 2010; 26(9):1666-1667.^,5959 Goldbaum M, Serruya SJ. O Ministério da Saúde e a política de ciência, tecnologia e inovação em saúde. Cad Saude Publica 2006; 22(3):470-471..

This study identified researchers who published the most about NCDs in C&SC, of which the majority were female. In Brazil, women answered for the authorship of approximately half of the publications between the years 2011 and 2015, representing an increase in relation to the period from 1996 to 2000, whose percentage was 38%⁶⁰60 Carvalho MS, Coeli CM, Lima LD. Mulheres no mundo da ciência e da publicação científica. Cad Saude Publica 2018; 34(3):e00025018.. However, women still have a lower proportion compared to men, in terms of receiving productivity grants from the National Council for Scientific and Technological Development (CNPq in Portuguese)⁶¹61 Valentova JV, Otta E, Silva ML, McElligott AG. Underrepresentation of women in the senior levels of Brazilian science. PeerJ 2017; 5:e4000..

Among the limitations of this study, we can mention the exclusive use of PubMed database for automatic retrieval of publications. The choice of the base can interfere with the recovered material, in quantitative and qualitative terms, depending on the particularities of the search engines used by each base. Furthermore, one must take into account the sensitivity and specificity of the search strategy, which, in this particular case, reflected the researchers’ option to focus on the four major groups of NCDs and their risk and protection factors, given a broad scope non-communicable diseases.

NCDs were widely addressed in C&SC, which has been reflecting this issue’s magnitude, priority, and transcendence. In the political-institutional sphere, the expansion of national surveys - the sources of data on NCDs - was observed, reflecting in an increase in publications and analyzes on risk and protection factors over time, with emphasis on the important leadership of public teaching and research institutions in the production of this scientific knowledge, whose evidence, in the end, can support the formulation of policies and support monitoring and evaluation processes. The journal fulfills its role by disseminating evidence, promoting debate, and expanding scientific knowledge on a topic of such relevance. In addition, NCDs have emerged as a priority in a coordinated manner on the national and global agendas, notably from the national coping plan, the global action plan, and the ODS. Before such a scenario, understanding morbidity and mortality, risk factors and distribution dynamics in the population, monitoring these events, as well as reflecting on the public management of these issues is essential in the scientific debate and also on the governmental agenda.

Acknowledgments

To the National Council for Scientific and Technological Development (CNPq) for the productivity grant for DCM and the scientific initiation grant for FTAA. EJSP thanks the Ministry of Health’s National Health Fund for the research grant. AGS, LSMC, FMDA and ACMGNS thank the Coordination for the Improvement of Higher Education Personnel (CAPES in Portuguese) for the grants.

References

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