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Revista de Saúde Pública, Volume: 54, Published: 2020
  • Association between cigarette use and adolescents’ behavior Original Articles

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

    Abstract in English:

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

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

    Abstract in Spanish:

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

    Abstract in English:

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

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

    Abstract in English:

    ABSTRACT OBJECTIVE Evaluate socio-demographic, family and behavioral factors associated with oral health literacy (OHL) in adolescents. METHODS Cross-sectional study conducted with adolescents aged 15 to 19 years in Campina Grande, Brazil. Parents/guardians answered a questionnaire addressing socio-demographic data. The adolescents answered validated instruments on family cohesion and adaptability (family adaptability and cohesion evaluation scale), drug use (alcohol, smoking and substance involvement screening test), type of dental service used for last appointment and OHL (Brazilian version of the Rapid Estimate of Oral Health Literacy in Dentistry). Two dentists were trained to evaluate OHL (K = 0.87–0.88). Descriptive analysis was performed, followed by Poisson regression analysis (α = 5%). A directed acyclic graph was used to select independent variables in the study. RESULTS The following variables remained associated with better OHL: high mother’s schooling level (RR = 1.07; 95%CI: 1.03–1.12), high income (RR = 1.04; 95%CI: 1.01–1.09), white ethnicity/skin color (RR = 1.05; 95%CI: 1.01–1.10), married parents (RR = 1.04; 95%CI: 1.01–1.09), “enmeshed” family cohesion (RR = 1.21; 95%CI: 1.12–1.30), “structured” (RR = 1.06; 95%CI: 1.01–1.12) or “rigid” (RR = 1.11; 95%CI: 1.04–1.19) family adaptability, having more than five residents in the home (RR = 1.07; 95%CI: 1.01–1.14) and having used a private dental service during the last appointment (RR = 1.08; 95%CI: 1.03–1.13). CONCLUSION Family functioning and socio-demographic factors influence the level of oral health literacy among adolescents.
  • Years of life lost by CNCD attributed to occupational hazards in Brazil: GBD 2016 study Original Articles

    Assunção, Ada Ávila; França, Elisabeth Barboza

    Abstract in Portuguese:

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

    Abstract in English:

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

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

    Abstract in Portuguese:

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

    Abstract in English:

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

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

    Abstract in English:

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

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

    Abstract in Portuguese:

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

    Abstract in English:

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

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

    Abstract in Portuguese:

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

    Abstract in English:

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

    Cabieses, Baltica; Oyarte, Marcela

    Abstract in Spanish:

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

    Abstract in English:

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

    Mendes, Yluska Myrna Meneses Brandão e; Rattner, Daphne

    Abstract in Portuguese:

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

    Abstract in English:

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

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

    Abstract in Portuguese:

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

    Abstract in English:

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

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

    Abstract in English:

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

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

    Abstract in Spanish:

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

    Abstract in English:

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

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

    Abstract in English:

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

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

    Abstract in English:

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

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

    Abstract in Portuguese:

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

    Abstract in English:

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

    Fuentes-López, Eduardo; Fuente, Adrian

    Abstract in English:

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

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

    Abstract in Portuguese:

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

    Abstract in English:

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

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

    Abstract in English:

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

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

    Abstract in Portuguese:

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

    Abstract in English:

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

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

    Abstract in Portuguese:

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

    Abstract in English:

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

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

    Abstract in Portuguese:

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

    Abstract in English:

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

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

    Abstract in English:

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

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

    Abstract in Portuguese:

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

    Abstract in English:

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

    Silva, Jefferson Peixoto da; Fischer, Frida Marina

    Abstract in Portuguese:

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

    Abstract in English:

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

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

    Abstract in Portuguese:

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

    Abstract in English:

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

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

    Abstract in English:

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

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

    Abstract in Portuguese:

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

    Abstract in English:

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