Abstract

This study aimed to analyze possible associations between the Infection Control Structure Score (ICSS), health services, and social characteristics of the municipalities in Brazil. Secondary data from the third cycle 2017-2018 of the Brazilian National Program for Improving Primary Care Access and Quality (PMAQ) was analyzed. Six independent variables - FIRJAN Index of Municipal Development, number of inhabitants, number of family health teams receiving a financial incentive from the federal government, healthcare expenditure per capita, and number of Oral Health Teams modalities 1 and 2 - were included to assess their influence on ICSS, measured for each Brazilian town. Data analysis used the Classification and Regression Tree model performed with IBM SPSS 25. A total of 4,900 municipalities were included, and the mean ICSS was 0.905 (±0.092). A positive relationship was observed between healthcare expenditure per capita, municipal development, and the outcome. Conversely, towns with a higher number of family health teams receiving a financial incentive from the federal government showed lower mean ICSS. The findings suggest that inequalities in the infection control structures exist within the country, and they were related to the health services and social characteristics of the municipalities.

Key words:
Infection control; Dental care; Primary Health Care

Resumo

Este estudo objetivou analisar as possíveis associações entre o Escore da Estrutura de Controle de Infecção (EECI), os serviços de saúde e características sociais dos municípios brasileiros. Foram analisados dados secundários do terceiro ciclo 2017-2018 do Programa Nacional de Melhoria do Acesso e Qualidade da Atenção Básica (PMAQ). Seis variáveis independentes - Índice FIRJAN de Desenvolvimento Municipal, número de habitantes, número de Equipes de Saúde da Família que recebiam incentivo financeiro do governo federal, gasto com saúde per capita e número de Equipes de Saúde Bucal modalidades 1 e 2 - foram incluídas para avaliar a influência sobre o EECI, medido para cada município brasileiro. Para a análise dos dados, foi utilizado o modelo de Árvore de Classificação e Regressão no IBM SPSS 25. Foram incluídos 4.900 municípios, e o EECI médio foi de 0,905 (±0,092). Observou-se uma associação positiva entre o gasto com saúde per capita, o desenvolvimento municipal e o desfecho. Por outro lado, municípios com maior número de Equipes de Saúde da Família com incentivo financeiro do governo federal apresentaram menor média do EECI. Os achados sugerem que existem desigualdades nas estruturas de controle de infecções no país, relacionadas aos serviços de saúde e às características sociais dos municípios.

Palavras-chave:
Controle de infecções; Assistência odontológica; Atenção Primária à Saúde

Introduction

In dental practice, both patients and providers are susceptible of being infected by pathogenic microorganisms, such as Hepatitis B virus, Mycobacterium tuberculosis, and SARS-CoV-2¹1 Sebastiani FR, Dym H, Kirpalani T. Infection Control in the Dental Office. Dent Clin North Am 2017; 61(2):435-457.

2 Li Y, Ren B, Peng X, Hu T, Li J, Gong T, Tang B, Xu X, Zhou X. Saliva is a non-negligible factor in the spread of COVID-19. Mol Oral Microbiol 2020; 35(4):141-145.^-33 Benahmed AG, Gasmi A, Anzar W, Arshad M, Bjørklund G. Improving safety in dental practices during the COVID-19 pandemic. Health Technol (Berl) 2022; 12(1):205-214.. This is critical within the dental environment by reasons of the routine usage of ultrasonic instruments, and high-speed handpieces during many oral procedures, which create airborne bioaerosols and droplets, that might be a source of transmission to pathogens¹1 Sebastiani FR, Dym H, Kirpalani T. Infection Control in the Dental Office. Dent Clin North Am 2017; 61(2):435-457.^,33 Benahmed AG, Gasmi A, Anzar W, Arshad M, Bjørklund G. Improving safety in dental practices during the COVID-19 pandemic. Health Technol (Berl) 2022; 12(1):205-214.. Furthermore, contaminated instruments, equipment, and surfaces that are frequently touched by dental staff may also be a vehicle of infection¹1 Sebastiani FR, Dym H, Kirpalani T. Infection Control in the Dental Office. Dent Clin North Am 2017; 61(2):435-457.^,33 Benahmed AG, Gasmi A, Anzar W, Arshad M, Bjørklund G. Improving safety in dental practices during the COVID-19 pandemic. Health Technol (Berl) 2022; 12(1):205-214.. Early investigations, conducted in different locations, found that dental visits were a significant risk factor for the transmission of Hepatitis B, and Hepatitis C virus⁴4 Nazzal Z, Sobuh I. Risk factors of hepatitis B transmission in northern Palestine: a case - control study. BMC Res Notes 2014; 7:190.

5 Averbukh LD, Wu GY. Highlights for Dental Care as a Hepatitis C Risk Factor: A Review of Literature. J Clin Transl Hepatol 2019; 7(4):346-351.^-66 Mandoh SS, Ayman K, Elbardakheny A, Raaft H, Ibrahim AA, Alshaikh RA, Mansour FR. A cross sectional study of the risk factors of hepatitis C infection in North Egypt. Virusdisease 2021; 32(1):22-28..

Healthcare-associated infections (HAI) are frequent adverse events at the point of care delivery contributing to morbidity, mortality, and have a substantial economic burden on overall society, especially in developing countries⁷7 World Health Organization (WHO). Health care without avoidable infections: the critical role of infection prevention and control. Geneva: WHO; 2016.. Fortunately, many HAI are evitable through adequate physical structure, awareness, and adherence to effective Infection Prevention and Control (IPC) practices⁸8 Centers for Disease Control and Prevention (CDC), Healthcare Infection Control Practices Advisory Committee. Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings-Recommendations of the Healthcare Infection Control Practices Advisory Committee. Atlanta: CDC; 2017.. This is corroborated by a longitudinal study conducted in a Brazilian dental school during the pandemic of coronavirus disease 2019 (COVID-19). It was found that a low number of dental staff 5.8% (n=6/103) and patients 0.9% (n=1/105) tested positive for SARS-CoV-2 during the study period⁹9 Miguita L, Martins-Chaves RR, Geddes VEV, Mendes SDR, Costa SFDS, Fonseca PLC, Menezes D, Souza RM, Queiroz DC, Alves HJ, Freitas RAB, Cruz AF, Moreira RG, Moreira FRR, Bemquerer LM, Aguilar DR, Silva MES, Sampaio AA, Jardilino FDM, Souza LN, Silva TA, Gomes CC, Abreu MHNG, Aguiar RS, Souza RP, Gomez RS. Biosafety in Dental Health Care During the COVID-19 Pandemic: A Longitudinal Study. Front Oral Health 2022; 3:871107.. A similar pattern was seen in primary dental care services in the United States¹⁰10 Araujo MWB, Estrich CG, Mikkelsen M, Morrissey R, Harrison B, Geisinger ML, Ioannidou E, Vujicic M. COVID-2019 among dentists in the United States: A 6-month longitudinal report of accumulative prevalence and incidence. J Am Dent Assoc 2021; 152(6):425-433.. As such, dental practice might be safely executed when tight compliance to biosafety protocols is applied.

Due to the pandemic of COVID-19, comprehensive discussions about IPC took place in the scientific community, and numerous guidelines, protocols, and research papers on this topic were published¹¹11 World Health Organization (WHO). Cleaning and disinfection of environmental surfaces in the context of COVID-19. Geneva: WHO; 2016.

12 Islam MS, Rahman KM, Sun Y, Qureshi MO, Abdi I, Chughtai AA, Seale H. Current knowledge of COVID-19 and infection prevention and control strategies in healthcare settings: A global analysis. Infect Control Hosp Epidemiol 2020; 41(10):1196-1206.

13 Australian Dental Association (ADA). Guidelines for Infection Prevention and Control. 4ª ed. Sydney: ADA; 2021.

14 Food and Drug Administration (FDA). Enforcement Policy for Sterilizers, Disinfectant Devices, and Air Purifiers During the Coronavirus Disease 2019 (COVID-19) Public Health Emergency. Silver Spring: FDA; 2020.^-1515 Amato A, Caggiano M, Amato M, Moccia G, Capunzo M, Caro F. Infection Control in Dental Practice During the COVID-19 Pandemic. Int J Environ Res Public Health 2020; 17(13):4769.. These documents underline the need to strengthen IPC practices, particularly in Primary Health Care (PHC). According to Starfield et al.¹⁶16 Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005; 83(3):457-502., PHC may account for several benefits on population health, such as great access to needed services, better quality of care, greater focus on prevention, early detection and management of diseases, and reduction of unnecessary specialized care. Under those positive aspects, PHC seems an important level of care to health systems.

Aiming to improve access and quality of services provided at PHC, the federal government, between 2011 and 2018, funded three cycles of the Brazilian National Program for Improving Primary Care Access and Quality (PMAQ, in Portuguese). The foundation of the program relied on the quality-of-care framework proposed by Donabedian, in which quality is related to structure, process, and outcome parameters¹⁷17 Donabedian A. Evaluating the quality of medical care. 1966. Milbank Q 2005; 83(4):691-729.. PMAQ was a public sector assessment of PHC facilities, compliance with the program was voluntary, and its main goal was to strengthen PHC by allocating financial resources from the Ministry of Health to municipalities based on the performance of primary care workers¹⁸18 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQAB): manual instrutivo. Brasília: MS; 2013.. PMAQ was terminated by the federal government in December 2019, establishing new bases for PHC funding¹⁹19 Harzheim E, D'Avila OP, Ribeiro DC, Ramos LG, Silva LED, Santos CMJD, Costa LGM, Cunha CRHD, Pedebos LA. New funding for a new Brazilian Primary Health Care. Cien Saude Colet 2020; 25(4):1361-1374..

Previous analysis of data from the second evaluation cycle of PMAQ revealed that only 1.3% (n=208) of all evaluated dental clinics, complied with all of the infection control items assessed in the study²⁰20 Abreu MHNG, Resende VLS, Lee KH, Matta-Machado ATGD, Starr JR. Regional differences in infection control conditions in a sample of primary health care services in Brazil. Cad Saude Publica 2017; 33(11):e00072416.. Additionally, of the Brazilian regions, South and Southeast showed a better structure of infection control in dental clinics²⁰20 Abreu MHNG, Resende VLS, Lee KH, Matta-Machado ATGD, Starr JR. Regional differences in infection control conditions in a sample of primary health care services in Brazil. Cad Saude Publica 2017; 33(11):e00072416.. Further investigations, using data from the third cycle of PMAQ demonstrated that inequalities in the structure of infection control within the country persisted. That is, the South region had the best infection control structure, while the North region had the worst structure²¹21 Fonseca EP, Pereira-Junior EA, Palmier AC, Abreu MHNG. A Description of Infection Control Structure in Primary Dental Health Care, Brazil. Biomed Res Int 2021; 2021:5369133..

Evidence suggests that characteristics of health services and local social factors may impact the performance of public dental clinics²²22 Machado FC, Silva JV, Ferreira MA. Factors related to the performance of Specialized Dental Care Centers. Cien Saude Colet 2015; 20(4):1149-1163.

23 Viana IB, Moreira RDS, Martelli PJL, Oliveira ALS, Monteiro IDS. Evaluation of the quality of oral health care in Primary Health Care in Pernambuco, Brazil, 2014. Epidemiol Serv Saude 2019; 28(2):e2018060.^-2424 Reis C, Mendes SDR, Matta-Machado A, Mambrini JVM, Werneck MAF, Abreu M. Factors associated with the performance of primary dental health care in Brazil: A multilevel approach. Medicine (Baltimore) 2020; 99(17):e19872.. Machado et al.²²22 Machado FC, Silva JV, Ferreira MA. Factors related to the performance of Specialized Dental Care Centers. Cien Saude Colet 2015; 20(4):1149-1163., pointed out that different forms of organization of work processes and, contextual characteristics of the place where the services were implanted, such as population size, municipal human development index, and primary healthcare coverage influenced the performance of oral health services. Coincidently, a multilevel analysis reported that organizational variables of the Brazilian dental services (dental appointment during pregnancy; delivery of home dental care; usage of guidelines for prostheses; referral for secondary care), and better socioeconomic status were positively associated with better performance of dental services²⁴24 Reis C, Mendes SDR, Matta-Machado A, Mambrini JVM, Werneck MAF, Abreu M. Factors associated with the performance of primary dental health care in Brazil: A multilevel approach. Medicine (Baltimore) 2020; 99(17):e19872.. In this context, we have the hypothesis that social characteristics of the municipalities (FIRJAN Index of Municipal Development [FIMD], and number of inhabitants), and health service organizational factors (number of family health teams receiving financial incentives from federal government, healthcare expenditure per capita, and number of Oral Health Teams [OHT] modalities 1 and 2) may influence the standards of infection control.

In a previous study, the development of an Infection Control Structure Score (ICSS) was presented for OHT in the Brazilian PHC²¹21 Fonseca EP, Pereira-Junior EA, Palmier AC, Abreu MHNG. A Description of Infection Control Structure in Primary Dental Health Care, Brazil. Biomed Res Int 2021; 2021:5369133.. Although preliminary studies reported inequalities related to infection control, the associated factors are not known. Hence, this study aimed to analyze possible associations between ICSS, health services, and social characteristics of the municipalities in Brazil.

Materials and methods

Ethics Statement

This study analyzed a publicly available database from the Brazilian Ministry of Health, which was approved by an Ethics Committee on Research involving human beings (CAAE 77847417.9.0000.0055; Approval number 234 6623).

Study design

This is a health evaluation study that analyzed secondary data from the third evaluation cycle (2017-2018) of the PMAQ. During the third cycle of the program, the evaluation of PHC units comprised of self-assessment of the teams, routine monitoring, and external evaluation. All the questions included in this study were obtained from the external evaluation phase of the program, which was produced by the Ministry of Health together with some national research institutions. The external evaluation consisted of collecting data about access and quality of PHC units, and the instrument used was structured with 903 questions²⁵25 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Nota Metodológica da Certificação das Equipes de Atenção Básica Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB) - Terceiro ciclo. Brasília: MS; 2018..

Of the 22,046 PHC units, 1,745 were excluded for the following reasons: unit deactivated; management did not authorize the evaluation of the unit; the OHT did not authorize assessment; the unit was undergoing remodeling or expansion and the staff was not delivering care anywhere else; the team did not adhere to PMAQ; the OHT permanently works elsewhere; the OHT works with a specific population (remote area, penitentiary system, and mobile team). Thus, 20,301 PHC units with OHT were included in this study.

Study variables

In our analysis, the outcome variable was the ICSS for each Brazilian municipality measured by 14 items related to the equipment and physical structure of the dental offices in the PHC units: 1) Good ventilation or air conditioning (yes, no); 2) Floor and walls with washables surfaces (yes, no); 3) Mold near sink (yes; no); 4) Faucet without running water (yes, no); 5) Pungent sewage smell (yes, no); 6) Lack of water (yes, no); 7) Autoclave in use (none, one or more); 8) Pack sealer in use (none, one or more); 9) Touchless sink faucet (none, one or more); 10) Sharp container (yes, no); 11) Rubber gloves for cleaning dental instruments (yes, no); 12) Materials/products for cleaning dental instruments and drills (yes, no); 13) Products for packaging dental instruments for sterilization (yes, no); 14) Personal protective equipment (safety glasses, surgical gloves, and masks) in sufficient quantity (yes, no). No missing data were identified for these 14 variables. Each PHC unit received an ICSS score. Higher values indicated better structure for infection control. The full description of the score was published elsewhere²¹21 Fonseca EP, Pereira-Junior EA, Palmier AC, Abreu MHNG. A Description of Infection Control Structure in Primary Dental Health Care, Brazil. Biomed Res Int 2021; 2021:5369133..

The independent variables included in the study were organized into two main groups: Social characteristics of the municipalities (FIMD, and number of inhabitants), and Health service organizational factors (number of family health teams receiving financial incentives from the federal government, healthcare expenditure per capita, and number of OHT modalities 1 and 2). All these variables were numeric, either discrete or continuous, measured at the municipal level and collected from official Brazilian government databases (Chart 1).

Statistical analysis

Initially, descriptive statistics were performed for both outcome and independent variables to estimate frequencies and variability. Next, Classification and Regression Tree (CaRT) analysis was deployed.

CaRT is a nonparametric statistical approach that is valuable for analyzing complex data, and usage has been growing in health sciences, and epidemiological research²⁶26 Lemon SC, Roy J, Clark MA, Friedmann PD, Rakowski W. Classification and regression tree analysis in public health: methodological review and comparison with logistic regression. Ann Behav Med 2003; 26(3):172-181.^,2727 Speybroeck N. Classification and regression trees. Int J Public Health 2012; 57(1):243-246.. This method can effectively identify subgroups within a population whose members have similar characteristics that influence the outcome variable²⁶26 Lemon SC, Roy J, Clark MA, Friedmann PD, Rakowski W. Classification and regression tree analysis in public health: methodological review and comparison with logistic regression. Ann Behav Med 2003; 26(3):172-181.^,2727 Speybroeck N. Classification and regression trees. Int J Public Health 2012; 57(1):243-246.. The result of CaRT is illustrated by an informative hierarchical chart, called decision tree, which is composed of a parent node - a group containing the entire sample - that branches into multiple descendent nodes, according to the independent variable with the strongest interaction to the outcome. At the point that no further subdivision is feasible, a terminal node is created²⁶26 Lemon SC, Roy J, Clark MA, Friedmann PD, Rakowski W. Classification and regression tree analysis in public health: methodological review and comparison with logistic regression. Ann Behav Med 2003; 26(3):172-181.. The advantage of using CaRT in public health studies is that identifying high-risk population subgroups could be helpful to target interventions, and consequently reduce health disparities²⁶26 Lemon SC, Roy J, Clark MA, Friedmann PD, Rakowski W. Classification and regression tree analysis in public health: methodological review and comparison with logistic regression. Ann Behav Med 2003; 26(3):172-181.^,2727 Speybroeck N. Classification and regression trees. Int J Public Health 2012; 57(1):243-246..

For this study, CaRT model was composed of a numeric continuous outcome variable and other six numeric independent variables The outcome was the average value for ICSS for each Brazilian municipality. Initially, mean, and median ICSS were tested to aggregate the indicators of the dental units in each municipality. The median showed a pronounced left asymmetry (negative asymmetry), then the mean ICSS was selected to run CaRT model. The Chi-square Automatic Interaction Detection (CHAID) method was used to perform successive divisions of the database. For each division, CHAID method automatically selected cutoff points for the covariates that interacted with the outcome (ICSS)²⁸28 Breiman L, Friedman J, Stone CJ, Olshen RA. Classification and regression trees. United Kingdom: CRC Press; 1998.. Some splitting criteria were established to develop CaRT: (1) each node should have at least 50 observations to perform subdivisions; (2) each terminal node should have at least 30 observations; (3) the model disregards subdivisions with p≥0.05²⁸28 Breiman L, Friedman J, Stone CJ, Olshen RA. Classification and regression trees. United Kingdom: CRC Press; 1998.. All statistical analysis was performed using SPSS software version 25 (SPSS Inc., Chicago, USA).

Results

Of the 5,570 municipalities in Brazil, a total of 670 (12.02%) were excluded from analysis because, by the time of the third evaluation cycle of PMAQ (2017-2018), they did not have any implemented PHC unit. The final sample consisted of 4,900 municipalities, which ICSS, social characteristics and health service organizational factors are shown in Table 1.

The CaRT generated a tree containing 14 nodes (Figure 1). The average ICSS ranged from 0.853 (±0.108) to 0.943 (±0.074) between the nodes. The first variable selected for splitting was healthcare expenditure per capita creating seven nodes (N1-N7). Municipalities that spent more money on care delivery showed high ICSS. Among those municipalities where expenditure per capita was $221.0-318.3 (N3; n=984), FIMD provided the most significant split, and two terminal nodes were created. The subgroup that FIMD was ≤0.579 presented low ICSS (mean=0.877 ±0.101; n=309), when compared to the subgroup with FIMD >0.579 (mean ICSS=0.899 ±0.080; n=675). FIMD also interacted with the group of municipalities, which expenditure per capita was $318.3-446.3 (N4; n=979), resulting in three terminal nodes. These nodes demonstrated that high FIMD is positively associated with ICSS. Finally, among the 20% of municipalities that had the second highest range of healthcare expenditure (N6; n=979), the variable number of family health teams receiving financial incentives from the federal government influenced the outcome, but in an inverse way. That is, municipalities with more than two family health teams receiving financial incentives had lower ICSS indicators.

Discussion

In this study, we could identify significant inequalities in the structure of infection control across the Brazilian municipalities, as well as the three main associated factors. A positive relationship was observed between healthcare expenditure per capita, FIMD, and the outcome. Conversely, municipalities with higher number of family health teams receiving financial incentives from the federal government showed lower mean ICSS.

The findings of this research suggest that the financial resources spent per person per year in care delivery dramatically impact the structure of IPC. This trend is somehow similar to other countries. In the United States, the sum of money spent per individual with healthcare increased from $5,259 in 1996 to $9,655 in 2016²⁹29 Dieleman JL, Cao J, Chapin A, Chen C, Li Z, Liu A, Horst C, Kaldjian A, Matyasz T, Scott KW, Bui AL, Campbell M, Duber HC, Dunn AC, Flaxman AD, Fitzmaurice C, Naghavi M, Sadat N, Shieh P, Squires E, Yeung K, Murray CJL. US Health Care Spending by Payer and Health Condition, 1996-2016. JAMA 2020; 323(9):863-884.. This substantial growth improved the general quality of healthcare including biosafety in care facilities, resulting in the overall reduction of HAI³⁰30 Vaughn VM, Saint S, Greene MT, Ratz D, Fowler KE, Patel PK, Krein SL. Trends in Health Care-Associated Infection Prevention Practices in US Veterans Affairs Hospitals From 2005 to 2017. JAMA Netw Open 2020; 3(2):e1920464.

31 Patrick SW, Kawai AT, Kleinman K, Jin R, Vaz L, Gay C, Kassler W, Goldmann D, Lee GM. Health care-associated infections among critically ill children in the US, 2007-2012. Pediatrics 2014; 134(4):705-712.

32 Fagan RP, Edwards JR, Park BJ, Fridkin SK, Magill SS. Incidence trends in pathogen-specific central line-associated bloodstream infections in US intensive care units, 1990-2010. Infect Control Hosp Epidemiol 2013; 34(9):893-899.

33 Center for Disease Control and Prevention (CDC). Winnable Battles Final Report 2015. Atlanta: CDC; 2017.^-3434 Magill SS, O'Leary E, Janelle SJ, Thompson DL, Dumyati G, Nadle J, Wilson LE, Kainer MA, Lynfield R, Greissman S, Ray SM, Beldavs Z, Gross C, Bamberg W, Sievers M, Concannon C, Buhr N, Warnke L, Maloney M, Ocampo V, Brooks J, Oyewumi T, Sharmin S, Richards K, Rainbow J, Samper M, Hancock EB, Leaptrot D, Scalise E, Badrun F, Phelps R, Edwards JR. Changes in Prevalence of Health Care-Associated Infections in U.S. Hospitals. N Engl J Med 2018; 379(18):1732-1744.. The incidence of some infections caused by multidrug-resistant microorganisms, such as Methicillin-resistant Staphylococcus aureus considerably decreased in recent years³⁵35 See I, Mu Y, Albrecht V, Karlsson M, Dumyati G, Hardy DJ, Koeck M, Lynfield R, Nadle J, Ray SM, Schaffner W, Kallen AJ. Trends in Incidence of Methicillin-resistant Staphylococcus aureus Bloodstream Infections Differ by Strain Type and Healthcare Exposure, United States, 2005-2013. Clin Infect Dis 2020; 70(1):19-25.^,3636 Jernigan JA, Hatfield KM, Wolford H, Nelson RE, Olubajo B, Reddy SC, McCarthy N, Paul P, McDonald LC, Kallen A, Fiore A, Craig M, Baggs J. Multidrug-Resistant Bacterial Infections in U.S. Hospitalized Patients, 2012-2017. N Engl J Med 2020; 382(14):1309-1319.. Additionally, the Centers for Disease Control and Prevention (CDC) reported that the national percentage of central-line bloodstream infections dropped by 50% between 2008 and 2014³³33 Center for Disease Control and Prevention (CDC). Winnable Battles Final Report 2015. Atlanta: CDC; 2017.. Besides that, health systems from low and middle-income nations like Brazil, usually have tight budgets, then basic structure and supplies (e.g., safe water supply, autoclaves, antiseptics, surgical gloves, gowns, and safety goggles) might be irregularly available, making IPC a challenge³⁷37 Vilar-Compte D, Camacho-Ortiz A, Ponce-de-Leon S. Infection Control in Limited Resources Countries: Challenges and Priorities. Curr Infect Dis Rep 2017; 19(5):20.. Therefore, to advance the standards of infection control in Brazil, authorities should deploy some schemes to expand healthcare expenditure per capita, especially in the more vulnerable municipalities.

Locations with great economic development, measured by the FIMD, presented high ICSS. Brazil is marked by profound socioeconomic inequalities within the country³⁸38 Victora CG, Barreto ML, Leal MC, Monteiro CA, Schmidt MI, Paim J, Bastos FI, Almeida C, Bahia L, Travassos C, Reichenheim M, Barros FC. Health conditions and health-policy innovations in Brazil: the way forward. Lancet 2011; 377(9782):2042-2053.

39 Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Use of and access to health services in Brazil, 2013 National Health Survey. Rev Saude Publica 2017; 51(Supl. 1):3s.^-4040 Boccolini CS, Souza Junior PR. Inequities in Healthcare utilization: results of the Brazilian National Health Survey, 2013. Int J Equity Health 2016; 15(1):150.. Typically, the South and Southeast geographic regions are the most developed, consequently, they present better health outcomes, PHC performance, and quality of care delivered⁴¹41 Global Burden of Disease Study 2016 Brazil Collaborators. Burden of disease in Brazil, 1990-2016: a systematic subnational analysis for the Global Burden of Disease Study 2016. Lancet 2018; 392(10149):760-775.

42 Mendes SR, Martins RC, Matta-Machado ATGM, Mattos GCM, Gallagher JE, Abreu MHNG. Dental Procedures in Primary Health Care of the Brazilian National Health System. Int J Environ Res Public Health 2017; 14(12):1480.^-4343 Scalzo MTA, Abreu M, Matta-Machado ATG, Martins RC. Oral health in Brazil: What were the dental procedures performed in Primary Health Care. PLoS One 2022; 17(1):e0263257.. A previous study conducted at the regional level reported that the most affluent Brazilian regions had better structure of infection control in dental offices²⁰20 Abreu MHNG, Resende VLS, Lee KH, Matta-Machado ATGD, Starr JR. Regional differences in infection control conditions in a sample of primary health care services in Brazil. Cad Saude Publica 2017; 33(11):e00072416.. Our results highlight that this pattern remains at the municipal level, mostly because the top-ranked towns, according to the FIMD, are in the South and Southeast⁴⁴44 Índice FIRJAN de Desenvolvimento Municipal. Ranking IFDM 2018 - Ordem De Pontuação. Rio de Janeiro: FIRJAN; 2018.. Other few surveys have considered the relationship between economic areas of outpatient settings, and IPC practices. Qiao et al.⁴⁵45 Qiao F, Huang W, Zong Z, Yin W. Infection prevention and control in outpatient settings in China-structure, resources, and basic practices. Am J Infect Control 2018; 46(7):802-807. assessed 146 facilities, including hospitals, and community centers in five Chinese provinces regarding the infrastructure, apparatus, materials, and basic activities of IPC. The authors found out that local development and local Gross Domestic Product were positively associated with better structure of infection control⁴⁵45 Qiao F, Huang W, Zong Z, Yin W. Infection prevention and control in outpatient settings in China-structure, resources, and basic practices. Am J Infect Control 2018; 46(7):802-807.. Similarly, Cleveland et al.⁴⁶46 Cleveland JL, Bonito AJ, Corley TJ, Foster M, Barker L, Brown GG, Lenfestey N, Lux L. Advancing infection control in dental care settings: factors associated with dentists' implementation of guidelines from the Centers for Disease Control and Prevention. J Am Dent Assoc 2012; 143(10):1127-1138., found that implementation of IPC recommendations in dental clinics varied across United States Census division; those located in rural regions had low rates of compliance with IPC guidelines. Public attempts should be made by the federal, state, and local governments to establish policies to strengthen IPC processes or practices.

Surprisingly, towns, where more family health teams received federal resources, had worse average ICSS. This finding is interesting since it is expected that towns with higher number of teams being funded should have greater conditions to organize the physical and organizational structure, equipment, supplies, and human resources for infection control in PHC units. A possible explanation for this finding may be the fact that there is more implantation of family health teams in municipalities with lower income, geographically and economically less favorable. More vulnerable regions may face fragilities in the physical structure, equipment, and supplies for infection control, and lack of personal protective equipment for practitioners²¹21 Fonseca EP, Pereira-Junior EA, Palmier AC, Abreu MHNG. A Description of Infection Control Structure in Primary Dental Health Care, Brazil. Biomed Res Int 2021; 2021:5369133.. However, this relationship is not entirely clear, and our results must be interpreted with caution. Thus, further primary studies are needed to understand this topic fully.

The current study has some drawbacks that should be addressed. First, secondary databases have some inherent limitations, such as missing information. Although 1,745 (7.9%) PHC units were excluded from our analysis, PMAQ collected data in almost 88% of the towns participating in the third cycle covering all five Brazilian geographical regions. In addition, it is pertinent to take into consideration the great complexity of the PMAQ scheme rolled out in Brazil, which is one of the largest pay-for-performance programs in the world⁴⁷47 Macinko J, Harris MJ, Rocha MG. Brazil's National Program for Improving Primary Care Access and Quality (PMAQ): Fulfilling the Potential of the World's Largest Payment for Performance System in Primary Care. J Ambul Care Manage 2017; 40(Supl. 2):S4-S11.. Second, the cross-sectional design of this survey does not allow the establishment of causal relationships, but rather associations. Third, compliance to PMAQ was not compulsory, then municipal management could have subscribed just some of the OHT, which may have biased the results. Despite that, PMAQ dataset is a relevant and robust source of data for PHC analysis at the national level.

Based on the results of this study, it could be concluded that those municipalities with higher healthcare expenditure per capita and, municipalities with higher degrees of development, measured by FIMD, showed better ICSS. On the other hand, towns with a higher number of family health teams receiving financial incentives from the federal government showed lower ICSS. As such, it seems that the health services and social characteristics of the Brazilian municipalities are associated with the structure of infection control in PHC.

Albeit accumulated evidence is necessary to understand this topic fully, our findings may bring some theoretical and practical implications to overcome the issue of infection control in dental primary care. To advance, political will and some schemes to expand fund-raising to healthcare are necessary. It is well documented that increasing healthcare resources is a relevant strategy for improving access, work processes, health outcomes, and the standards of infection control²⁹29 Dieleman JL, Cao J, Chapin A, Chen C, Li Z, Liu A, Horst C, Kaldjian A, Matyasz T, Scott KW, Bui AL, Campbell M, Duber HC, Dunn AC, Flaxman AD, Fitzmaurice C, Naghavi M, Sadat N, Shieh P, Squires E, Yeung K, Murray CJL. US Health Care Spending by Payer and Health Condition, 1996-2016. JAMA 2020; 323(9):863-884.^{, 30, 48, 49}. Also, we observed that municipal development was linked to the outcome. As such, broad policies focusing on general municipal development might indirectly improve the structure in the towns and, consequently narrow inequalities related to the structure of infection control.

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