Brazil's unified health system: the first 30 years and prospects for the future

Cardiovascular disease mortality in Brazilian municipalities: estimates from the lobal urden of isease study, 2000-2018

Background

Age-standardized mortality rates (ASMR) for cardiovascular diseases (CVD) have decreased in Brazil in the last decades due to better control of risk factors and access to healthcare. However, how this reduction is distributed across the country's municipalities is unknown. We aimed to evaluate changes in CVD mortality rates across Brazilian municipalities from 2000 to 2018 using estimates from the Global Burden of Disease (GBD) study.

Methods

In this ecological study, ASMR for CVD were estimated using GBD methodology for 5564 Brazilian municipalities from 5 regions in the triennials: 2000-2002, 2009-2011, 2016-2018. A visuospatial analysis was applied to create clusters in ASMR with Moran Local analysis. Municipalities were stratified by population size in <30,000, 30,000-300,000, and >300,000 inhabitants per region. The % changes in ASMR from 2000-2002 to 2016-2018 were calculated.

Findings

In 2000-2002, ASMR for CVD were higher in more developed regions and in larger municipalities of all regions, except for the South. In 2016-2018, CVD ASMR increased in the least developed Northern regions. The % reduction in CVD ASMR was lower in small vs large municipalities within all 5 regions, varying from -3% in small Northern municipalities to -43% in large Southern municipalities.

Interpretation

The reduction in CVD mortality in Brazil was lower in municipalities from the most vulnerable regions and smaller populations. Public policies tailored to these smaller municipalities, particularly on the least developed regions, must be considered a priority.

Funding

Brazilian Ministry of Health [grant 148/2018] and Pan American Health Organization [Letter of Agreement SCON2021-00288].

Multidimensional challenges in Brazil's decision-making process of vaccines adoption: The case of childhood pneumococcal conjugate vaccines

The objective of this paper was to examine the process of adopting new vaccines in a middle-income country.

METHODS

We used an intrinsic explanatory case study to analyze the recent decision-making process of switching 10-valent Pneumococcal Conjugate Vaccine (PCV10) to PCV13 in the Brazilian childhood immunization schedule. We analyzed Conitec (Comissão Nacional de Incorporação de Tecnologias no Sistema Único de Saúde) official documents.

RESULTS

In November 2022, the Conitec plenary recommended, at first, switching from PCV10 to PCV13, considering PCV13 non-inferiority and similar safety profile to PCV10, the price proposed by Wyeth/Pfizer, below the currently practiced, and the scenario of possible resource savings observed in an economic analysis conducted by Wyeth/Pfizer. In a second meeting, in April 2023, Conitec final decision was not to introduce PCV13 at that moment, based on additional scientific, administrative and technical data presented by the National Immunization Program, mainly epidemiological data showing no recent increase of pneumococcal disease (PD), the need to increase vaccination coverage to better control PD and to implement a sentinel surveillance of vaccine-preventable bacterial diseases with nationwide representation to better evaluate PD burden and serotypes replacement, and the country technological development and self-sufficiency in vaccine production.

CONCLUSIONS

Our case showed the decision-making process of adopting new vaccines is country-specific and involve many levels of political prioritization and complex technical aspects, and depends on the presence of strong public health institutions.

Predicting health literacy in Brazil: a machine learning approach

Health literacy is essential for promoting well-being and the ability to make informed decisions. We investigated the level of health literacy in Brazil and identified the predictive factors that influence it. Our data contribute to the international context, with a focus on countries in the Global South and, in particular, Latin America. By analyzing health literacy in Brazil, this study sheds light on the challenges faced by populations with similar socioeconomic backgrounds in low- and middle-income countries, where disparities in access to education and health services are widespread. In addition to descriptive analysis, we used the Random Forest machine learning algorithm, which uses bootstrap aggregation (bagging). To make the results interpretable, we implemented Shapley's Additive exPlanation values. The results show a predominance of problematic levels of health literacy among the population. The analysis reveals that factors such as medication use, dependence on the Unified Health System (Sistema Único de Saúde), and educational level are significant predictors of health literacy. The findings highlight the need for public policies aimed at reducing socioeconomic disparities and improving the public health system in order to promote better access to and understanding of health information.

Secular trend in height and associated factors among adolescents in Florianópolis, Santa Catarina, Brazil, between 2007 and 2017/2018

OBJECTIVE

To assess the secular trend in height among adolescents in Florianópolis between 2007 and 2017/2018, and identify factors associated with height by sex.

METHODS

The sample included 664 adolescents from public schools in 2007 and 1,008 in 2017/2018. Height was the dependent variable, with age, economic status, sexual maturity, physical activity, body fat (skinfold thickness), and fat-free mass as independent variables. Analysis of covariance evaluated the secular trend, and multiple linear regression identified associated factors.

RESULTS

There was a positive secular trend in height in both sexes when comparing the two surveys, with average increases of 3.5 cm in both sexes. Fat-free mass was a positive predictor and body fat was a negative predictor of height in both sexes. Additionally, physical activity emerged as a negative predictor of height specifically in boys.

CONCLUSIONS

The research revealed a positive secular trend in the height of adolescents in Florianópolis. Fat-free mass contributes positively to gains in height, whereas body fat provides a negative contribution.

Professional training to implement the dietary guidelines for the Brazilian population in primary health care: development and content validity of a massive open online course

BACKGROUND

The Dietary Guidelines for the Brazilian Population provide recommendations for healthy diets to prevent noncommunicable chronic diseases, emphasizing the golden rule: always prefer natural or minimally processed foods and freshly prepared dishes and meals to ultra-processed foods. While widely recognized, the integration of dietary advice based on the Dietary Guidelines recommendations has not yet been sufficiently incorporated into Primary Health Care. Protocols based on the Brazilian Dietary Guidelines for Individual Dietary Advice were developed to support healthcare professionals in providing individualized dietary advice based on the Brazilian Dietary Guidelines tailored to different stages of lifetime. Training healthcare professionals to use the Protocols might increase their confidence and is a strategic step toward implementing the Guidelines in routine care. This study aimed to develop and validate a Massive Open Online Course (MOOC) on the Protocols based on the Brazilian Dietary Guidelines for individual dietary advice.

METHODS

This methodological study investigated the development and content validity of a Massive Open Online Course designed to qualify Primary Health Care professionals in dietary advice based on the Protocols. Development and validation involved defining objectives, theoretical frameworks and learning skills; creating content and structure; conducting content validity assessments through a panel of experts; analyzing the results via content validity index scores and thematic content analysis with a comprehensive approach; and refining pedagogical tools in the virtual learning environment.

RESULTS

A Massive Open Online Couse, titled QualiGuia, was developed. All the content sessions achieved content validity index scores above the cutoff grade (0.8). Experts' perceptions were categorized to assess content adequacy, clarity, relevance, and alignment with the theoretical framework. Suggestions for improvement and potential implementation challenges were also addressed. The course included case studies reflecting typical Primary Health Care situations with appropriate complexity and depth, effectively meeting learning objectives.

CONCLUSIONS

The Massive Open Online Course QualiGuia was validated as an effective tool for training Primary Health Care professionals to use the Protocols based on the Brazilian Dietary Guidelines. Its content and structure align with the goals of the Guidelines, supporting healthcare providers in integrating dietary advice into Primary Health Care practices.

Prenatal care among adolescent women in the extreme South of Brazil: a secular trend study

This study aims to measure prevalence and evaluate trends for a set of indicators of prenatal care among pregnant adolescents in Rio Grande, Southern Brazil. Between 01/01 and 31/12 of the years 2007, 2010, 2013, 2016 and 2019, was applied a standardized questionnaire in the maternity ward to all parturient women residing in this municipality who had children in the local hospitals. Chi-square test was used to compare proportions and assess trends. Among the 12,645 pregnant women identified, 2,184 (17.3%) were adolescents (<20 years). Of the 36 indicators evaluated, there was a worsening in 2 (pregnancy planning and occurrence of diabetes mellitus), stability in 5 (abdominal ultrasound, immunization against tetanus, possession of the pregnancy card and occurrence of low birth weight and prematurity) and improvement in 29, with emphasis on the reduction in the occurrence of teenage pregnancy, maternal education, clinical and laboratory examinations and adequate prenatal care, rising from 13.8% in 2007 to 52.5% in 2019. There was a substantial improvement in pregnancy and childbirth care, but almost half of the adolescents in the municipality were unable to receive adequate prenatal care, at the same time as the occurrence of unplanned pregnancies increased.

The Evolution of Acupuncture in Brazil: History, Regulation, and Professional Education

Background

Acupuncture is a widely accepted practice in Brazil. However, training programs lack integration and uniformity, despite alignment with international standards.

Objective

To evaluate the evolution of acupuncture in Brazil and determine whether teaching and professional training are in compliance with international guidelines. In addition, to identify any discrepancies in integration and uniformity.

Methods

This study involved a comprehensive review of historical and contemporary sources regarding the practice of acupuncture in Brazil. These sources included government publications, academic journals, and records from health councils and educational institutions. Additionally, a survey of acupuncture courses registered with the Ministry of Education was conducted to analyze curriculum and training practices.

Results

Acupuncture is a widely accepted practice in Brazil, with 557 courses offering varying hours of training. While most courses comprehensively cover Traditional Chinese Medicine principles and clinical practice, the lack of regulation hinders professional development. Despite financial and regulatory challenges, the field continues to grow, reflecting strong interdisciplinary interest.

Conclusion

Despite differences in educational standards, integrating traditional practices with international guidelines and collaboration across health disciplines have advanced research and professional training in acupuncture. Multidisciplinary has played a key role in improving practice and education.

Study on the spatial and temporal differences and influencing factors of out-of-pocket payments as a share of total health expenditure in China

BACKGROUND

Globally, Out-of-pocket (OOP) payments as a share of Total Health Expenditure (THE) has always been a focus of attention in the field of health economics, which affects the economic burden of medical treatment for residents. At present, countries around the world have widely used spatial econometric models to conduct in-depth discussions and analyses of their own OOP, exploring the spatial distribution characteristics and influencing factors of OOP in different regions. However, in China, research in this area is relatively scarce, and few studies have been conducted from a macro perspective and space-time dimension.

METHODS

Based on the panel data of 31 provinces in China, the spatiotemporal distribution characteristics of the proportion of OOP payments in China from 2013 to 2022 were analyzed using spatial autocorrelation. The spatial Durbin model (SDM) was employed to explore the factors influencing OOP payments as a share of THE in China.

RESULTS

The results indicate that the proportion of OOP in China shows a decreasing trend, and there is a significant spatial positive correlation. The change in spatial agglomeration is relatively stable, and only some provinces have a slight change. SDM shows that the main factors affecting the inter-provincial differences in the OOP proportion in China include the elderly dependency ratio (direct effect - 0.181, indirect effect - 0.585), the child dependency ratio (direct effect 0.292, indirect effect 0.686), per capita GDP(direct effect 11.235), and the proportion of government health expenditure to fiscal expenditure (direct effect - 0.254, indirect effect - 0.994), the average number of medical visits per year (direct effect - 0.444), the expenditure of basic medical insurance (direct effect - 1.519, indirect effect - 3.940), and the average medical cost of outpatients (direct effect 3.142, indirect effect - 10.064). These factors collectively influence the spatial variation in OOP payments across provinces in China.

CONCLUSION

The spatial distribution difference of OOP proportion in China is obvious. Factors such as demographics, economics, policy, and health service utilization can all significantly influence OOP. The government should further implement differentiated medical security policies, optimize the allocation structure of health resources, enhance the capacity of primary medical services, promote cross-provincial medical cooperation, and ensure that local residents can enjoy equal access to high-quality medical services and reduce their medical burden.

Colonial shadows - a systematic review of the Xavante health transformation

BACKGROUND

From a biocultural perspective, health is a multifaceted concept shaped not only by biomedical factors but also by social, cultural, political, and economic forces. In Indigenous contexts, health is particularly vulnerable, as it is profoundly influenced by external socioeconomic and cultural changes, often introduced or imposed by the broader society. The Xavante Indigenous community, located in the Central-Western region of Brazil, is one of the most extensively studied Indigenous groups in the country in terms of health. Despite a rich body of literature addressing various aspects of their health, there has been a notable absence of comprehensive studies that trace the historical evolution of their health status through bibliographic analysis. This article seeks to fill this gap by providing an in-depth examination of the historical transformation of the Xavante health, positioning this issue within the broader discourse of Indigenous health as a public health concern, while applying a decolonial perspective.

METHODS

A systematic bibliographic analysis was conducted to trace the historical trajectory of health among the Xavante people from Mato Grosso, Brazil.

RESULTS

A total of 109 academic publications meeting the inclusion criteria were identified. The analysis revealed sustained scholarly interest in the health of the Xavante community, particularly since their first sustained contact with the urbanized society. A comparative examination of the earliest and most recent, comprehensive studies on this topic highlighted a marked decline in the health status of the Xavante people over time.

CONCLUSIONS

Despite periodic shifts in the administrative frameworks governing Indigenous healthcare in Brazil, including reductions in mortality rates and increased utilization of hospital services, the overall health status of the Xavante has significantly deteriorated. This article critically analyzes this trend through a decolonial lens, highlighting the limitations and shortcomings of existing health policies and interventions. It argues that the prevailing colonial approach to healthcare, compounded by the denial of culturally appropriate services, represents a clear violation of human rights. Furthermore, the article underscores the substantial impact of social determinants-such as historical trauma, cultural disruption, and systemic inequality-on the health outcomes of this community.

Time trends in subarachnoid haemorrhage mortality across the BRICS (Brazil, Russian Federation, India, China and South Africa): an age-period-cohort analysis for the GBD 2021

OBJECTIVES

Subarachnoid haemorrhage (SAH) is the third most prevalent subtype of stroke, representing a critical and potentially life-threatening cerebrovascular emergency. Given their large populations and diverse healthcare infrastructures, the BRICS (Brazil, Russian Federation, India, China and South Africa) nations play a pivotal role in the global SAH landscape. This investigation assesses the mortality trends of SAH in BRICS countries from 1982 to 2021.

DESIGN AND PARTICIPANTS

This study uses data from the Global Burden of Disease (GBD) 2021 public dataset to investigate the temporal trends in SAH mortality over four decades globally and within BRICS countries. The age-period-cohort (APC) model was employed to estimate net drift, local drift, age-specific curves and period (cohort) relative risks.

PRIMARY OUTCOME MEASURES

Mortality.

RESULTS

From 1982 to 2021, there was a 3.85% increase in global SAH deaths and a 59.46% decrease in age-standardised mortality rates. SAH mortality rates are increasing across various age groups in BRICS countries, except in China and the Russian Federation, where most age groups show increasing trends. The annual net drift in SAH mortality varied from a decrease of 5.62% in China to an increase of 0.31% in the Russian Federation. Countries demonstrated similar age-effect patterns, with risk decreasing as age increased. However, period and cohort effects varied, suggesting different control measures and temporal mortality trends.

CONCLUSIONS

Changing patterns of mortality from SAH in the BRICS countries over the last four decades vary. We suggest using local resources to step up SAH prevention. Healthcare for all ages, especially the vulnerable, should improve to prevent and treat SAH better.

The Double Burden of Malnutrition in the Brazilian Legal Amazon: Spatial Distributions and Temporal Trends (2013-2023)

Malnutrition and overweight are significant public health challenges, especially in low- and middle-income countries. In the Amazon, high rates of malnutrition and the alarming rise of obesity highlight persistent regional inequalities. Therefore, the aim of this study was to analyze spatial distributions and temporal trends of malnutrition among children under five, adults, and elderly individuals in primary healthcare services across municipalities in the Legal Amazon from 2013 to 2023.

METHODS

This ecological study used data from the Food and Nutritional Surveillance System (SISVAN). The analysis included the prevalences of underweight, overweight, and obesity, stratified by year, sex, and federative unit. Spatial distributions were analyzed using QGIS version 3.22, and temporal trends were assessed with Joinpoint version 4.6 and expressed as annual percentage changes (APCs) and 95% confidence intervals (95% CIs).

RESULTS

Between 2013 and 2023, SISVAN monitored 10,451,758 children under five years, 30,831,720 adults, and 4,456,650 elderly individuals in the Legal Amazon. Stunting in children under five years decreased from 20.45% to 15.30%, with a significant downward trend (APC: -2.7; 95% CI: -3.7; -1.6). Childhood overweight exhibited a general downward trend but with notable fluctuations. Overweight in adults increased from 48.85% to 64.64%, and obesity from 17.10% to 28.49%, both showing significant upward trends. For the elderly, underweight decreased from 17.47% to 13.04%, with a downward trend until 2018, while overweight increased from 42.35% to 48.22%, with a significant upward trend until 2017.

CONCLUSIONS

Despite progress in reducing childhood underweight, its prevalence in the Legal Amazon remains high compared to national averages. Significant regional disparities and rising overweight rates among adults and elderly individuals indicate a need for targeted public health strategies to address these nutritional issues.

The effect of health insurance reimbursement rates on middle-aged and elderly people's hospital choices: evidence from China

BACKGROUND

Adjusting the health insurance reimbursement rate is essential to optimize the allocation of medical resources. This paper investigates the effect of health insurance reimbursement rates on middle-aged and elderly people's choice of hospitals in China.

METHODS

This study is conducted using the China Health and Retirement Longitudinal Study (CHARLS) database. This paper uses the widely used ordered logit model for estimation. We build three types of instrumental variables, Bartik instrumental variable, per capita financial income, and health risk perception bias, with the help of the propensity score matching method, aiming at the cleanest possible identification of causal relationship. Furthermore, we use a mediating effects model to investigate the specific mechanism by which the reimbursement rate influences patients' choice of hospitals.

RESULTS

Our findings reveal that the higher a hospital's reimbursement rate, the more likely a patient is to choose to seek care. This paper further calculates the marginal effects based on the benchmark regression. For every 1% increase in health insurance reimbursement rates, the probability of patients choosing primary hospitals decreases by 5.75%, choosing secondary hospitals decreases by 1.47%, and choosing tertiary hospitals increases by 7.22%. According to mechanistic analysis, this paper reveals for the first time that health signals from medical checkups significantly impact patients' health care choices. In addition, we discuss the heterogeneity of hospital choices by region, age, and health status.

CONCLUSIONS

The results mean that when individuals are faced with a multitude of hospitals and are overwhelmed with choices, some small institutional designs can act as a nudge to help policymakers achieve a desirable outcome. The government should fully utilize health insurance's benefit adjustment role and implement a differentiated reimbursement strategy.

Germline Genetic Testing in Breast Cancer: Utilization and Disparities in a Middle-Income Country

PURPOSE

Low rates of germline genetic testing (GGT) for breast cancer (BC) have been reported globally, with limited data from low- and middle-income countries (LMICs). In this study, we used real-world data to assess the GGT rate for BC in an LMIC and identified barriers to its use.

METHODS

We analyzed 2,974 newly diagnosed patients with BC from the AMAZONA III study, the largest Brazilian multicenter, prospective BC cohort. GGT rates were determined for the entire cohort and the high-risk hereditary BC group (HR), defined by the National Comprehensive Cancer Network criteria, between 2019 and 2020. Barriers to GGT performance associated with patient characteristics and health care systems were identified using multivariable Poisson regression model. Values of P < .05 were considered significant.

RESULTS

In the AMAZONA III cohort, 1,476 (49%) were classified as HR. Genetic counseling was recommended for 521 patients (35% of HR), and 282 (19%) underwent GGT. Notably, 97% of patients with HR treated within the public health care systems and 56% in the private system did not undergo GGT. Age, education, occupation, monthly income, availability of onsite genetic counseling, and treatment at a teaching center were factors associated with GGT uptake (P < .05). Of those tested, 50 (17%) harbored a germline pathogenic or likely pathogenic variant.

CONCLUSION

Only 9% of this robust Brazilian BC cohort underwent GGT, highlighting a considerable gap from the current recommendation to test all patients with BC under age 65 years. GGT is underused by patients with HR in both public and private health care systems, with those in the public system being more affected. The disparities and barriers identified emphasize the need for educational interventions and enhanced access to GGT. Prioritizing GGT is critical to improving BC outcomes in LMICs.

Scaling of cardiovascular risk factors in 230 Latin American cities

Urbanization results in increased numbers of people living in cities and poses challenges and opportunities to public health policies. Studies of urban scaling have unveiled how cities' socio-economic and infrastructural attributes vary systematically with city size. Previous studies have explored the scaling properties of health outcomes across metropolitan areas in different countries, but chronic diseases have been infrequently examined. This paper examines scaling behaviors of 4 cardiovascular risk factors: hypertension, diabetes, tobacco smoking, and obesity across 230 cities in six countries of Latin America. In analyses pooled across countries, diabetes and hypertension showed weakly superlinear scaling (higher prevalence in larger cities). In comparison, obesity showed linear scaling, and tobacco showed weakly sublinear scaling (lower prevalence in larger cities), although most coefficients did not differ significantly from the null. In country-specific analyses, hypertension and diabetes tended to show a superlinear pattern across most countries, obesity tended to show a sublinear pattern in most countries, and tobacco tended to be superlinear (in contrast to the analysis pooled across countries where it was sublinear). Results suggest the need to examine further the drivers of this varying scaling of risk factors.

The side effects of the pandemic on all-cause postoperative mortality in a COVID reference Hospital in Brazil: a before and after cohort study with 15156 patients

BACKGROUND

Before the pandemic, healthcare systems in Low-Middle Income Countries (LMIC) experienced a limited capacity to treat postoperative complications. It is uncertain whether the interference of the Coronavirus (COVID-19) pandemic on surgical systems has increased postoperative mortality.

METHODS

This before and after cohort study aimed to assess the pandemic's impact on in-hospital postoperative mortality in a university COVID-19 reference hospital in southern Brazil. Data from patients who underwent surgery before (January 2018 to December 2019) the pandemic were compared to data from patients who underwent surgery during the pandemic (February to December 2020). The primary outcome was in-hospital mortality. We developed Poisson regression models to examine the mortality risk of being operated on during the COVID-19 pandemic.

RESULTS

We assessed 15156 surgical patients, 12207 of whom underwent surgery before the pandemic and 2949 during the first year of the pandemic. Mortality rates were 2.5% (309/12207) in the pre-pandemic versus 7.2% (212/2949) in the pandemic. Of these, 25.8% (32/124) of patients with COVID-19 and 6.4% (80/2816) of patients without COVID-19 died. The proportion of urgent surgeries and ASA-PS III was higher in the pandemic group. After adjusting for mortality-related variables, the Relative Risk (RR) associated with undergoing surgery during the pandemic was 1.51 (95% CI 1.27 to 1.79). We excluded COVID-19-positive to perform a sensitivity analysis that confirmed the increased risk of undergoing surgery during the pandemic RR = 1.50 (95% CI 1.27 to 1.78).

CONCLUSION

The substantial number of additional deaths, even amongst those without COVID-19 infection, suggests the pandemic disrupted the surgical service in an LMIC context. Fragile surgical systems may suffer more significant adverse impacts from external stressors such as a pandemic, and urging measures are needed to increase their performance and resilience.

Diagnostic performance of Alzheimer's disease blood biomarkers in a Brazilian cohort

Blood-based biomarkers (BBMs) have emerged as promising tools to enhance Alzheimer's disease (AD) diagnosis. Despite two-thirds of dementia cases occurring in the Global South, research on BBMs has predominantly focused on populations from the Global North. This geographical disparity hinders our understanding of BBM performance in diverse populations. To address this, we evaluated the diagnostic properties of AD BBMs in a real-world memory clinic from Brazil, one of the largest countries in the Global South. We measured blood and cerebrospinal fluid (CSF) biomarkers - amyloid-β (Aβ)40, Aβ42, phosphorylated tau (p-tau) 217, neurofilament light (NfL) chain, and glial fibrillary acidic protein (GFAP) - in 59 individuals. Sample comprised 20 cognitively unimpaired (CU) individuals, 22 with AD dementia, and 17 with vascular dementia (VaD). We compared BBM levels across diagnostic groups and assessed their discriminative ability for AD. Notably, individuals with VaD and AD had lower educational levels (6.8±3.0) compared to CU individuals (61.4±6.6). Among the BBMs tested, plasma p-tau217 demonstrated the best performance, exhibiting high accuracy in differentiating CU from AD (AUC 0.96) and Aβ pathology (AUC 0.98). However, the ability of AD BBMs to distinguish between AD and VaD was lower than expected (AUC from 0.52 to 0.79), particularly when compared to studies from the Global North. Our findings highlight the potential utility of BBMs for AD diagnosis in real-world settings within the Global South. However, they also underscore the need for proper implementation and validation of these biomarkers within these populations to ensure accurate and reliable results.

Global strategies for implementing health financing equity - a state-of-the-art review of political declarations

BACKGROUND

Implementing health financing equity plays a determining role in achieving Universal Health Coverage. For this reason, the global health community stated multiple political declarations to guide health financing equity implementation in countries. The aim of this study was to investigate the global strategies for implementing health financing equity that emerged from political declarations made before 2024.

METHODS

Using a state-of-the-art review design, we identified the political declarations from the search of United Nations databases and the snowball search. We used textual and theoretical thematic analysis methods to extract the global strategies of health financing equity implementation that emerged from the political declarations. We grounded the global strategies in the existing practical framework - the Health Financing Progress Matrix of the World Health Organization. We employed a time-based descriptive analysis method to document the results. Quantitative information was used to shape the analysis.

RESULTS

In total, 40 political declarations were included in the review. From these declarations emerged the strategies of targeted, selective, contributive, universal, claims, proportionate, experimental, united, and aggregated financing to implement health financing equity in countries. Thirty nine of the 40 political declarations that labelled the global health community from 1944 until 2023 placed more efforts on duplicating the prevailing strategies. The declarations, categorised into nine groups (target, unity, universality, selectivity, contribution, aggregation, claims, experience, and proportionality-oriented political declarations), were insistent to press countries effectively implement the strategies.

CONCLUSION

The political declarations proved to be the essential markers of the global health community's efforts to raise the profile of health financing equity in countries. Although some of the global strategies that emerged from the political declarations have been shown promise in different countries, any global strategy is neither effective nor optimal for providing efficient and sustainable UHC in all countries. This lays the groundwork for careful management and adaptation of the global strategies to the diverse needs of the diverse population.

Optimizing resources: financial evaluation of flow diverters versus stent assisted coiling in large and giant cerebral aneurysm management in Brazil public health system

BACKGROUND

Cerebral aneurysms, especially large and giant aneurysms, pose challenges in neurointerventional surgery. Treatment choices involve clinical presentation, aneurysm details, and global resource variations. Neurointerventional methods, while innovative, may be cost restrictive in certain regions. In public healthcare, cost is crucial, notably in countries like Brazil. This study examines the device specific cost estimation of flow diverters (FD) and traditional stent assisted coiling (SAC) for large and giant cerebral aneurysms, providing insights into optimizing neurosurgical interventions within the Brazilian public health system's unique challenges.

METHODS

A comprehensive retrospective analysis was conducted at our medical center of cases of large and giant aneurysms treated between 2013 and 2023. Determination of the estimated number of coils for aneurysms previously treated with FDs at our center was made, with the cost of each case, and the difference between both treatments was calculated.

RESULTS

We investigated the profiles of 77 patients: 40 had large aneurysms (51.9%) and 37 had giant aneurysms (48.1%). Large aneurysms had a mean cost difference of US$274 (standard deviation (SD) $2071), underscoring the device specific cost estimation of FDs over SAC in their treatment. For giant aneurysms, the mean cost difference increased to $6396 (SD $2694), indicating FDs as the more economically sound choice.

CONCLUSION

Our study indicated that, for the treatment of giant aneurysms and some large aneurysms, the FD intervention was more economical than SAC.

Oral health surveys of traditional peoples and communities in Brazil: a scope review

OBJECTIVE

The objective of this review was to map the available evidence on oral health surveys of traditional peoples and communities (TPC) in Brazil, addressing the question, 'What evidence is available on oral health surveys of traditional peoples and communities in Brazil?'.

DESIGN

Scoping review according to the Scoping Review extension for the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

DATA SOURCES

MEDLINE/PubMed, Scopus, Web of Science, Embase and Latin American and Caribbean Literature in Health Sciences were searched up until June 2023.

ELIGIBILITY CRITERIA

Studies involving individuals from indigenous groups, quilombolas, riverside communities and Romani communities, all included in TPC in Brazil, were included without any age restrictions.

DATA EXTRACTION AND SYNTHESIS

Data were extracted by two independent reviewers, and studies were categorised considering the author and year of publication, the traditional group, study type, geographical location, age group, sample size, data collection method and the main oral health condition assessed.

RESULTS

After the searches, 39 studies were included in the review, and 2 studies were manually added. The studies included in the review were published between the years 1968 and 2023. Of the total, 31 studies investigated the oral health condition of indigenous peoples, 7 were studies on quilombola communities and 3 studies focused on riverside communities. No studies on Romani people were found in the search. The majority of studies were located in the Northeast region (n=12) of the country, with dental caries being the main oral health issue assessed (n=13) through clinical examinations (n=25), with a high prevalence observed among TPC (n=11).

CONCLUSION

This review reveals that in Brazil, studies on the oral health of TPC are ongoing, although they occur in an isolated and independent manner, indicating a considerably high prevalence of oral health problems in these communities.

Screening, diagnosis, treatment and outcomes of developmental dysplasia of the hip in Brazilian population: a scoping review

OBJECTIVE

This study aims to map the literature on screening, diagnosis, treatment and outcomes of developmental dysplasia of the hip (DDH) in the Brazilian population aged 0-18 years, to describe regional variations in its presentation and management.

DESIGN

Scoping review.

DATA SOURCES

PubMed/MEDLINE, Web of Science, Scopus, "Biblioteca Virtual em Saúde" and "Biblioteca Digital Brasileira de Teses e Dissertações". The journals, Revista Brasileira Ortopedia and Acta Ortopédica Brasileira, were manually searched for non-indexed issues. Databases were searched from their inception to February 2024.

ELIGIBILITY CRITERIA

This scoping review included studies on Brazilian patients aged 0-18 years diagnosed with or being assessed for DDH. No language or date restrictions were applied.

DATA EXTRACTION AND SYNTHESIS

Studies were assessed based on title, authors, publication year, study design, sample size, level of evidence, region of Brazil and healthcare setting (public or private). The articles were then analysed across four categories: screening, diagnosis, treatment and outcomes.

RESULTS

52 studies, published between 1951 and 2023, were included. Reported prevalence rates ranged from 0.75 to 56.4 cases per 1000 children. No study examined the effectiveness of specific screening programmes or compared their outcomes. The most common diagnostic methods were the Ortolani manoeuvre and ultrasonography using the Graf method. Of the 27 articles on treatment, 17 focused exclusively on surgical interventions, with the Salter osteotomy being the most frequent procedure.

CONCLUSIONS

There should be a greater focus on understanding the prevalence of DDH in Brazil, the availability of ultrasound devices and trained operators, and the follow-up of conservative treatments. More information on DDH in Brazil is essential for designing and implementing effective screening and treatment programmes. Future research should be done to understand the prevalence of the disease, optimal forms of screening and early treatment.

Impact of Funding Source on Long-Term Outcomes in Prostate Cancer: Analysis of a Large Public Database From Sao Paulo, Brazil

PURPOSE

We investigated the impact of the funding source (public v private) on the overall survival (OS) of men with prostate cancer in Brazil.

METHODS

We retrospectively analyzed patients with prostate cancer from a large hospital registry from the state of São Paulo, Brazil. Patients age 50-99 years diagnosed with prostate acinar adenocarcinoma or adenocarcinoma not otherwise specified (NOS) between January 2014 and December 2017 were eligible. Demographic and clinical features were analyzed alongside the funding source. On the basis of clinical characteristics at diagnosis (lymph node status, distant metastasis, prostate-specific antigen [PSA], and Gleason score), patients were categorized into low-risk, intermediate-risk, high-risk, and metastatic groups.

RESULTS

Of 25,009 patients analyzed, 85% had a public funding source. These patients were slightly older, had greater proportion of adenocarcinoma NOS, and higher PSA levels and risk category. There was a significant difference in OS favoring patients with a private funding source (P < .0001). The estimated OS rates at 5 years were 76.2% (95% CI, 75.6 to 76.9) and 86.9% (95% CI, 85 to 88.7) for the public and private groups, respectively (P < .0001). The funding source was significantly associated with OS independent of age, educational level, and receipt of any treatment in the intermediate-risk (hazard ratio [HR], 2.28 [95% CI, 1.58 to 3.30]; P < .001) and high-risk (HR, 1.36 [95% CI, 1.02 to 1.80]; P = .04) groups, but not in the low-risk (HR, 0.85 [95% CI, 0.60 to 1.21]; P = .38) or metastatic groups (HR, 0.84 [95% CI, 0.64 to 1.11]; P = .23).

CONCLUSION

The worse OS observed for patients with prostate cancer with a public source of funding underscores the need for actions directed to improve the standards of public health care in Brazil.

Neonatal near miss and associated factors among neonates delivered at East Gojjam zone public health hospitals, Northwest Ethiopia

Neonatal mortality and morbidity is a significant public health issue globally, particularly in low-income countries including Ethiopia. This study aimed to determine the proportion and associated factors of neonatal near misses among newborns delivered at public hospitals in the East Gojjam zone of Northwest Ethiopia. A facility-based cross-sectional study was conducted from April 21 to June 20, 2023, among 560 newborns and their mothers in randomly selected five public hospitals. Data was collected using an interviewer-administered questionnaire, medical record review, and a standard checklist with a systematic random sampling technique in each proportionally allocated hospital. The data was entered using 4.6 Epi-data software and exported to SPSS version 25. Bivariable and multivariable logistic regression analyses were performed using a backward stepwise approach method, and statistical significance was declared at a 95% confidence interval with a p-value < 0.05. A total of 552 participants responded to the study, with a response rate of 98.6%. The prevalence of neonatal near miss was 41.3% with a 95% confidence interval of 37.1-45.3. Unplanned pregnancy (AOR = 4.91, 95% CI: 2.43-9.94), current obstetric complications at birth (AOR = 5.48, 95% CI: 2.92-10.27), pregnancy-induced hypertension (AOR = 2.75, 95% CI: 1.23-6.12), premature rupture of membrane (AOR = 3.40, 95% CI: 1.71-6.78), mother referred from other healthcare facilities (AOR = 7.12, 95% CI: 4.01-12.63), delivered on-duty time (AOR = 5.04, 95% CI: 2.94-8.65), less than three ultrasound scans (AOR = 3.71, 95% CI: 2.11-6.53), and no ultrasound scan (AOR = 9.44, 95% CI: 2.55-34.99) were significantly associated with neonatal near miss. The prevalence of neonatal near-misses was 41.3% (95% CI: 37.1%, 45.3%). Unplanned pregnancy, obstetric complications at birth, ultrasound scan, premature rupture of membrane, pregnancy-induced hypertension, and mothers referred from other healthcare facilities, and delivered on-duty time were significant factors associated with neonatal near misses.

Viewpoints of nurse auditors regarding the profession: a qualitative study

PURPOSE

This study aims to understand the experiences of Brazilian nurse auditors in the practice of their profession, exploring the importance, challenges, rewards and strategies related to the occupation.

DESIGN/METHODOLOGY/APPROACH

This is a qualitative descriptive study conducted with 44 nurse auditors. An online, open-ended questionnaire was used. Thematic content analysis was performed.

FINDINGS

Five themes were identified: (1) functions of a nurse auditor; (2) skills required for a nurse auditor; (3) learning to be a nurse auditor; (4) advantages of being a nurse auditor and (5) challenges faced by a nurse auditor. Also, a total of 16 subthemes were presented.

RESEARCH LIMITATIONS/IMPLICATIONS

The study critically examined essential aspects of auditing through the lens of nurse auditors, addressing a relevant topic. However, limitations must be acknowledged, including the use of self-report questionnaires, regional representation disparities, the scarcity of international articles on the topic and potential researcher bias.

PRACTICAL IMPLICATIONS

The study underscores the importance of increasingly integrating nurse auditors into the workforce while emphasizing the need to enhance the capacitation of these professionals through theoretical and practical education. It highlights the significance of educating other multidisciplinary team members about the nurse auditor's crucial role in fostering teamwork and ensuring the quality of healthcare services.

ORIGINALITY/VALUE

To the best of the author's knowledge, this is the first study conducted with Brazilian nurse auditors, exploring crucial aspects of auditing from the perspective of these professionals. Understanding the critical role of nurse auditors in maintaining and improving healthcare quality can enhance public trust in healthcare systems.

On the epistemology of resilience in public health: a novel perspective in a changing world

This review proposes the foundations for an epistemology of resilience in public health, addressing the need for a theoretical framework to guide research and policy. Resilience, often ambiguously defined, is reexamined here as a critical attribute of public health systems, enabling them to adapt, absorb, and respond to routine and extraordinary demands without compromising universal and equitable service delivery. By integrating logical, sociological, historical, and philosophical perspectives, the paper delineates resilience as a structured and measurable concept, distinguishing it from common ambiguities in academic and policy discourse. It further introduces a set of foundational axioms to clarify the boundaries of resilience and support its operationalization within public health. These axioms emphasize the interplay between structural and functional dynamics, responses to internal and external stressors, and the importance of systems-level design over reliance on individual adaptations. This epistemological approach aims to bridge the gap between theory and practice, providing a robust basis for developing evidence-based policies that strengthen public health systems' ability to meet evolving challenges while promoting equity and universality.

Can role model women in politics help married women reduce suicides? Evidence from a quasi-experimental study in Brazil

Background

The medical literature has demonstrated that macro-variables and social factors can influence suicide rates. Additionally, social science literature has shown that women in prominent political positions (such as mayors) can influence the behavior of other women. The purpose of our work is to demonstrate that women in such positions reduce suicide rates within a group affected by gender inequality: married women.

Methodology

We use regression discontinuity methodology and quasi-experimental electoral designs (elections with a margin of victory very close to zero) to ensure causal inference between the election of women and suicide rates among married women.

Principal findings

Municipalities that elected women as mayors have 1.33 fewer suicides among married women per 100,000 inhabitants compared to those that elected men as mayors.

Conclusion

These results offer new insights into how empowered women can challenge social norms and improve public health outcomes.

Prompt Initiation of Maternal Antiretroviral Therapy After HIV Seroconversion in Pregnancy Effectively Prevents Vertical Transmission and Other Adverse Infant Outcomes

From January 2008 to December 2018, 1348 HIV-exposed infants were born in Porto Alegre, Brazil; 18.8% had adverse infant outcomes (AIO) including vertical transmission (1.9%), stillbirth/neonatal death (4.0%) and loss to follow-up before HIV diagnosis (12.9%). Timing of maternal HIV diagnosis was not associated with AIO but absent antiretroviral therapy use was. Lack of maternal antiretroviral therapy use is a significant risk factor for AIO.

Hospitalization due to pneumococcal disease in the Unified Health System in Brazil: A retrospective analysis of administrative data

INTRODUCTION

Community-Acquired Pneumonia (CAP) caused by pneumococcus and Invasive Pneumococcal Disease (IPD) pose a substantial economic burden on health systems. The objective of the present study is to explore hospitalization costs of pneumococcal disease in the public health system in Brazil, the Unified Health System.

METHODS

Retrospective analysis of administrative data on hospitalized cases of pneumococcal disease from January 2019 to July 2023. Hospitalization cases recorded with ICD-10 codes of CAP due to S. pneumoniae and IPD were retrieved from DATASUS, the inpatient information system of the Unified Health System in Brazil. Costs were converted to US dollars by Using Purchasing Power Parity (USD-PPP). Absolute number of hospitalizations, costs of hospitalizations and healthcare resource utilization were presented descriptively. The annual cost estimate was calculated. Differences in costs by type of clinical presentation and age group were assessed. Factors associated with higher costs were explored by multiple linear regression models.

RESULTS

A total of 22,498 hospitalization episodes were analyzed. Total cost of hospitalizations was USD-PPP 13,958,959 (BRL 34,659,578) with an annual mean estimate of USD-PPP 3,045,591 (BRL 7,562,090). Cost per hospitalization episode was significantly higher for meningitis, followed by septicemia, CAP and arthritis, with median values ranging from USD-PPP 190.93 to 615.14 (BRL 476.20 to 1529.02). (Kruskal-Wallis χ2 = 6473, df = 3, p-value < 0.0001). Costs were significantly higher among individuals aged 60-years and older. (Kruskal-Wallis test; χ2 = 773.53; df = 2, p-value < 0.0001). There were differences in age at hospitalization, length of stay, and ICU utilization among types of clinical presentations.

CONCLUSIONS

Our findings reveal the economic burden associated with pneumococcal disease in the Unified Health System in Brazil. Hospitalization costs were higher for cases of meningitis and among individuals aged 60-years and above.

Psychosocial Impact of the COVID-19 Pandemic in Brazilian Post-Peak Period: Differences Between Individuals with and Without Pre-Existing Psychiatric Conditions

(1) Background: Validated instruments to measure mental health variables related to sanitary crises can provide data for prevention or intervention plans. The objectives of this study were: (1) to evidence the psychometric factorial internal structure of the Battery for Assessing Mental Health-Pandemic Version (BASM-P) in the sample; (2) to investigate the psychosocial impact of the COVID-19 pandemic in Brazilian post-peak period among individuals with and without pre-existing psychiatric conditions using the BASM-P; and (3) to analyze relationships between the mental health variables measured by the BASM-P in both groups. (2) Methods: This is an internet-based quantitative, cross-sectional study with a non-probabilistic convenience sample. The participants (n = 209) were divided into a non-psychiatric group (n = 168) and a psychiatric group (n = 41). The instruments were the BASM-P and a sociodemographic questionnaire. Data were collected throughout the second semester of 2022 and analyzed with JASP software. (3) Results: The BASM-P demonstrated robust psychometric factorial internal structure. Significant differences were observed between the two groups across all variables. In the non-psychiatric group, obsessive thoughts presented strong connections to fear, distress, and grief from job loss. (4) Conclusions: This study highlights the central role of obsessive thoughts in shaping the psychosocial impact of the COVID-19 pandemic in the Brazilian post-peak period.

Reducing the Travel Burden for Patients to Access Specialized Medicines in Paraná, Brazil

OBJECTIVES

This study aimed to evaluate the potential reduction in distance and travel time with a hypothetical municipal distribution of specialized component medicines in the state of Paraná.

METHODS

This was a cross-sectional study. Distances and travel times from all the 1025 residential locations in the state of Paraná to dispensing pharmacies were calculated in 2 different models: centralized model with drugs dispensed in the 22 state-owned pharmacies and decentralized model with drugs dispensed in the 399 municipal pharmacies. Road routes were calculated using the Google Maps Distance Matrix API and Euclidean distance using the haversine formula for the southern hemisphere. A sinuosity index was computed by the quotient between these 2 distances. Differences were evaluated through bivariate analyses and effect size measures were reported.

RESULTS

In the centralized model, the mean distance to the pharmacy was 59.5 km (SD 34.1), with a travel time of 1.0 hour (SD 0.5) and 579 residential locations (56.7%) more than 50 km away from the pharmacy, 286 (28.0%) between 25 and 50 km, and 156 (15.3%) less than 25 km. In the decentralized model, the mean distance was 10.8 km (SD 16.6), with a travel time of 0.2 hours (SD 0.3) and 14 locations (1.4%) more than 50 km away from the pharmacy, 96 (9.4%) between 25 and 50 km, and 911 (89.2%) less than 25 km. The decentralized model significantly reduced the sinuosity index.

CONCLUSIONS

Implementing a decentralized dispensing of the specialized component drugs in the state of Paraná would produce a significant reduction in distance and travel time for patients enhancing drug accessibility.

Full vaccination coverage with valid doses among the 2017 and 2018 live birth cohort in the Southeast region of Brazil

OBJECTIVE

To analyze factors associated with full vaccination coverage with valid doses, in children from four state capitals and three other cities in Southeast Brazil.

METHOD

Analysis of a population survey conducted in 2020-2021, with a sample stratified according to socioeconomic levels of children born in 2017-2018, with data collected through photographic records of their vaccination cards. Odds ratios (OR) and 95% confidence intervals (95%CI) for full vaccination coverage were estimated based on the characteristics of the family, mother and child.

RESULTS

Among 8703 children, lowest coverage occurred in strata A and B (OR=0.39; 95%CI 0.23;0.67 and OR=0.38; 95%CI 0.25;0.58); in consumption level A/B (OR=0.38; 95CI% 0.28;0.52); among those with income >BRL8000/month (OR=0.23; 95%CI 0.12;0.42); in children of mothers with higher education (OR=0.47; 95%CI 0.32;0.71); in children not vaccinated exclusively in the public service (OR=0.37; 95%CI 0.26;0.51) and in children with a vaccination delay of up to 6 months (OR=0.28; 95%CI 0.22;0.37).

CONCLUSION

Coverage did not reach the targets for controlling vaccine-preventable diseases and was negatively associated with higher socioeconomic status.

MAIN RESULTS

Vaccination coverage for the full schedule with valid doses was very low, putting the control of vaccine-preventable diseases at risk in the four state capitals and three other cities in the interior region of Southeast Brazil.

IMPLICATIONS FOR SERVICES

Brazilian National Health System managers and workers need to know the factors associated with low vaccination coverage and increased risk of abandoning the schedule, access problems and National Immunization Program difficulties.

PERSPECTIVES

Understanding determinants of low vaccination coverage provides support for the discussion and design of effective public policies to address barriers and qualify health services for vaccination.

Economic burden of measles outbreaks: a cost-of-illness study in a middle-income country in the post-elimination era

Objective

To estimate the direct costs associated with the diagnosis, treatment, and control of measles cases in Brazil from 2018 to 2020.

Methods

This cost-of-illness study utilized a prevalence-based approach, considering direct costs incurred by the Brazilian Public Health System (SUS) related to measles outbreaks, including costs of inpatient care, outpatient care, and laboratory tests, as well as measles-containing vaccines and laboratory tests (viral isolation) used for outbreak control. Costs are presented in 2020 US dollars. Univariate and bivariate sensitivity analyses were performed.

Results

There were 36 236 confirmed measles cases from 2018 to 2020. The estimated outbreaks cost was USD 107 960 122, with the cost per case ranging from USD 2 601 to USD 3 654 (mean USD 2 979).

Conclusions

These findings highlight the substantial economic burden imposed by measles outbreaks in Brazil and emphasize the importance of measles prevention and control measures. Policymakers and public health authorities can use these results to plan and allocate resources, to mitigate the economic impact of future outbreaks.

Non-surgical endodontic retreatments in Brazil's public dental services: a 15-year nationwide register-based study

The objective of this study was to analyze the provision of non-surgical endodontic retreatments in Brazil's public dental services from 2008 to 2022. A time series was outlined for this purpose. The annual numbers of non-surgical endodontic retreatments were retrieved from the Brazilian National Outpatient Information System and adjusted per 100,000 inhabitants to obtain the incidence between 2008 and 2022. Comparison of the incidence between types of teeth, temporal trend estimation, and evaluation of the COVID-19 pandemic-related impacts were conducted with a significance level of 5%. In this timeframe, 1,270,182 non-surgical endodontic retreatments were carried out. A higher incidence was observed among single-rooted teeth (328/100,000) when compared to double-rooted (183/100,000) and multi-rooted teeth (112/100,000) (p <0.05). The annual incidences showed a significantly decreasing trend over the last 15 years for all types of teeth (p <0.05), as well as demonstrated a highly correlated pattern of temporal variation (p <0.05). In addition, there was no influence on this outcome when removing the period between 2020 and 2022 (all temporal trends remained decreasing). However, the monthly incidence was significantly lower in the first, second, and third years after the COVID-19 pandemic onset (p <0.05). The provision of non-surgical endodontic retreatments in Brazil's public dental services has experienced a dramatic decline over the past 15 years, including after the COVID-19 pandemic.

Racial and ethnic disparities in alcohol-associated liver disease hospitalizations in Brazil before and after the COVID-19 pandemic

INTRODUCTION AND OBJECTIVES

The COVID-19 pandemic has resulted in a greater incidence of alcohol-associated liver disease (ALD) and simultaneously magnified health-related inequalities. We evaluated the impact of race and ethnicity on ALD-related hospitalizations in Brazil.

MATERIALS AND METHODS

An interrupted time series analysis was used to estimate ALD-related hospitalization in public hospitals in Brazil. Monthly hospitalization rates for 34 consecutive months before and after the point of interruption (March 2020) were calculated using the Sistema de Informações Hospitalares database across four ethnic groups: Black, Pardo, Black, and Pardo combined, and Others (White and Unknown Ethnicity).

RESULTS

A total of 84,787 ALD-related hospitalizations were recorded during the study period. The mean age of hospitalized patients was 53 years (SD=12.5); 83.6% were male. Immediately after the start of the pandemic, there was a statistically significant decrease in monthly ALD-related hospitalization rates for the whole population and for all ethnic groups. Subsequently, compared to pre-pandemic rates, there was a statistically significant trend increase in the referred hospitalization rates for the total population (0.065, 95% CI= 0.045 to 0.085, p<0.01), black population (0.0028, 95% CI= 0.006 to 0.050, p<0.05), pardo population (0.077, 95% CI= 0.063 to 0.090, p<0.01), and for black and pardo combined population (0.066, 95% CI= 0.053 to 0.079, p<0.01); however, the increase in hospitalization rates among the Others population (0.059, 95% CI= -0,014 to 0.133, p>0.1) was not statistically significant.

CONCLUSIONS

The pandemic impacted ALD-related monthly hospitalization rates and disproportionately impacted Black and Pardo populations in Brazil.

Stroke in Brazil: prevalence, activity limitations, access to healthcare, and physiotherapeutic treatment

BACKGROUND

 Stroke remains a public health problem, reported as the third cause of disability. Among survivors, the ability to perform usual daily activities may be reduced, requiring rehabilitation.

OBJECTIVE

 To investigate the prevalence of self-reported stroke, the accessibility of healthcare, and the degree and percentage of patients with limitations in usual activities who are unassisted by physiotherapeutic treatment in different regions of the country.

METHODS

 This cross-sectional study was conducted using data from the 2019 National Health Survey. Participants aged 15 years or older from all five geographic regions of Brazil who reported a diagnosis of stroke were included. The data were analyzed using sample weighting and expressed as estimates along with a 95% confidence interval (CI).

RESULTS

 The national prevalence of self-reported stroke in Brazil was 1.9% (95%CI 1.7-2.0), equivalent to 1,975 individuals with diagnosis. Of these, 50.2% reported limitations in their daily activities, and more than half (54.6%) had regular follow-ups with healthcare professionals. However, only 24.6% reported having access to rehabilitation, while 73.4% of individuals with activity limitations received no physiotherapeutic treatment.

CONCLUSION

 The prevalence of' self-reported stroke in the Brazilian population was 1.9%, with more than half experiencing limitations in their activities. While more than half of the stroke patients underwent follow-ups from a health professional, only ¼ of them reported having access to rehabilitation. Government interventions are necessary to ensure effective access to healthcare, including rehabilitation for the Brazilian population.

Current data science capacity building initiatives for health researchers in LMICs: global & regional efforts

Background

Data science approaches have proved crucial for generating major insights to address public health challenges. While such approaches have played significant roles during the COVID-19 pandemic, there has been limited investment in capacity building in data science skills and infrastructure for health researchers in LMICs.

Objectives

This review aims to identify current health data science capacity building initiatives and gaps in Africa, Asia, and Latin America and the Caribbean (LAC), to support knowledge sharing and collaborations, and inform future initiatives and associated investment.

Methods

We conducted a literature review using PubMed and Scopus, supplemented by a grey literature search on Google to identify relevant initiatives. Articles were screened based on inclusion criteria.

Findings

From 212 records, 85 met inclusion criteria, with 20 from PubMed and Scopus, and 65 from grey literature. The majority of programmes are tailored to specific disease areas, varying by region. Despite these efforts, there are limited initiatives with a clear, documented strategy on data science capacity building to accelerate global research insights, with the majority adopting a fragmented approach.

Conclusion and future directions

Despite the integration of data science approaches into health research initiatives in LMICs, there is a need for a standardised framework on data science capacity building to facilitate multidisciplinary and global collaboration. Structured approaches, inter-disciplinary, inter-regional connections and robust impact measurement will all be vital for advancing health research insights in these settings.

Time from treatment initiation to HIV viral suppression in public care facilities in Brazil: A nationwide linked databases cohort

OBJECTIVES

To analyze the time between antiretroviral therapy (ART) initiation and the first HIV viral load (VL) test <40 copies-time to suppression (TS)-in a cohort of persons aged ≥15 years, between 2015-2018 in outpatient HIV care facilities of the Brazilian Unified Health System, as well as to analyze whether individual and facility characteristics accelerate or delay TS.

METHODS

This was a cohort study with data from a linkage of national HIV databases, following a previously published procedure. Two types of variables were examined: individual-level (sex, age group, race/skin color, education, baseline CD4 cell count and VL, initial ART regimen, adherence, ART regimen change and number of VL tests until suppression) and facility-level (national and metropolitan region, caseload). Multilevel parametric accelerated failure time survival models were used. Fixed and random effects were analyzed through null, sociodemographic, combined sociodemographic and clinical, and facility-related variables, adjusted for the number of VL tests until suppression. Likelihood, interquartile range, and proportion of change in variance were used for comparisons.

RESULTS

Of 132,540 participants, 89.4% (114,696) achieved viral suppression: 20.8% within three months, and 56.4% within six months. Median TS was 161 days, varying from 31 to 1,426 days, depending on the time interval between initiation and VL testing. Among those who had VL testing within 66 days, median TS was 55 days. All individual and facility-related variables were associated with TS, explaining the 16.2% and 13.2% variability, respectively.

CONCLUSIONS

This was the first Brazilian nationwide cohort to analyze TS. It is also one of the largest operational cohorts globally to assess healthcare facility characteristics. The findings indicated that both individual and facility-related characteristics contribute to TS. Strengthening VL monitoring should be included as part of a coordinated effort to improve the quality of care provided for people living with HIV/AIDS in Brazil.

Population molecular genetics in Brazil: From genomic databases and research to the implementation of precision medicine

Precision medicine (PM) stands on the brink of revolutionizing medical practice throughout the world, holding significant potential for enhancing patient outcomes. However, its practical implementation, particularly in resource-limited countries, is not without challenges. The success of PM largely hinges on the availability of extensive datasets, including genetic and genomic information. This paper delves into the PM landscape and the current state of genetic and genomic testing in Brazil. We also shed light on the unique challenges posed by the country's diverse population and discuss ongoing initiatives to tackle these obstacles.

The Amazonian snakebite burden: Unveiling seasonal dynamics in a region with tenfold higher incidence compared to the Brazilian average

BACKGROUND

Accidents caused by snakes constitute a serious public health problem in Latin America and worldwide. The situation in the Brazilian Amazon region is neglected, resulting in the highest incidence of cases per capita in the country. Furthermore, the distance from urban areas makes it difficult for the population to access timely and effective medical care, including antivenom treatment. The Brazilian Amazon is characterised by high ethnic and cultural diversity, yet it lacks robust epidemiological information that would allow for the development of surveillance and prevention policies. This study aimed to assess the epidemiological profile of individuals affected by snakebite accidents from 2007 to 2021 in a poorly studied region of the Brazilian Amazon.

METHODS

To assess the relationship between snakebite accidents, rainfall and river flood levels, cross-correlation functions were employed. Data from the public healthcare system database was used for this analysis.

RESULTS

The results indicate that the study area experiences a snakebite rate 10 times greater than the Brazilian average and double that of other Amazonian regions. The most affected victims consist of adult males residing in rural areas, with snakebite accidents being more common during the rainy season. Viperid snakes were responsible for most bites, with the lower limbs being the most common location of injury. The data revealed a positive correlation between the number of snakebite accidents both rainfall and fluvial data.

CONCLUSIONS

The accident peak coincides with the Brazil nut harvest season, a highly significant forest product for the economy of rural communities. Our data reinforces the need for public policies focused on environmental education and prevention, such as the use of boots and leg guards. These preventive measures have the potential to reduce the number of snakebites accidents by approximately 85%.

The negative impact of the COVID-19 pandemic on breast cancer care in Brazil: a time series study in regions with different human development indices

BACKGROUND

The impact of the COVID-19 pandemic on breast cancer care across Brazilian regions with varying Human Development Index (HDI) levels remains unclear. This study evaluates the pandemic's effects on screening mammograms, tumor staging at diagnosis, and treatment initiation in the Brazilian Public Health System between 2017 and 2022, focusing on regions with different HDI levels.

METHODS

This ecological time series study uses an inflection point regression model and monthly percentage change (MPC) to analyze an open-access Brazilian Public Healthcare System dataset. The study focuses on trends and variations in these variables among women aged 50-69 in three state groups classified by HDI: Group A (very high), Group B (medium), and Group C (high).

RESULTS

The average monthly rate of screening mammograms was highest in Group A (10.70) and lowest in Group B (8.38). At the onset of the COVID-19 pandemic, screening rates dropped significantly, with the most significant decline in Group B (58.6% decrease) and the smallest in Group A (45.7% decrease), lasting for three months. Subsequently, this variable recovered until December 2022 but was insufficient to restore the total series MPC to pre-pandemic levels. Group B had the lowest average rate of early-stage (0-II) diagnoses (2.88), while Group C had the highest (3.68). Early-stage diagnoses declined in the first three months of the pandemic, followed by a partial recovery that was insufficient to restore the pre-pandemic MPC levels. The proportion of advanced-stage diagnoses was highest in Group B (49.02%) and lowest in Group A (45.97%). The pandemic maintained the upward trend of advanced-stage (III-IV) diagnoses across all groups in the total time series. The average proportion of treatments initiated after 60 days of diagnosis was above 60% across all groups, with Group B at 64.50%. This variable began to rise 3 to 4 months after the pandemic and continued increasing until December 2022, with a greater intensity than the pre-pandemic period across all groups.

CONCLUSION

The COVID-19 pandemic reduced breast cancer screening and early diagnosis in Brazil, leading to more advanced cases and treatment delays across all regions, with varying impacts according to regional HDI levels.

Low-pass whole genome sequencing as a cost-effective alternative to chromosomal microarray analysis for low- and middle-income countries

Low-pass whole genome sequencing (LP-WGS) has been applied as alternative method to detect copy number variants (CNVs) in the clinical setting. Compared with chromosomal microarray analysis (CMA), the sequencing-based approach provides a similar resolution of CNV detection at a lower cost. In this study, we assessed the efficiency and reliability of LP-WGS as a more affordable alternative to CMA. A total of 1363 patients with unexplained neurodevelopmental delay/intellectual disability, autism spectrum disorders, and/or multiple congenital anomalies were enrolled. Those patients were referred from 15 nonprofit organizations and university centers located in different states in Brazil. The analysis of LP-WGS at 1x coverage (>50kb) revealed a positive testing result in 22% of the cases (304/1363), in which 219 and 85 correspond to pathogenic/likely pathogenic (P/LP) CNVs and variants of uncertain significance (VUS), respectively. The 16% (219/1363) diagnostic yield observed in our cohort is comparable to the 15%-20% reported for CMA in the literature. The use of commercial software, as demonstrated in this study, simplifies the implementation of the test in clinical settings. Particularly for countries like Brazil, where the cost of CMA presents a substantial barrier to most of the population, LP-WGS emerges as a cost-effective alternative for investigating copy number changes in cytogenetics.

Trends in Hospitalization and Mortality Rates Associated with Subarachnoid Hemorrhage and Unruptured Cerebral Aneurysms in Brazil

BACKGROUND

Epidemiology of spontaneous subarachnoid hemorrhage (SAH) and unruptured intracranial aneurysm (UIA) is valuable for determining neurosurgical and general health care effectiveness. There is an information gap regarding these conditions in middle- and low-income countries. Therefore, we aimed to investigate hospitalization and mortality rates for SAH and UIA in Brazil from 2011 to 2019.

METHODS

This observational, population-based study used hospital admission and mortality data and included all SAH- and UIA-related public hospitalizations and deaths occurring from 2011 to 2019. Data were obtained from the Ministry of Health National Hospitalisation and Mortality Information Systems. Population data were obtained from the Brazilian Institute of Geography and Statistics. Simple linear regression models with normal responses were adjusted to explain the temporal evolution of variables. Joinpoint regression models were adjusted to detect moments of significant change in variable behavior. Graduated choropleth maps were generated using georeferencing and geospatial analyses.

RESULTS

Annual SAH hospitalization and mortality coefficients were 4.81/100,000 and 2.49/100,000 persons, respectively. UIA hospitalization and mortality coefficients were 1.21/100,000 and 0.24/100,000 persons, respectively. In addition to regional differences, we found a stable SAH hospitalization trend and an increasing mortality rate of 0.062 cases/100,000 inhabitants annually. The UIA hospitalization rate increased by 0.074 cases/100,000 inhabitants annually, and mortality decreased by 0.07 deaths/100,000 inhabitants annually.

CONCLUSIONS

In Brazil, the SAH hospitalization trend is stable, although there is a worrisome increasing SAH-related mortality trend. A better scenario was observed for UIA, with an increase in hospitalizations and decrease in mortality.

Transition towards cancer mortality predominance over cardiovascular disease mortality in Brazil, 2000-2019: a population-based study

Background

Cardiovascular disease (CVD) and cancer are the first and second leading causes of death in Brazil and worldwide. However, an ongoing epidemiological transition in which cancer surpasses CVD has been observed in many high and middle-income countries. In this study, we provided a nationwide analysis of the transition towards cancer mortality predominance over CVD mortality in Brazil.

Methods

We leveraged data from 5570 municipalities using the Mortality Information System and classified the causes of death using ICD-10 codes. Age-standardized CVD and cancer mortality rates were calculated annually between 2000 and 2019. Mortality rate ratios (MRRs = CVD rates divided by cancer rates) described the predominance of cancer or CVD mortality across municipalities and states. Choropleth maps displayed state-specific MRRs and the transition in the predominant cause of death over time.

Findings

From 2000 to 2019, CVD mortality rates declined in 25 out of 27 states, whereas cancer mortality increased in 15 states, indicating a shift towards cancer predominance. While in 2000 cancer mortality was lower than CVD in all states and only exceeded the latter in 7% of the municipalities, by 2019 the gap narrowed considerably, with 13% of municipalities displaying higher cancer mortality rates vs CVD mortality rates. Additionally, higher household income correlated with higher mortality from cancer vs CVD.

Interpretation

An ongoing epidemiological transition in which cancer mortality surpasses CVD mortality is occurring in Brazil, particularly in municipalities with higher household incomes. Our findings may provide important information for policymakers and public health practitioners in Brazil.

Funding

National Council for Scientific and Technological Development (CNPq).

The negative impact of the COVID-19 pandemic on breast cancer tackle in Brazil's public and private healthcare system: time series study between 2014 and 2022

BACKGROUND

The COVID-19 pandemic has overwhelmed the healthcare systems of many countries and negatively impacted the care of other diseases.

OBJECTIVE

To evaluate the trend of screening mammograms, oncological breast surgeries, and breast cancer hospitalizations in Brazil's public and private healthcare system between 2014 and 2022.

METHOD

This ecological time series study uses the inflection point regression model and semester percentage change (SPC). We use the open-access dataset of the different healthcare systems in Brazil. We analyzed the trend of the variables in the pre-pandemic and the effect of the pandemic on the total time series.

RESULTS

In 2020, compared to 2019, the decrease in screening mammograms, oncological breast surgeries, and breast cancer hospitalization was - 41.44%, -23.13%, and - 10.52% (public health system) and - 29.49%, -18.96%, and - 15.35% (private healthcare system). In the public healthcare system, the pandemic has enhanced the decreasing trend of mammograms (SPC - 1.6% before and - 3.4% after), has reverted the stationary trend of oncological breast surgeries to decreasing (SPC - 1.0%), has slowed the increasing trend of breast cancer hospitalization (SPC 1.8% before and 0.9% after). In the private healthcare system, the pandemic has reverted the stationary trend of mammograms to decreasing (SPC - 1.0%), has slowed the increasing trend of breast cancer surgeries (SPC 2.3% before and 0.8% after), has reverted the growing trend of breast cancer hospitalization (SPC 3.9%) to stationary.

CONCLUSION

During the COVID-19 pandemic, there was an increase in inequalities between healthcare systems, especially in breast cancer screening.

Supporting a rapid primary care response to emergent communicable disease threats with PACK (Practical Approach to Care Kit) in Florianópolis, Brazil

Emerging infectious diseases present a significant challenge to healthcare systems with their need for a rapid response and reallocation of resources. This paper explores the implementation of the Practical Approach to Care Kit (PACK) programme in Florianópolis, Brazil as a strategic tool for reinforcing primary healthcare (PHC) responses to emergent communicable diseases. With its focus on enhancing PHC delivery in resource-limited settings, PACK provides a flexible, evidence-based framework that integrates into local health systems. The paper describes experiences adapting PACK to provide rapid responses to outbreaks of Zika, leishmaniasis, COVID-19, Mpox and dengue in primary care between 2014 and 2023. Key features of PACK, including its flexibility to incorporate new clinical content, responsive implementation strategy and health system strengthening approach, are highlighted. The paper emphasises how PACK supported responses to specific disease outbreaks and helped maintain mainstream PHC delivery, preventing the system from becoming condition-centric during crises. We describe the limitations of the PACK approach in an outbreak scenario, the challenges experienced and efforts to tackle these. The lessons learnt from Florianópolis underscore the adaptability and relevance of comprehensive primary care approaches like PACK in supporting PHC professionals and local health systems to navigate emerging health challenges.

Market concentration of the Brazilian hospital medical supplementary health system

BACKGROUND

The Brazilian supplementary health market has undergone transformations in recent years due to constant mergers and acquisitions of by large corporations, contributing to the increase in market concentration, especially in the poorest and least developed regions of the country. Thus, given the care it provides and its economic relevance, understanding the fundamentals of these movements, the likely consequences and trends for the health market are relevant, important, and strategic.

OBJECTIVE

To understand the general and specific context of Brazilian supplementary health, its scenarios, and trends, with emphasis on the analysis of market concentration and recent mergers and acquisitions.

METHODOLOGY

The research is applied, descriptive and exploratory and uses secondary data from various sources, submitted to quantitative data analysis methods. The data are organized into three groups: historical and regulatory documents; industry data; and market.

RESULTS

The results show the growing concentration of the market promoted by large publicly traded corporations, the growing relevance of tech startups on the healthcare landscape, the predominant use of the relative valuation model, with implicit multiples for asset pricing and the prevalence of corporate health plans.

CONCLUSION

The growing concentration of the system projects a market with fewer options and less competitiveness, since the growth of large operators is evident, in addition to the relevant increase in the number of complaints from users of the system, which signals the growing gap between the expectations of users and the levels of quality care offered. The study also highlights the predominance of corporate health plans, revealing the direct relationship between access to supplementary health services and employability rates. The analysis of M&A operations, in addition to the increase in market concentration, reveals the prevalence of the use of the relative valuation model and implicit multiples for the pricing of traded assets. This denotes the future expectation of wealth generation, at least equivalent to the historical series of the sector, on the part of investors, whose frustration may signal the decreasing attractiveness of resources and M&A operations in the sector in the coming years.

Outcomes of SARS-CoV-2 and Seasonal Viruses Among 2 Million Adults Hospitalized for Severe Acute Respiratory Infection During the COVID-19 Pandemic in Brazil

BACKGROUND

The outbreak of the COVID-19 pandemic has had a profound impact on the circulation of seasonal respiratory viruses. This study aimed to compare the outcomes of SARS-CoV-2 and seasonal viruses in adults hospitalized with severe acute respiratory infection during the COVID-19 pandemic.

METHODS

This population-based cohort study included patients aged >18 years hospitalized for severe acute respiratory infection in Brazil between February 2020 and February 2023. The primary outcome was in-hospital mortality. A competing risk analysis was used to account for competing events.

RESULTS

In total, 2 159 171 patients were included in the study. SARS-CoV-2 was the predominant virus (98.7%). Among patients testing positive, the cumulative incidence of in-hospital mortality was 33.1% for SARS-CoV-2, 31.5% for adenovirus, 21.0% for respiratory syncytial virus, 18.7% for influenza, and 18.6% for other viruses. SARS-CoV-2 accounted for 99.3% of the deaths. Older age, male sex, comorbidities, hospitalization in the northern region, and oxygen saturation <95% were the common risk factors for death among all viruses.

CONCLUSIONS

In this large cohort study, individuals infected with SARS-CoV-2 or adenovirus had the highest risk of mortality. Irrespective of the virus type, older age, male sex, comorbidities, hospitalization in vulnerable regions, and low oxygen saturation were associated with an increased risk of fatality.

Time series analysis of comprehensive maternal deaths in Brazil during the COVID-19 pandemic

The effects of the COVID-19 pandemic on comprehensive maternal deaths in Brazil have not been fully explored. Using publicly available data from the Brazilian Mortality Information (SIM) and Information System on Live Births (SINASC) databases, we used two complementary forecasting models to predict estimates of maternal mortality ratios using maternal deaths (MMR) and comprehensive maternal deaths (MMRc) in the years 2020 and 2021 based on data from 2008 to 2019. We calculated national and regional standardized mortality ratio estimates for maternal deaths (SMR) and comprehensive maternal deaths (SMRc) for 2020 and 2021. The observed MMRc in 2021 was more than double the predicted MMRc based on the Holt-Winters and autoregressive integrated moving average models (127.12 versus 60.89 and 59.12 per 100,000 live births, respectively). We found persisting sub-national variation in comprehensive maternal mortality: SMRc ranged from 1.74 (95% confidence interval [CI] 1.64, 1.86) in the Northeast to 2.70 (95% CI 2.45, 2.96) in the South in 2021. The observed national estimates for comprehensive maternal deaths in 2021 were the highest in Brazil in the past three decades. Increased resources for prenatal care, maternal health, and postpartum care may be needed to reverse the national trend in comprehensive maternal deaths.

Screening, diagnosis, treatment and outcomes of developmental dysplasia of the hip in Brazilian population: a scoping review protocol

INTRODUCTION

Developmental dysplasia of the hip (DDH) includes a spectrum of clinical and imaging findings at birth or early infancy. The circumstances in which this condition is detected and managed may be heterogeneous in Brazil owing to its large territory and regional socio-economic differences. Mapping DDH perspectives in a country is fundamental for designing guidelines and strategies for public policy. This scoping review aims to map the available literature related to screening, diagnosis, treatment and outcomes of DDH in the Brazilian population to provide an overview of this condition and to describe regional variations in presentation and management across the country.

METHODS AND ANALYSIS

This study will follow the methods outlined in the Joanna Briggs Institute Reviewers manual for conducting a scoping review. Relevant publications will be first searched in PubMed/MEDLINE, Scientific Electronic Library Online, Web of Science, Scopus, "Biblioteca virtual em saúde" and "Biblioteca Digital Brasileira de Teses e Dissertações" using search terms developed from a brief preliminary search of those databases. There were no language or date range limitations for study inclusion. Databases will be searched from their inception until February 2024. Titles and abstracts will be analysed by two or more independent reviewers to assess them against the inclusion criteria for the review. The search results and study inclusion process will be reported in full in the final version of the scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review (PRISMA-ScR) flowchart. The resulting data will be recorded and organised to present the key information contained in all examined articles.

ETHICS AND DISSEMINATION

This review will include existing available studies and does not require a specific ethical review or approval. The final study will be submitted for presentation at conferences that focus on Brazilian healthcare and publication in peer-reviewed journals. This scoping review protocol was registered in the Open Science Framework. DOI registration (https://doi.org/10.17605/OSF.IO/V3AYH).

Massive Education in Prison Health in Brazil: A Look Beyond the Walls

Equal access to health initiatives and services under the principles of universal and comprehensive care remains a challenge in Brazil. The realization of public health policies is further intricate when one examines the health situation of people deprived of liberty. This study showcases the "Prison System: Beyond the Walls" educational pathway, available on the Virtual Learning Environment of the Brazilian National Health System (AVASUS). The action research methodological strategy guided the pathway development, emphasizing dialogic learning. The goal was to address the need for massive training on the topic of prison health, with the model focusing on engagement through spontaneous, non-mandatory participation in the pathway courses. The pathway comprised four modules, whose educational offerings were based on the self-learning model. Students were free to choose which courses to take and in what order, as there was no prerequisite for participating in modules. Hence, students could either take all the courses or only those with which they identify their learning needs, regardless of work demands or personal interests. Structuring the pathway through action research facilitated a massive, cohesive, and continuous training process. This approach expanded knowledge and established meaningful relationships among the related topics and the key players involved: health professionals, prison officers, and people deprived of liberty. Notably, the pathway courses have surpassed the 50,000-enrollment mark, spanning all five regions of Brazil. In this context, this article presents and discusses the development of the "Prison System: Beyond the Walls" pathway, emphasizing the massive improvement of health within Brazil's prison system and highlighting the results achieved.

"We didn't even have time to worry about our mental health." Long-term impact of the pandemic on nursing professionals' experiences

Explore the experiences of nursing professionals during the COVID-19 pandemic and the impact these experiences continue to have on their personal and professional lives. This qualitative study utilized interpretative phenomenological analysis with nine nursing professionals from southern Brazil. Two main themes and five subthemes were developed. The first theme, "Ongoing trauma response," had three subthemes: (a) Fear of dying and family dying, (b) Loneliness and isolation, and (c) My emotions don't matter. The second theme highlights the "Continued problems with the larger healthcare system" and is made up of two subthemes: (a) We are humans, not superheroes, and (b) We are still invisible. Symptoms of trauma response continued to be a significant challenge among nursing professionals even after the end of the pandemic. Recommendations for improving working conditions and making mental health services more readily available are discussed.