Factors associated with notification of noise-induced hearing loss in Brazil, 2013-2015: an ecological study21Article derived from the master’s degree dissertation entitled ‘Contextual factors associated with the notification of noise-induced hearing loss on Sinan, in Brazil’, submitted by Aline Cristina Gusmão Souza Gomes to the Public Health Postgraduate Program of the Federal University of Bahia, on July 24, 2019. The study received financial support from the Coordination for the Improvement of Higher Education Personnel/Ministry of Education (Capes/MEC): Process No. 001.

Aline Cristina Gusmão Tatiane Costa Meira Silvia Ferrite About the authors

Abstract

Objective

To investigate factors associated with the notification of noise-induced hearing loss (NIHL), on the Notifiable Health Conditions Information System (SINAN) in Brazil.

Methods

This was an ecological study to estimate the proportion of municipalities that had notified NIHL. Logistic regression models were used to identify associated factors.

Results

Between 2013-2015, 277 (5.0%) municipalities notified NIHL. Notification was more prevalent among municipalities in an Occupational Health Referral Center (CEREST) coverage area (OR=1.62 - 95%CI 1.02;2.59) or those that had a CEREST in their territory (OR=4.37 - 95CI% 2.75;6.93), those that were closer to the state capital (OR=1.43 - 95%CI 1.06;1.92) and those with a high human development index (OR=2.35 - 95%CI 1.16;4.75). Among the municipalities located in a CEREST coverage area, notification was more frequent when there was a speech-language-hearing professional in the team (OR=1.96 - 95%CI - 1.47;2.63) and when employee turnover was low (OR=1.88 - 95%CI 1.40;2.52).

Conclusion

Contextual factors influence NIHL notification, particularly the presence of CERESTs and their qualification.

Keywords:
Hearing Loss, Noise-Induced; Health Information Systems; Public Health Surveillance; Occupational Health; Ecological Studies

Introduction

Noise-induced hearing loss (NIHL) is one of the most widespread and prevalent occupational health problems in the world.11. Nelson DI, Nelson RY, Concha-Barrientos M, Fingerhut M. The global burden of occupational noise-induced hearing loss. Am J Ind Med. 2005 Dec;48(6):446-58. doi: https://doi.org/10.1002/ajim.20223
https://doi.org/10.1002/ajim.20223...

2. Basner M, Babisch W, Davis A, Brink M, Clark C, Janssen S, Stansfeld S. Auditory and non-auditory effects of noise on health. Lancet. 2013 Oct;383(9925):1325-32. doi: https://doi.org/10.1016/S0140-6736(13)61613-X.
https://doi.org/10.1016/S0140-6736(13)61...

3. Sayler SK, Roberts BJ, Manning MA, Sun K, Neitzel RL. Patterns and trends in OSHA occupational noise exposure measurements from 1979 to 2013. Occup Environ Med. 2019 Feb;76(2):118-24. doi: https://doi.org/10.1136/oemed-2018-105041.
https://doi.org/10.1136/oemed-2018-10504...
-44. National Institute for Occupational Safety and Health. Occupational Hearing Loss (ohl) Surveillance: facts and definitions [Internet]. 2018 [citado 26 abr. 2018]. Disponível em: https://www.cdc.gov/niosh/topics/ohl /.
https://www.cdc.gov/niosh/topics/ohl...
According to the World Health Organization (WHO), in 2000, NIHL accounted for 19.0% of the years lived with disability caused by all diseases and health conditions due to occupational factors worldwide.55. Concha-Barrientos M, Nelson DI, Driscoll T, Steenland NK, Punnett L, Fingerhut M, et al. Selected occupational risk factors. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, organizadors. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: WHO; 2004, p. 1651-801. NIHL is listed in the International Statistical Classification of Diseases and Related Health Problems - 10th Revision (ICD-10) and is referred to by code H83.3.

In Brazil, notification of NIHL on the Notifiable Health Conditions Information System (SINAN) is compulsory and is to be monitored by the Occupational Health Surveillance service (VISAT).66. Santana VS, Silva JM. Os 20 anos da saúde do trabalhador no Sistema Único de Saúde do Brasil: limites, avanços e desafios. In: Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Saúde Brasil 2008: 20 anos de Sistema Único de Saúde no Brasil. Brasília, DF: MS; 2009. p.175-204. In 2002 the Brazilian National Health System (SUS), responsible for VISAT, created the National Comprehensive Occupational Healthcare Network (RENAST), which includes 210 Occupational Health Referral Centers (CEREST) responsible for coordinating actions in regions, each one covering a set of municipalities.66. Santana VS, Silva JM. Os 20 anos da saúde do trabalhador no Sistema Único de Saúde do Brasil: limites, avanços e desafios. In: Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Saúde Brasil 2008: 20 anos de Sistema Único de Saúde no Brasil. Brasília, DF: MS; 2009. p.175-204. One of CEREST’s duties is to act as a specialized support center for prevention, promotion and health care, ensuring the notification of work-related health problems on the information systems administered by the Informatics Department of the SUS (DATASUS), including SINAN.77. Ministério da Saúde (BR). Portaria nº 2.437, de 7 de dezembro de 2005. Dispõe sobre a ampliação e o fortalecimento da Rede Nacional de Atenção Integral à Saúde do Trabalhador - RENAST no Sistema Único de Saúde - SUS e dá outras providências. Diário Oficial da República Federativa do Brasil. Brasília, DF, 7 dez. 2005 [citado 22 fev. 2018]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2005/prt2437_07_ 12_2005.html
http://bvsms.saude.gov.br/bvs/saudelegis...
Despite the time that has elapsed since its inclusion in 2004, the number of NIHL cases reported on SINAN continues to be low,88. Ferrite S, Meira TC, Santana VS, Cavalcante F, Gusmão AC, Peres MC, et al. Boletim da vigilância dos agravos à saúde relacionados ao trabalho: perda auditiva induzida por ruído ocupacional: informe do centro colaborador PISAT/ISC/UFBA - MS/DSAST/CGSAT [Internet]. Nov. 2013 [citado 14 mar 2018]. Disponível em: http://renastonline.ensp.fiocruz.br/sites/default/files/arquivos/recursos/BOL7_PAIR.pdf
http://renastonline.ensp.fiocruz.br/site...
considering its prevalence found in studies conducted with samples or populations of specific companies.99. Guerra MR, Lourenço PMC, Bustamante-Teixeira MT, Alves MJM. Prevalência de perda auditiva induzida por ruído em empresa metalúrgica. Rev Saude Publica. 2005 abr.;39(2):238-44. doi: https://doi.org/10.1590/S0034-89102005000200015.
https://doi.org/10.1590/S0034-8910200500...
,1010. Caldart AU, Adriano CF, Terruel I, Martins RF, Caldart AU, Mocellin M. Prevalência da perda auditiva induzida pelo ruído em trabalhadores de indústria têxtil. Arq Int Otorrinolaringol. 2006 jul-set;10(3):192-6.

No studies were found on factors associated with NIHL notification, but rather on factors that increased the notification of work injuries on SINAN (2008-2009) within the scope of CERESTs: adequate infrastructure; greater amount and supply of staff training; and meeting external demands.1111. Galdino A, Santana VS, Ferrite S. Os centros de referência em saúde do trabalhador e a notificação de acidentes de trabalho no Brasil. Cad Saude Publica. 2012 Jan;28(1):145-59. doi: https://doi.org/10.1590/S0102-311X2012000100015.
https://doi.org/10.1590/S0102-311X201200...
In the municipality of Fortaleza, capital of the state of Ceará, the professionals’ years of service at the sentinel units, participation in training courses regarding work-related injuries, knowledge of ordinances and legislation that support notification, understanding of the compulsory nature of notifications, and discussions on daily work subjects, were also identified as favorable characteristics for the notification of work-related injuries, between 2013 and 2014.1212. Ferreira MJM, Lima RKS, Silva AMC, Filho JGB, Cavalcanti LPG. Vigilância dos acidentes de trabalho em unidades sentinela em saúde do trabalhador no município de Fortaleza, nordeste do Brasil. Cien Saude Colet. 2017 Oct;22(10):3393-402. doi: https://doi.org/10.1590/1413-812320172210.17422017.
https://doi.org/10.1590/1413-81232017221...

Knowledge of these factors can support actions that favor the notification of NIHL on SINAN, contributing to its viability as a strategy for NIHL surveillance in the country. This study aimed to investigate contextual factors associated with the notification of NIHL in Brazil.

Methods

This was an ecological study on factors associated with the notification of NIHL in Brazil, between 2013 and 2015. According to data from the Brazilian Institute of Geography and Statistics (IBGE), the country had 202,768,562 inhabitants in 2014, and its economically active and occupied population - henceforth referred to as occupied population - corresponded to 99.4 million workers (49.0%).1313. Instituto Brasileiro de Geografia e Estatística (BR). Sistema IBGE de Recuperação Automática. Pesquisa Nacional por Amostra de Domicílios. Tabela 1869: pessoas de 10 anos ou mais de idade, ocupadas na semana de referência, por anos de estudo, sexo e classes de rendimento mensal de todos os trabalhos. [Internet]. 2014 [citado 27 de out. 2020]. Disponível em: https://sidra.ibge.gov.br/Tabela/1869
https://sidra.ibge.gov.br/Tabela/1869...
All 5,570 municipalities in the period, distributed over the country’s 27 Federative Units, were observation units.

Once all NIHL cases reported in the study period had been identified, by municipality, the outcome variable was defined: notifying municipality - ‘yes’ (1) - when it presented at least one notification of NIHL; and non-notifying municipality - (0) - in the absence of notification. The ‘notifying source’ variable was used to indicate whether municipal notifications were recorded exclusively via CEREST, only by other routes (except CEREST), or by both sources.

The variables analyzed as potential predictors for the outcome were:

  1. CEREST coverage (yes; no);

  2. Municipality is home to a CEREST (yes; no);

  3. Macro-region of the country (North; Northeast; Southeast; South; Midwest);

  4. Federative Unit;

  5. Distance from the municipality to the capital of the Federative Unit in kilometers (km), calculated by a line from the centroid of the geographic coordinates of the municipality and adjusted with the Euclidean factor, categorized by the median as (0) ≥275 or (1) <275;

  6. Territorial extension in square kilometers (km2) categorized based on median as (0) ≤418 and (1) >418;

  7. Occupied population, based on the 2010 census (≤5,000; >5 to 20,000; >20 to 50,000; >50 to 100,000; >100,000);

  8. Workers in the manufacturing/mining/construction industries, which represent the proportion of workers in the municipality in these branches of activity, categorized as <15.0% or ≥15.0%;

  9. Workers in the manufacturing industry, categorized by the proportion ≤6.4% or >6.4%, based on the median;

  10. Workers in the mining industry, categorized as ≤0.1% or >0.1%, based on the median;

  11. Construction workers, categorized as ≤6.0% or >6.0%, based on the median;

  12. Workers with formal employment, categorized on the basis of the median, as ≤34.1% or >34.1%, considering formal employment to be workers with a formal contract, military, statutory civil servants and employers, and taking informal employment to be self-employed people, production for self-consumption, unpaid and employees working off the books;

  13. Municipal human development index (HDI-M), based on the 2010 census, categorized as low/very low (0.000 to 0.599), medium (0.600 to 0.699) or high/very high (0.700 to 1.000), based on the classification proposed by the Atlas of Human Development in Brazil.1414. Programa das Nações Unidas para o Desenvolvimento. Atlas de desenvolvimento humano no Brasil [Internet]. 2013 [citado 21 jun. 2019]. Disponível em: http://www.atlas brasil.org.br/2013/pt/o_atlas/idhm /
    http://www.atlas brasil.org.br/2013/pt/o...

For the municipalities with coverage, that is, belonging to the area covered by a given CEREST, the following variables were also analyzed:

  1. Year that the CEREST started operating, categorized by median, ≤2005 or >2005;

  2. Average number of CEREST team employees, calculated by the average National Health Establishment Registry (CNES) employee records for 2013 and 2015, categorized as <10 or ≥10, based on the legislation in force at the time, which established the minimum human resources for regional CERESTs;

  3. Proportion of the team with statutory employment relationship, categorized as ≤50% or >50%;

  4. Average number of speech-language-hearing professionals in the CEREST team, calculated by the average number of speech-language-hearing professionals recorded on the CNES in 2013 and 2015, categorized as <1 or ≥1;

  5. Turnover in the team composition between 2013-2015, defined from the CNES nominal data, considering ‘higher turnover’ when more than one third of the professionals that made up the CEREST team in 2013 were not included on the list of the team professionals in 2015, and ‘lower turnover’ when this occurred for a maximum of one third of the professionals;

The study’s data sources included:

  1. Brazilian Institute of Geography and Statistics1515. Instituto Brasileiro de Geografia e Estatística (BR). Conheça cidades e estados do Brasil [Internet]. 2017. Salvador: IBGE; [citado 14 nov. 2018]. Disponível em: https://cidades.ibge.gov.br /
    https://cidades.ibge.gov.br...
    data for the year 2018, to obtain the list and codes of Brazilian municipalities and their territorial extension; and data for the year 2010, to obtain the size of the employed population, the proportion of workers with formal employment, the size and proportion of workers in the manufacturing/mining/construction industry and the HDI-M;

  2. Google Maps,1616. Google. Google Maps [Internet]. 2018 [citado 14 nov. 2018]. Disponível em: https:// www.google.com.br/maps
    https:// www.google.com.br/maps...
    for the year 2018, to obtain the geographical coordinates of the municipalities;

  3. NIHL notification database on SINAN (updated in August 2018), provided by the General Coordination of Occupational Health/Ministry of Health (CGSAT/MS) to the Collaborating Center for Occupational Health Conditions Surveillance/Integrated Environmental and Occupational Health Program, Institute of Public Health, Federal University of Bahia,1717. Centro Colaborador da Vigilância aos Agravos à Saúde do Trabalhador. Sistema de Informação de Agravos de Notificação - Sinan. Banco de notificações de pair no Sinan [Internet]. 2018 [citado 14 nov. 2018]. Disponível em: http://www.ccvisat.ufba.br /
    http://www.ccvisat.ufba.br...
    to obtain the list of reported cases of NIHL, the calendar year of the notification, the notifying source and the municipality of residence;

  4. Document on CEREST historical activities, provided by CGSAT/MS in January 2018, to access the calendar year of accreditation and cancelled accreditation of each CEREST;

  5. RENAST Online Website1818. Rede Nacional de Atenção à Saúde do Trabalhador. Centros de Referência em Saúde do Trabalhador [Internet]. 2018. Salvador: Centros de Referência em Saúde do Trabalhador; [citado 14 nov. 2018]. Disponível em: http://renastonline.ensp.fiocr uz.br
    http://renastonline.ensp.fiocr uz.br...
    (2014) and complementary document (October 2017), provided by CGSAT/MS, to identify the municipalities in the area covered by each CEREST;

  6. National Health Establishment Registry (CNES)1919. Cadastro Nacional de Estabelecimentos de Saúde (BR). Consulta estabelecimento - identificação [Internet]. 2018. Salvador: Cadastro Nacional de Estabelecimentos de Saúde; 2013-2015 [citado 14 nov. 2018]. Disponível em: http://cnes.datasus.gov.br/pages/estabelecimentos/consulta.jsp
    http://cnes.datasus.gov.br/pages/estabel...
    between 2013-2015, to obtain the composition of the CEREST teams.

In order to verify whether the variables were associated with the occurrence of NIHL notification in the municipalities, the number and proportion of notifying municipalities per calendar year and for the entire period 2013-2015 were described, according to the predictor variables; the measures of association between each of the outcome variables (notifying municipality) were estimated, using logistic regression to obtain the crude and adjusted odds ratio (OR) from the size of the occupied population (ORadj),and respective 95% confidence intervals (95%CI); and multivariate analysis was conducted (iii) separately for the variable sets related to the municipalities and CERESTs. In the modeling, in addition to the occupied population, variables that presented p-value <0.20 were kept in the model, and those variables associated with the outcome considering an alpha ≤0.05 were kept in the respective final models of each dimension.

The database was organized from Excel spreadsheets® and the analyses were conducted using Stata statistical software, version 12.0. The QGIS version 2.6 georeferencing tool was used to build maps. The study project was approved by the Research Ethics Committee of the Institute of Public Health of the Federal University of Bahia (CEP/ISC/UFBA): Certificate of Submission for Ethical Appraisal (CAAE) No. 93708218.0.0000.5030, opinion No. 2,799,319, issued on August 3, 2018. Free and Informed Consent was not required due to the public, aggregate and anonymous nature of the data.

Results

Of the 5,570 Brazilian municipalities, 277 (5.0%) reported cases of NIHL on SINAN in the period, expanding from 113 (2.0%) in 2013 to 164 municipalities (2.9%) in 2015, representing an increase of 45.1%. Among the Federative Units, Mato Grosso do Sul had the highest proportion of notifying municipalities (25.3%), followed by Rio de Janeiro (18.5%) and São Paulo (10.1%), while in Acre, Amapá and Pará, none of the municipalities notified NIHL in the period (Figure 1). Among the notifying municipalities, 42.0% notified NIHL only via CEREST, 52.8% only from other notification sources, and 5.2% notified it both via CEREST and other sources.

Figure 1
Proportion of municipalities (N=5,570) notifying at least one case of noise-induced hearing loss on the NotifiableHealth Conditions Information System, by Federative Unit, Brazil, 2013-2015

Considering all municipalities, 4,400 (79.0%) belonged to areas covered by CERESTs, with 3.2% of municipalities being home to a CEREST; most municipalities had up to 5,000 workers as their occupied population; and less than 15.0% of the workers were in the manufacturing, mining or construction industry. A quarter of the municipalities were classified as having very low/low HDI-M, among other characteristics (Table 1). Of the 4,400 municipalities located in the area covered by a CEREST, most of them had this unit in operation by 2005, on average teams had at least ten professionals, more than half of the team comprised of statutory employees and average number of speech-language-hearing professionals lower than one professional, in the period; and with team turnover greater than 33.3% (Table 2).

Table 1
Distribution of municipalities (N=5,570) according to contextual variables related to the municipality, Brazil, 2013-2015

The proportion of municipalities notifying NIHL on SINAN increased with the increase in the size of the occupied population, from 1.4% in the group of municipalities with an occupied population ≤5,000 inhabitants, to 4.0%, 11.0%, 33.3% and 56.0%, respectively to the occupied population >5,000 to 20,000, >20,000 to 50,000, >50,000 to 100,000 and >100,000 inhabitants. This variable was used to adjust the ORs in all analyses.

Table 2
Distribution of municipalities covered by CERESTsa (N=4,400) according to contextual variables related to CERESTsa and their teams, Brazil, 2013-2015

In the bivariate analysis, all variables related to the municipalities were associated with the outcome (Table 3). In the modeling for this dimension, two models were conducted separately: one including only ‘workers in the manufacturing/mining/construction industries’ variable, and another with each of the three worker variables of these industries, given that it was same-origin data, inducing collinearity. In both models, a higher proportion of the occupied population in these branches of activity was not a factor associated with the notification of NIHL by the municipalities. In the final model, they remained positively associated with the outcome: having CEREST coverage; being home to a CEREST; belonging to the Midwest region; being closer to the state capital; and having high/very high HDI-M (Table 3). Belonging to the Northern region was negatively associated with the outcome.

Table 3
Proportion of municipalities (N=5,570) that reported noise-induced hearing loss (NIHL) on the Notifiable Health Conditions Information System, odds ratio and multivariate analysis, according to contextual variables related to the municipality, Brazil, 2013-2015

All variables related to CERESTs were associated with the outcome in the bivariate analysis, except for the proportion of team members with a statutory employment relationship (Table 4). In the final model, they remained positively associated with the outcome: having at least one speech-language-hearing professional in the CEREST team; and the team having lower staff turnover (Table 4).

Table 4
Proportion of municipalities covered by CERESTsa (N=4,400) that reported noise-induced hearing loss (NIHL) on the Notifiable Health Conditions Information System, odds ratio and multivariate analysis, according to contextual variables related to CERESTsa and their teams, Brazil, 2013-2015

Discussion

In Brazil, between 2013 and 2015, few municipalities notified NIHL on SINAN. The factors that were positively associated with being a notifying municipality were: being a municipality that was home to a CEREST or having CEREST coverage, being close to the state capital and having high HDI-M. While municipalities located in the Midwest region notified NIHL more often, in comparison with other regions, the opposite was observed in the Northern region. Among the municipalities with coverage, that is, located in an area covered by a CEREST, the factors that positively influenced the notification of NIHL were low staff turnover and the presence of a speech-language-hearing professional in the CEREST team.

Although only one out of 20 municipalities notified NIHL during the study period, the increase of notifying municipalities between 2013 and 2015 was significant. This increase is compatible with the implementation and expansion of CERESTs in Brazil. There has been an increase in the number of CERESTs since 2002, when the first 17 in the country were accredited.66. Santana VS, Silva JM. Os 20 anos da saúde do trabalhador no Sistema Único de Saúde do Brasil: limites, avanços e desafios. In: Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Saúde Brasil 2008: 20 anos de Sistema Único de Saúde no Brasil. Brasília, DF: MS; 2009. p.175-204.,2020. Ministério da Saúde (BR), Fundação Oswaldo Cruz, Universidade Federal da Bahia. 2º Inventário de saúde do trabalhador, 2010-2011: acompanhamento da Rede Nacional de Atenção Integral em Saúde do Trabalhador, 2010-2011. [Internet]. Brasília, DF. 2013 set [citado 4 maio 2019]. 138 p. Disponível em: http://renastonline.ensp.fiocruz.br/sites/default/files/arquivos/recursos/Inventario%20RENAST%202010-2011.pdf
http://renastonline.ensp.fiocruz.br/site...
However, even reaching 210 units in 2011,2121. Ministério da Saúde (BR). Portaria n° 2.978, de 15 de dezembro de 2011. Amplia para 210 (duzentos e dez) a quantidade de Centros de Referência em Saúde do Trabalhador (CEREST) passíveis de implantação no território nacional. Diário Oficial da República Federativa do Brasil . Brasília,DF; 15 dez. 2011. [citado 4 maio 2019]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2978_15_12_201 1.html
http://bvsms.saude.gov.br/bvs/saudelegis...
1,170 Brazilian municipalities had still not been covered by CEREST during this study.

In three states, Acre, Amapá and Pará, there were no NIHL notifying municipalities between 2013 and 2015, in contrast to Mato Grosso do Sul, Rio de Janeiro and São Paulo, which had the highest proportions of notifying municipalities. It can be seen that between 2007-2009, NIHL notifications were absent (n=8) or fewer than ten reported cases (n=12) in 20 of the 27 Federative Units.88. Ferrite S, Meira TC, Santana VS, Cavalcante F, Gusmão AC, Peres MC, et al. Boletim da vigilância dos agravos à saúde relacionados ao trabalho: perda auditiva induzida por ruído ocupacional: informe do centro colaborador PISAT/ISC/UFBA - MS/DSAST/CGSAT [Internet]. Nov. 2013 [citado 14 mar 2018]. Disponível em: http://renastonline.ensp.fiocruz.br/sites/default/files/arquivos/recursos/BOL7_PAIR.pdf
http://renastonline.ensp.fiocruz.br/site...
It can be inferred that there has been an evolution, although it has shown quite different situations in the national territory. In the Southeast region, where there is important industrial activity, it is possible to see the development of systematic occupational health programs and actions,2020. Ministério da Saúde (BR), Fundação Oswaldo Cruz, Universidade Federal da Bahia. 2º Inventário de saúde do trabalhador, 2010-2011: acompanhamento da Rede Nacional de Atenção Integral em Saúde do Trabalhador, 2010-2011. [Internet]. Brasília, DF. 2013 set [citado 4 maio 2019]. 138 p. Disponível em: http://renastonline.ensp.fiocruz.br/sites/default/files/arquivos/recursos/Inventario%20RENAST%202010-2011.pdf
http://renastonline.ensp.fiocruz.br/site...
significant scientific production in the area2222. Bezerra MLS, Neves EB. Perfil da produção científica em saúde do trabalhador. Saude Soc. 2010 Jun;19(2):384-394. doi: http://doi.org/10.1590/S0104-12902010000200014.
http://doi.org/10.1590/S0104-12902010000...
and an earlier history of CERESTs being accredited.2323. Secretaria de Estado da Saúde de São Paulo. Centro de Referência em Saúde do Trabalhador de São Paulo. Processo de implantação da saúde do trabalhador no SUS/SP. Rev Saude Publica . 2004 jun;38(3):471-4. doi: http://dx.doi.org/10.1590/S0034-89102004000300021.
http://dx.doi.org/10.1590/S0034-89102004...
São Paulo was the first state to have a regional network of CERESTs in operation,2323. Secretaria de Estado da Saúde de São Paulo. Centro de Referência em Saúde do Trabalhador de São Paulo. Processo de implantação da saúde do trabalhador no SUS/SP. Rev Saude Publica . 2004 jun;38(3):471-4. doi: http://dx.doi.org/10.1590/S0034-89102004000300021.
http://dx.doi.org/10.1590/S0034-89102004...
and six (35.3%) of the first 17 CERESTs implemented in 2002, were located in the state of São Paulo and the remainder in Minas Gerais, Rio Grande do Sul and Bahia.66. Santana VS, Silva JM. Os 20 anos da saúde do trabalhador no Sistema Único de Saúde do Brasil: limites, avanços e desafios. In: Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Saúde Brasil 2008: 20 anos de Sistema Único de Saúde no Brasil. Brasília, DF: MS; 2009. p.175-204. In the regions with higher density of workers - Southeast, South and Northeast - there is a higher concentration of CERESTs, while in the North and Midwest regions there is a limited number of units.2020. Ministério da Saúde (BR), Fundação Oswaldo Cruz, Universidade Federal da Bahia. 2º Inventário de saúde do trabalhador, 2010-2011: acompanhamento da Rede Nacional de Atenção Integral em Saúde do Trabalhador, 2010-2011. [Internet]. Brasília, DF. 2013 set [citado 4 maio 2019]. 138 p. Disponível em: http://renastonline.ensp.fiocruz.br/sites/default/files/arquivos/recursos/Inventario%20RENAST%202010-2011.pdf
http://renastonline.ensp.fiocruz.br/site...
Nevertheless, the Midwest stood out with the highest proportion of NIHL notifying municipalities, a possible consequence of well-structured implementation of surveillance and well-structured flow of case notification in the areas covered by CERESTs. Consistently with this, a study conducted in Brazil on the evolution of notification of serious work injuries on SINAN, between 2007 and 2011, showed the Midwest region as having the highest proportion of notifying municipalities (9.7%) among the macro-regions in 2007, reaching 31.1% in 2011, representing significant growth. 2424. Bastos-Ramos TP, Santana VS, Ferrite S. Estratégia saúde da família e notificações de acidentes de trabalho, Brasil, 2007-2011. Epidemiol Serv Saude. 2015 out.-dez.;24(4):641-50. doi: http://dx.doi.org/10.5123/S1679-49742015000400006.
http://dx.doi.org/10.5123/S1679-49742015...

In this study, the municipalities closest to the state capitals notified a greater proportion of cases, compared to those farthest from the capitals. This finding may be related to the presence of a stronger health system, greater access of professionals to continuing education, presence of an occupational health reference technician, actions implemented for health promotion and disease prevention, greater supervision of work environments, and other contributory factors. The proposal for a new model of CEREST organization2525. Ministério da Saúde (BR). Resolução nº 603, de 8 de novembro de 2018. Rede Nacional de Atenção Integral à Saúde do Trabalhador - Proposta de Reorganização das Ações e Serviços de Saúde do Trabalhador na Rede SUS. Brasília, DF: MS ; 2018 nov. 8. [citado 4 maio 2019]. 40 p. Disponível em: https://renastonline.ensp.fiocruz.br/sites/ default/files/arquivos/recursos/resoluca_n_603_de_8_de_novembro_de_2018_cns_cerest_renast.pdf
https://renastonline.ensp.fiocruz.br/sit...
considers different levels of technical reference on occupational health, and the functioning of the network should be planned according to municipal population size. This reorganization may minimize difficulties generated by municipalities being distant from large centers, with greater service capillarization, contributing to the increase of occupational health notifications on SINAN. Notifications can also be enhanced in municipalities through implementation of decentralized Intersectoral Occupational Health Commissions.2525. Ministério da Saúde (BR). Resolução nº 603, de 8 de novembro de 2018. Rede Nacional de Atenção Integral à Saúde do Trabalhador - Proposta de Reorganização das Ações e Serviços de Saúde do Trabalhador na Rede SUS. Brasília, DF: MS ; 2018 nov. 8. [citado 4 maio 2019]. 40 p. Disponível em: https://renastonline.ensp.fiocruz.br/sites/ default/files/arquivos/recursos/resoluca_n_603_de_8_de_novembro_de_2018_cns_cerest_renast.pdf
https://renastonline.ensp.fiocruz.br/sit...

High HDI-M was also a factor associated with NIHL notification by the municipalities, with an increase in gradient. The higher the HDI-M, the better the living conditions, the greater the access to knowledge and the better the standard of living measured by municipal per capita income.1414. Programa das Nações Unidas para o Desenvolvimento. Atlas de desenvolvimento humano no Brasil [Internet]. 2013 [citado 21 jun. 2019]. Disponível em: http://www.atlas brasil.org.br/2013/pt/o_atlas/idhm /
http://www.atlas brasil.org.br/2013/pt/o...
These qualities can contribute to good organization of health surveillance information in the territories. In contrast, although low HDI generally reflects the worst morbidity and mortality estimates, notification of NIHL was less frequent in these municipalities, which may suggest a hypothesis that case underreporting is more prevalent in municipalities that offer a poor quality of life to their citizens.

Among the municipalities covered by CERESTs, having at least one speech-language-hearing professional in the team was a factor associated with NIHL notification. Consistently with this, health surveillance actions directed towards NIHL and work-related voice disorders were reported by the General Coordination of the CERESTs as habitual in the daily work of these professionals (73.7%).2626. Gusmão AC, Meira TC, Santos FCCN, Ferrite S. A Fonoaudiologia nos centros de referência em saúde do trabalhador no Brasil. Rev CEFAC. 2018 nov.-dez.;20(6):723-33. doi: http://doi;org/10.1590/1982-0216201820621117.
http://doi;org/10.1590/1982-021620182062...
The speech-language-hearing professional, a professional with technical knowledge and experience in the management of NIHL cases, is able to identify the type of hearing loss and discuss with the team its possible relationship with work. Although the number of these professionals in the teams has been increasing since 2002, the majority of CEREST units (51.9%) did not have a speech-language-hearing professional in 2014.2626. Gusmão AC, Meira TC, Santos FCCN, Ferrite S. A Fonoaudiologia nos centros de referência em saúde do trabalhador no Brasil. Rev CEFAC. 2018 nov.-dez.;20(6):723-33. doi: http://doi;org/10.1590/1982-0216201820621117.
http://doi;org/10.1590/1982-021620182062...

With regard to the factors related to CEREST coverage in the municipalities, the factor most strongly associated with NIHL notification was lower CEREST work team turnover. That is, higher team turnover seems to impair surveillance actions. Health professional turnover is one of the problems faced by the CERESTs because it interferes with team integration and with worker’s healthcare.2727. Santos APL, Lacaz FAC. Apoio matricial em saúde do trabalhador: tecendo redes na atenção básica do SUS, o caso de Amparo/SP. Cienc Saude Colet. 2012;17(5):1143-50. doi: http://doi.org/10.1590/S1413-81232012000500008.
http://doi.org/10.1590/S1413-81232012000...
A study conducted in Minas Gerais,2828. Dias EC, Chiavegatto CV, Silva TL, Reis JC, Silva JM. Construção da RENAST em Minas Gerais: a contribuição dos centros de referência em saúde do trabalhador (CEREST), 2002-2007. Rev Med Minas Gerais. 2010;20( Suppl 2):66-74. from 2002 to 2007, focusing on regional CEREST performance, found that almost three quarters of the workers who made up the CEREST team had a permanent employment relationship, that being a proportion higher than that identified in this study. RENAST’s new reorganization proposal indicates the need for a mostly multi-professional team to be hired through a public competitive selection process and to have a fixed employment relationship.2525. Ministério da Saúde (BR). Resolução nº 603, de 8 de novembro de 2018. Rede Nacional de Atenção Integral à Saúde do Trabalhador - Proposta de Reorganização das Ações e Serviços de Saúde do Trabalhador na Rede SUS. Brasília, DF: MS ; 2018 nov. 8. [citado 4 maio 2019]. 40 p. Disponível em: https://renastonline.ensp.fiocruz.br/sites/ default/files/arquivos/recursos/resoluca_n_603_de_8_de_novembro_de_2018_cns_cerest_renast.pdf
https://renastonline.ensp.fiocruz.br/sit...
The measure may contribute to a lower turnover in the CERESTs’ technical and managerial teams and, as a result, better development of surveillance actions, including notifications of diseases and health conditions on SINAN. It is worth noting, however, that although a permanent employment relationship favors a certain stability in the teams’ composition, it does not guarantee low staff turnover, given that there may be employee allocation mobility.

Achieving 100% of health regions with at least one CEREST operating by 2019, was a goal established in 2015 by the Ministry of Health Multiannual Plan and National Health Plan (2016-2019).2929. Ministério da Saúde (BR). Planejamento estratégico da RENAST: reunião com os coordenadores estaduais de saúde do trabalhador [Internet]. [Brasília, DF]: 2015 [citado 4 maio 2019]. 4 p. Disponível em: http://renastonline.ensp.fiocruz.br/sites/default/files/arquivos/paginas/Planejamento%20Estrategico%20da%20Renast_Reuni%C3%A3o%20dos%20Coordenadores%20da%20Renast.pdf .
http://renastonline.ensp.fiocruz.br/site...
Although this goal had not been achieved, Resolution No. 603 was published on November 8, 2018,2525. Ministério da Saúde (BR). Resolução nº 603, de 8 de novembro de 2018. Rede Nacional de Atenção Integral à Saúde do Trabalhador - Proposta de Reorganização das Ações e Serviços de Saúde do Trabalhador na Rede SUS. Brasília, DF: MS ; 2018 nov. 8. [citado 4 maio 2019]. 40 p. Disponível em: https://renastonline.ensp.fiocruz.br/sites/ default/files/arquivos/recursos/resoluca_n_603_de_8_de_novembro_de_2018_cns_cerest_renast.pdf
https://renastonline.ensp.fiocruz.br/sit...
containing a proposal to reorganize Comprehensive Occupational Health in the SUS, the objective of which was to develop a new organizational model for the CERESTs. In this model, each Health Region would have at least one regional CEREST as a technical support for its municipalities. Considering the relevance of CERESTs for occupational health surveillance ratified by this study, its expansion is one of the strategies for ensuring institutional, technical and pedagogical support for occupational health in the territory in which it provides coverage. However, it is worth mentioning that there are factors that impact the functioning of the CERESTs, and that only having one unit operating neither guarantees working to full potential capacity, nor provision of services to the population with the equity, quality and efficiency that is expected.2020. Ministério da Saúde (BR), Fundação Oswaldo Cruz, Universidade Federal da Bahia. 2º Inventário de saúde do trabalhador, 2010-2011: acompanhamento da Rede Nacional de Atenção Integral em Saúde do Trabalhador, 2010-2011. [Internet]. Brasília, DF. 2013 set [citado 4 maio 2019]. 138 p. Disponível em: http://renastonline.ensp.fiocruz.br/sites/default/files/arquivos/recursos/Inventario%20RENAST%202010-2011.pdf
http://renastonline.ensp.fiocruz.br/site...

Among the limitations of this study, data quality may have been affected by incompleteness and inconsistency, as it is secondary data from information systems. Moreover, the absence of notification in very small municipalities, as opposed to potential underreporting, could simply mean non-occurrence of NIHL cases during the study period. As such, the model was adjusted according to occupied population size, as a strategy to minimize possible bias in the results. It is noteworthy that this is the first epidemiological study dedicated to investigating contextual factors associated with NIHL notification in Brazil and to adopt the strategy of using of several public data sources.

Contextual factors influence NIHL notification the municipalities. It is worth noting that most of these factors refer to the existence and qualification of occupational health care services. The study provides evidence that can contribute to strategy planning for strengthening NIHL notification, and therefore, reduce the underreporting of this health condition on SINAN. Possible recommendations include the expansion of the number of CERESTs, greater service capillarization, training courses for notification that reach the entire national territory, greater investment in surveillance in municipalities with low human development index, presence of speech-language-hearing professionals and measures to reduce team turnover in Occupational Health Referral Centers.

References

  • 1
    Nelson DI, Nelson RY, Concha-Barrientos M, Fingerhut M. The global burden of occupational noise-induced hearing loss. Am J Ind Med. 2005 Dec;48(6):446-58. doi: https://doi.org/10.1002/ajim.20223
    » https://doi.org/10.1002/ajim.20223
  • 2
    Basner M, Babisch W, Davis A, Brink M, Clark C, Janssen S, Stansfeld S. Auditory and non-auditory effects of noise on health. Lancet. 2013 Oct;383(9925):1325-32. doi: https://doi.org/10.1016/S0140-6736(13)61613-X.
    » https://doi.org/10.1016/S0140-6736(13)61613-X.
  • 3
    Sayler SK, Roberts BJ, Manning MA, Sun K, Neitzel RL. Patterns and trends in OSHA occupational noise exposure measurements from 1979 to 2013. Occup Environ Med. 2019 Feb;76(2):118-24. doi: https://doi.org/10.1136/oemed-2018-105041.
    » https://doi.org/10.1136/oemed-2018-105041.
  • 4
    National Institute for Occupational Safety and Health. Occupational Hearing Loss (ohl) Surveillance: facts and definitions [Internet]. 2018 [citado 26 abr. 2018]. Disponível em: https://www.cdc.gov/niosh/topics/ohl /.
    » https://www.cdc.gov/niosh/topics/ohl
  • 5
    Concha-Barrientos M, Nelson DI, Driscoll T, Steenland NK, Punnett L, Fingerhut M, et al. Selected occupational risk factors. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, organizadors. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: WHO; 2004, p. 1651-801.
  • 6
    Santana VS, Silva JM. Os 20 anos da saúde do trabalhador no Sistema Único de Saúde do Brasil: limites, avanços e desafios. In: Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação de Saúde. Saúde Brasil 2008: 20 anos de Sistema Único de Saúde no Brasil. Brasília, DF: MS; 2009. p.175-204.
  • 7
    Ministério da Saúde (BR). Portaria nº 2.437, de 7 de dezembro de 2005. Dispõe sobre a ampliação e o fortalecimento da Rede Nacional de Atenção Integral à Saúde do Trabalhador - RENAST no Sistema Único de Saúde - SUS e dá outras providências. Diário Oficial da República Federativa do Brasil. Brasília, DF, 7 dez. 2005 [citado 22 fev. 2018]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2005/prt2437_07_ 12_2005.html
    » http://bvsms.saude.gov.br/bvs/saudelegis/gm/2005/prt2437_07_ 12_2005.html
  • 8
    Ferrite S, Meira TC, Santana VS, Cavalcante F, Gusmão AC, Peres MC, et al. Boletim da vigilância dos agravos à saúde relacionados ao trabalho: perda auditiva induzida por ruído ocupacional: informe do centro colaborador PISAT/ISC/UFBA - MS/DSAST/CGSAT [Internet]. Nov. 2013 [citado 14 mar 2018]. Disponível em: http://renastonline.ensp.fiocruz.br/sites/default/files/arquivos/recursos/BOL7_PAIR.pdf
    » http://renastonline.ensp.fiocruz.br/sites/default/files/arquivos/recursos/BOL7_PAIR.pdf
  • 9
    Guerra MR, Lourenço PMC, Bustamante-Teixeira MT, Alves MJM. Prevalência de perda auditiva induzida por ruído em empresa metalúrgica. Rev Saude Publica. 2005 abr.;39(2):238-44. doi: https://doi.org/10.1590/S0034-89102005000200015.
    » https://doi.org/10.1590/S0034-89102005000200015.
  • 10
    Caldart AU, Adriano CF, Terruel I, Martins RF, Caldart AU, Mocellin M. Prevalência da perda auditiva induzida pelo ruído em trabalhadores de indústria têxtil. Arq Int Otorrinolaringol. 2006 jul-set;10(3):192-6.
  • 11
    Galdino A, Santana VS, Ferrite S. Os centros de referência em saúde do trabalhador e a notificação de acidentes de trabalho no Brasil. Cad Saude Publica. 2012 Jan;28(1):145-59. doi: https://doi.org/10.1590/S0102-311X2012000100015.
    » https://doi.org/10.1590/S0102-311X2012000100015.
  • 12
    Ferreira MJM, Lima RKS, Silva AMC, Filho JGB, Cavalcanti LPG. Vigilância dos acidentes de trabalho em unidades sentinela em saúde do trabalhador no município de Fortaleza, nordeste do Brasil. Cien Saude Colet. 2017 Oct;22(10):3393-402. doi: https://doi.org/10.1590/1413-812320172210.17422017.
    » https://doi.org/10.1590/1413-812320172210.17422017.
  • 13
    Instituto Brasileiro de Geografia e Estatística (BR). Sistema IBGE de Recuperação Automática. Pesquisa Nacional por Amostra de Domicílios. Tabela 1869: pessoas de 10 anos ou mais de idade, ocupadas na semana de referência, por anos de estudo, sexo e classes de rendimento mensal de todos os trabalhos. [Internet]. 2014 [citado 27 de out. 2020]. Disponível em: https://sidra.ibge.gov.br/Tabela/1869
    » https://sidra.ibge.gov.br/Tabela/1869
  • 14
    Programa das Nações Unidas para o Desenvolvimento. Atlas de desenvolvimento humano no Brasil [Internet]. 2013 [citado 21 jun. 2019]. Disponível em: http://www.atlas brasil.org.br/2013/pt/o_atlas/idhm /
    » http://www.atlas brasil.org.br/2013/pt/o_atlas/idhm
  • 15
    Instituto Brasileiro de Geografia e Estatística (BR). Conheça cidades e estados do Brasil [Internet]. 2017. Salvador: IBGE; [citado 14 nov. 2018]. Disponível em: https://cidades.ibge.gov.br /
    » https://cidades.ibge.gov.br
  • 16
    Google. Google Maps [Internet]. 2018 [citado 14 nov. 2018]. Disponível em: https:// www.google.com.br/maps
    » https:// www.google.com.br/maps
  • 17
    Centro Colaborador da Vigilância aos Agravos à Saúde do Trabalhador. Sistema de Informação de Agravos de Notificação - Sinan. Banco de notificações de pair no Sinan [Internet]. 2018 [citado 14 nov. 2018]. Disponível em: http://www.ccvisat.ufba.br /
    » http://www.ccvisat.ufba.br
  • 18
    Rede Nacional de Atenção à Saúde do Trabalhador. Centros de Referência em Saúde do Trabalhador [Internet]. 2018. Salvador: Centros de Referência em Saúde do Trabalhador; [citado 14 nov. 2018]. Disponível em: http://renastonline.ensp.fiocr uz.br
    » http://renastonline.ensp.fiocr uz.br
  • 19
    Cadastro Nacional de Estabelecimentos de Saúde (BR). Consulta estabelecimento - identificação [Internet]. 2018. Salvador: Cadastro Nacional de Estabelecimentos de Saúde; 2013-2015 [citado 14 nov. 2018]. Disponível em: http://cnes.datasus.gov.br/pages/estabelecimentos/consulta.jsp
    » http://cnes.datasus.gov.br/pages/estabelecimentos/consulta.jsp
  • 20
    Ministério da Saúde (BR), Fundação Oswaldo Cruz, Universidade Federal da Bahia. 2º Inventário de saúde do trabalhador, 2010-2011: acompanhamento da Rede Nacional de Atenção Integral em Saúde do Trabalhador, 2010-2011. [Internet]. Brasília, DF. 2013 set [citado 4 maio 2019]. 138 p. Disponível em: http://renastonline.ensp.fiocruz.br/sites/default/files/arquivos/recursos/Inventario%20RENAST%202010-2011.pdf
    » http://renastonline.ensp.fiocruz.br/sites/default/files/arquivos/recursos/Inventario%20RENAST%202010-2011.pdf
  • 21
    Ministério da Saúde (BR). Portaria n° 2.978, de 15 de dezembro de 2011. Amplia para 210 (duzentos e dez) a quantidade de Centros de Referência em Saúde do Trabalhador (CEREST) passíveis de implantação no território nacional. Diário Oficial da República Federativa do Brasil . Brasília,DF; 15 dez. 2011. [citado 4 maio 2019]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2978_15_12_201 1.html
    » http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2978_15_12_201 1.html
  • 22
    Bezerra MLS, Neves EB. Perfil da produção científica em saúde do trabalhador. Saude Soc. 2010 Jun;19(2):384-394. doi: http://doi.org/10.1590/S0104-12902010000200014.
    » http://doi.org/10.1590/S0104-12902010000200014.
  • 23
    Secretaria de Estado da Saúde de São Paulo. Centro de Referência em Saúde do Trabalhador de São Paulo. Processo de implantação da saúde do trabalhador no SUS/SP. Rev Saude Publica . 2004 jun;38(3):471-4. doi: http://dx.doi.org/10.1590/S0034-89102004000300021.
    » http://dx.doi.org/10.1590/S0034-89102004000300021.
  • 24
    Bastos-Ramos TP, Santana VS, Ferrite S. Estratégia saúde da família e notificações de acidentes de trabalho, Brasil, 2007-2011. Epidemiol Serv Saude. 2015 out.-dez.;24(4):641-50. doi: http://dx.doi.org/10.5123/S1679-49742015000400006.
    » http://dx.doi.org/10.5123/S1679-49742015000400006.
  • 25
    Ministério da Saúde (BR). Resolução nº 603, de 8 de novembro de 2018. Rede Nacional de Atenção Integral à Saúde do Trabalhador - Proposta de Reorganização das Ações e Serviços de Saúde do Trabalhador na Rede SUS. Brasília, DF: MS ; 2018 nov. 8. [citado 4 maio 2019]. 40 p. Disponível em: https://renastonline.ensp.fiocruz.br/sites/ default/files/arquivos/recursos/resoluca_n_603_de_8_de_novembro_de_2018_cns_cerest_renast.pdf
    » https://renastonline.ensp.fiocruz.br/sites/ default/files/arquivos/recursos/resoluca_n_603_de_8_de_novembro_de_2018_cns_cerest_renast.pdf
  • 26
    Gusmão AC, Meira TC, Santos FCCN, Ferrite S. A Fonoaudiologia nos centros de referência em saúde do trabalhador no Brasil. Rev CEFAC. 2018 nov.-dez.;20(6):723-33. doi: http://doi;org/10.1590/1982-0216201820621117.
    » http://doi;org/10.1590/1982-0216201820621117.
  • 27
    Santos APL, Lacaz FAC. Apoio matricial em saúde do trabalhador: tecendo redes na atenção básica do SUS, o caso de Amparo/SP. Cienc Saude Colet. 2012;17(5):1143-50. doi: http://doi.org/10.1590/S1413-81232012000500008.
    » http://doi.org/10.1590/S1413-81232012000500008.
  • 28
    Dias EC, Chiavegatto CV, Silva TL, Reis JC, Silva JM. Construção da RENAST em Minas Gerais: a contribuição dos centros de referência em saúde do trabalhador (CEREST), 2002-2007. Rev Med Minas Gerais. 2010;20( Suppl 2):66-74.
  • 29
    Ministério da Saúde (BR). Planejamento estratégico da RENAST: reunião com os coordenadores estaduais de saúde do trabalhador [Internet]. [Brasília, DF]: 2015 [citado 4 maio 2019]. 4 p. Disponível em: http://renastonline.ensp.fiocruz.br/sites/default/files/arquivos/paginas/Planejamento%20Estrategico%20da%20Renast_Reuni%C3%A3o%20dos%20Coordenadores%20da%20Renast.pdf
    » http://renastonline.ensp.fiocruz.br/sites/default/files/arquivos/paginas/Planejamento%20Estrategico%20da%20Renast_Reuni%C3%A3o%20dos%20Coordenadores%20da%20Renast.pdf

  • 1
    Article derived from the master’s degree dissertation entitled ‘Contextual factors associated with the notification of noise-induced hearing loss on Sinan, in Brazil’, submitted by Aline Cristina Gusmão Souza Gomes to the Public Health Postgraduate Program of the Federal University of Bahia, on July 24, 2019. The study received financial support from the Coordination for the Improvement of Higher Education Personnel/Ministry of Education (Capes/MEC): Process No. 001.

Publication Dates

  • Publication in this collection
    26 May 2021
  • Date of issue
    2021

History

  • Received
    09 Aug 2020
  • Accepted
    21 Dec 2020
Secretaria de Vigilância em Saúde - Ministério da Saúde do Brasil Brasília - Distrito Federal - Brazil
E-mail: leilapgarcia@gmail.com