Use of and access to health services in Brazil, 2013 National Health Survey

Social inequalities in indicators of use of healthcare services by adolescents in Campinas, São Paulo, Brazil

This study aimed to analyze the prevalence of indicators of use of healthcare services according to sex, income and race/skin color, in adolescents (aged 10-19 years old) based on data from the Health Survey of the Municipality of Campinas (ISACamp), carried out in 2014/2015 in Campinas, São Paulo, Brazil. The chi-square test was used to evaluate the differences between the outcome variables (indicators of use of healthcare service) and sex, income and race/skin color. Adjusted prevalence ratios (PR) were estimated using Poisson multiple regression models. The demand for medical care was high in the last year of the interview (79.2%), mostly attended by the Brazilian Unified National Health System (65.2%), with routine consultations being more prevalent for females (PR = 1.17; 95%CI: 1.01-1.34) and injury for the male population (PR = 0.47; 95%CI: 0.26-0.84). Economic and racial differences were found in the evaluation of the last medical consultation, with a higher prevalence of worse care among those with lower income (PR = 1.46; 95%CI: 1.14-1.87) and black people (PR = 1.27; 95%CI: 1.01-1.61). Inequalities remained for delay or failure to carry out exams (PR = 1.64; 95%CI: 1.02-2.64) and worse quality of dental care (PR = 2.10; 95%CI: 1.38-3.21) in those with lower income. Also, black people had fewer appointments with dentists (PR = 0.90; 95%CI: 0.82-0.99).

Factors associated with non-treatment of hypertension and gender differences at baseline in the ELSA-Brasil cohort

The treatment of arterial hypertension (AH) contributes to the reduction of morbidity and mortality. Gender differences are likely to play a role, as non-treatment is associated with clinical and sociodemographic aspects. The aim of this study was to investigate the factors associated with non-treatment of AH and gender differences in hypertensive individuals from the ELSA-Brasil cohort. The study was conducted with 5,743 baseline hypertensive cohort participants. AH was considered if there was a previous diagnosis or if systolic blood pressure (SBP) was ≥140 and/or diastolic BP (DBP) was ≥90 mmHg. Sociodemographic and anthropometric data, lifestyle, comorbidities, and use of antihypertensive medications were evaluated through interviews and in-person measurements. Treatment with renin-angiotensin-aldosterone system inhibitors (RAASi) or other antihypertensive medications and non-treatment were evaluated with multivariate logistic regression. Non-treatment was observed in 32.8% of hypertensive individuals. Of the 67.7% treated individuals, 41.1% received RAASi. Non-treatment was associated with alcohol consumption in women (OR=1.41; 95%CI: 1.15-1.73; P=0.001), lowest schooling level in men (OR=1.70; 95%CI: 1.32-2.19; P<0.001), and younger age groups in men and women (strongest association in males aged 35-44 years: OR=4.58, 95%CI: 3.17-6.6, P<0.001). Among those using RAASi, a higher proportion of white, older individuals, and with more comorbidities was observed. The high percentage of non-treatment, even in this civil servant population, indicated the need to improve the treatment cascade for AH. Public health policies should consider giving special attention to gender roles in groups at higher risk of non-treatment to reduce inequities related to AH in Brazil.

Twenty-first-century demographic and social inequalities of heat-related deaths in Brazilian urban areas

Population exposure to heat waves (HWs) is increasing worldwide due to climate change, significantly affecting society, including public health. Despite its significant vulnerabilities and limited adaptation resources to rising temperatures, South America, particularly Brazil, lacks research on the health impacts of temperature extremes, especially on the role played by socioeconomic factors in the risk of heat-related illness. Here, we present a comprehensive analysis of the effects of HWs on mortality rates in the 14 most populous urban areas, comprising approximately 35% of the country's population. Excess mortality during HWs was estimated through the observed-to-expected ratio (O/E) for total deaths during the events identified. Moreover, the interplay of intersectionality and vulnerability to heat considering demographics and socioeconomic heterogeneities, using gender, age, race, and educational level as proxies, as well as the leading causes of heat-related excess death, were assessed. A significant increase in the frequency was observed from the 1970s (0-3 HWs year-1) to the 2010s (3-11 HWs year-1), with higher tendencies in the northern, northeastern, and central-western regions. Over the 2000-2018 period, 48,075 (40,448-55,279) excessive deaths were attributed to the growing number of HWs (>20 times the number of landslides-related deaths for the same period). Nevertheless, our event-based surveillance analysis did not detect the HW-mortality nexus, reinforcing that extreme heat events are a neglected disaster in Brazil. Among the leading causes of death, diseases of the circulatory and respiratory systems and neoplasms were the most frequent. Critical regional differences were observed, which can be linked to the sharp North-South inequalities in terms of socioeconomic and health indicators, such as life expectancy. Higher heat-related excess mortality was observed for low-educational level people, blacks and browns, older adults, and females. Such findings highlight that the strengthening of primary health care combined with reducing socioeconomic, racial, and gender inequalities represents a crucial step to reducing heat-related deaths.

Socioeconomic inequalities in the use of medical consultation services in Peru, 2019

BACKGROUND

Socioeconomic inequalities in the population influence access to health services and constitute a challenge for health systems, especially in low- and middle-income countries. In Peru, an increase in the use of medical services has been estimated; however, the study of inequalities in the use of medical services is limited. Therefore, the objective of this research was to analyze and decompose socioeconomic inequalities in the use of medical consultation services in Peru.

METHODS

A cross-sectional analytical study was conducted using data from the National Household Survey 2019. The outcome variable was the use of a consultation attended by a physician in the last 4 weeks in persons who presented symptom or discomfort, illness, relapse of chronic disease and/or accident. Concentration curves and Erreygers concentration indices were used to determine socioeconomic inequalities, and a generalized linear regression model was used for the decomposition analysis of inequalities.

RESULTS

A total of 52,715 persons were included in the study. The frequency of medical consultation was 25.4% (95% confidence interval: 24.8 - 26.1%). In the inequality analysis, it was found that the use of medical consultations was concentrated among the wealthiest individuals. The main contributing factors were having another type of health insurance (social health insurance [EsSalud], private health insurance, health provider, the Armed Forces, and the Police), residing in an urban area, belonging to the richest wealth quintile, having a chronic disease, and residing in the highlands of Peru.

CONCLUSIONS

Based on our findings, government institutions seeking to achieve equitable access to health services should consider the main factors contributing to this inequality in the formulation of strategies to lessen the negative impact of inadequate disease control in the population.

A systematic review of population and patient perspectives and experiences as measured in Latin American and Caribbean surveys

High-quality health systems must provide accessible, people-centred care to both improve health and maintain population trust in health services. Furthermore, accurate measurement of population perspectives is vital to hold health systems accountable and to inform improvement efforts. To describe the current state of such measures in Latin America and the Caribbean (LAC), we conducted a systematic review of facility and population-based assessments that included patient-reported experience and satisfaction measures. Five databases were searched for publications on quantitative surveys assessing healthcare quality in Spanish- or Portuguese-speaking LAC countries, focusing on the domains of processes of care and quality impacts. We included articles published since 2011 with a national sampling frame or inclusion of multiple subnational regions. We tabulated and described these articles, identifying, classifying and summarizing the items used to assess healthcare quality into the domains mentioned earlier. Of the 5584 publications reviewed, 58 articles met our inclusion criteria. Most studies were cross-sectional (95%), assessed all levels of healthcare (57%) and were secondary analyses of existing surveys (86%). The articles yielded 33 unique surveys spanning 12 LAC countries; only eight of them are regularly administered surveys. The most common quality domains assessed were satisfaction (in 33 out of 58 articles, 57%), evidence-based/effective care (34%), waiting times (33%), clear communication (33%) and ease of use (31%). Items and reported ratings varied widely among instruments used, time points and geographical settings. Assessment of patient-reported quality measures through population- and facility-based surveys is present but heterogeneous in LAC countries. Satisfaction was measured frequently, although its use in accountability or informing quality improvement is limited. Measurement of healthcare quality in LAC needs to be more systematic, regular, comprehensive and to be led collaboratively by researchers, governments and policymakers to enable comparison of results across countries and to effectively inform policy implementation.

Notifications of physical, sexual and emotional violence and neglect against children in Brazil, 2011-2019: an ecological time-series study

OBJECTIVE

To describe the temporal trend of notifications of physical, sexual and emotional violence and neglect against children in Brazil between 2011 and 2019.

METHODS

This was an ecological time-series study based on notifications of violence against children aged 0-9 years held on the Brazilian Notifiable Health Conditions Information System. Age-adjusted notification rates were calculated for Brazil as a whole, by national macro-region and by sex. Trends were assessed using Joinpoint Regression.

RESULTS

We analyzed 88,820 notifications of physical violence, 87,141 notifications of sexual violence, 52,359 notifications of emotional violence and 166,664 notifications of neglect. A rising trend was identified for notifications of physical, sexual and emotional violence and neglect for Brazil as a whole and for both sexes. Neglect accounted for the highest rate (95.24 notifications per 100,000 children in 2019). The Northeast and Southeast macro-regions had rising trends for all forms of violence.

CONCLUSION

Notifications of physical, sexual and emotional violence and neglect showed rising trends in Brazil in the period studied.

IMPLICATIONS FOR SERVICES

Increasing trends in notifications of violence against children highlight the continued need for capacity building in health services, crucial for early detection, effective prevention and coordinated intervention, taking regional variations into account.

PERSPECTIVES

Notification of violence against children by health services requires greater commitment by health workers. Future studies could combine multiple national databases and surveys to increase the accuracy of rates and trends.

Hospitalizations in Brazil according to National Health Survey estimates, 2013 and 2019

OBJECTIVE

To compare the profile and prevalence of hospitalizations in Brazil based on estimates from the National Health Survey (PNS), 2013 and 2019.

METHODS

A cross-sectional study that used data from the 2013 PNS and the 2019 PNS. The outcome was having been hospitalized for 24 hours or more in the last 12 months. We calculated the proportion of the population in different categories of age group, presence or absence of chronic diseases, and perception of health status. We estimated the total number of hospitalizations and the proportion corresponding to each category of age group, chronic disease, and perceived health status. We calculated the prevalence of hospitalization according to geographic, socioeconomic, and health conditions. We compared the estimates of two editions of the PNS using Student's t-test for independent samples. We considered significant differences when the p-value was less than 0.01. And finally, we compared hospitalization estimates with administrative data to assess data consistency.

RESULTS

We observed that the proportion of chronically ill people in the population increased from 15.04% to 31.48%. This group was responsible for 36.76% of the total number of hospitalizations in 2013 and 57.61% in 2019. The prevalence of hospitalizations increased significantly between the two surveys and the increases were higher in the Southeast region and among people who have private health insurance. A discrepancy was found between administrative data and survey estimates. Obstetric hospitalizations and health insurance hospitalizations were underestimated.

CONCLUSION

There was an increase in overall hospitalization rates in the period between the PNS 2013 and PNS 2019, especially among people with better access to health services. The hospitalization profile also changed-in the 2013 PNS, hospitalizations of people without chronic diseases predominated. This was reversed in PNS 2019.

Poor access to health services for depression treatment in Brazil

OBJECTIVE

To analyze the factors associated with poor access to health services for the depression treatment in Brazil.

METHODS

This study used data from the Brazilian National Survey of Health, conducted in the years 2019 and 2020. The sample consisted of 8,332 individuals with a self-reported diagnosis of depression, and poor access to healthcare was identified from the question "what is the main reason for you to not visit the physician/health service regularly for your depression?" From which poor access was identified by the affirmative answer reporting distance of health services or difficulties with transportation; waiting time at the health service; financial difficulties; opening hours of the health service; Not being able to schedule a consultation via health insurance; does not know who to look for or where to go, among others. Sociodemographic aspects and health conditions were analyzed. Bivariate and multivariate analysis was performed using Poisson Regression.

RESULTS

The prevalence of poor access to health services for depression treatment was 14.9% (95%CI: 13.6-16.2), relating to individuals aged 15-29 years (PR = 1.52) and 30-59 years old (PR = 1.22), without education (PR = 1.43), who rate their health as regular/poor/very poor (PR = 1.26), who have some limitation in their usual activities (PR = 2.71), who had the last consultation within 6 months of less than 2 years (PR = 2.63) and for more than 2 years (PR = 2.25) and who do not undergo psychotherapy (PR = 4.28).

CONCLUSION

Poor access to health services for depression treatment was associated with individual factors and health conditions.

The effects of social determinants of health on acquired immune deficiency syndrome in a low-income population of Brazil: a retrospective cohort study of 28.3 million individuals

Background

Social determinants of health (SDH) include factors such as income, education, and race, that could significantly affect the human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS). Studies on the effects of SDH on HIV/AIDS are limited, and do not yet provide a systematic understanding of how the various SDH act on important indicators of HIV/AIDS progression. We aimed to evaluate the effects of SDH on AIDS morbidity and mortality.

Methods

A retrospective cohort of 28.3 million individuals was evaluated over a 9-year period (from 2007 to 2015). Multivariable Poisson regression, with a hierarchical approach, was used to estimate the effects of SDH-at the individual and familial level-on AIDS incidence, mortality, and case-fatality rates.

Findings

A total of 28,318,532 individuals, representing the low-income Brazilian population, were assessed, who had a mean age of 36.18 (SD: 16.96) years, 52.69% (14,920,049) were female, 57.52% (15,360,569) were pardos, 34.13% (9,113,222) were white/Asian, 7.77% (2,075,977) were black, and 0.58% (154,146) were indigenous. Specific socioeconomic, household, and geographic factors were significantly associated with AIDS-related outcomes. Less wealth was strongly associated with a higher AIDS incidence (rate ratios-RR: 1.55; 95% confidence interval-CI: 1.43-1.68) and mortality (RR: 1.99; 95% CI: 1.70-2.34). Lower educational attainment was also greatly associated with higher AIDS incidence (RR: 1.46; 95% CI: 1.26-1.68), mortality (RR: 2.76; 95% CI: 1.99-3.82) and case-fatality rates (RR: 2.30; 95% CI: 1.31-4.01). Being black was associated with a higher AIDS incidence (RR: 1.53; 95% CI: 1.45-1.61), mortality (RR: 1.69; 95% CI: 1.57-1.83) and case-fatality rates (RR: 1.16; 95% CI: 1.03-1.32). Overall, also considering the other SDH, individuals experiencing greater levels of socioeconomic deprivation were, by far, more likely to acquire AIDS, and to die from it.

Interpretation

In the population studied, SDH related to poverty and social vulnerability are strongly associated with a higher burden of HIV/AIDS, most notably less wealth, illiteracy, and being black. In the absence of relevant social protection policies, the current worldwide increase in poverty and inequalities-due to the consequences of the COVID-19 pandemic, and the effects of war in the Ukraine-could reverse progress made in the fight against HIV/AIDS in low- and middle-income countries (LMIC).

Funding

National Institute of Allergy and Infectious Diseases (NAIDS), National Institutes of Health (NIH), US Grant Number: 1R01AI152938.

Impact of COVID-19 on surgical procedures for stress urinary incontinence in the Brazilian public health system

INTRODUCTION AND HYPOTHESIS

The objective was to characterize the impact of the COVID-19 pandemic on the surgical treatment of female stress urinary incontinence (FSUI) in Brazil.

METHODS

This study was conducted with population-based data from the Brazilian public health system database. We obtained data on the number of surgical procedures for FSUI in 2019 (before the coronavirus disease [COVID-19] pandemic), 2020, and 2021 (during the pandemic) in each of the 27 Brazilian states. We included official Brazilian Institute of Geography and Statistics (IBGE) data on the population, Human Development Index (HDI), and annual per capita income of each state.

RESULTS

A total of 6,718 surgical procedures for FSUI were performed in the Brazilian public health system in 2019. The number of procedures was reduced by 56.2% in 2020, and an additional reduction of 7.2% was seen in 2021. The distribution of procedures by state showed important differences, ranging from 4.4 procedures/1,000,000 inhabitants in Paraíba and Sergipe to 67.6 procedures/1,000,000 inhabitants in Paraná (p<0.01) in 2019. The number of surgical procedures was higher in states with a higher HDI (p=0.0001) and per capita income (p=0.042). The decrease in the number of surgical procedures affected the whole country and its rate did not correlate with HDI (p=0.289) or per capita income (p=0.598).

CONCLUSION

The impact of the COVID-19 pandemic on the surgical treatment of FSUI in Brazil was significant in 2020 and persisted in 2021. Access to surgical treatment of FSUI varied according to geographic region, HDI, and per capita income, even before COVID-19.

Differential Factors Are Associated with Physical Activity in Older Adults in Brazil with and without Non-Communicable Chronic Diseases: A Cross-Sectional Analysis of the 2019 National Health Survey

This study analyzed whether sociodemographic factors, health perception, dietary habits, and screen time are related to physical activity (PA) in older people with and without non-communicable chronic diseases (NCDs). This cross-sectional study analyzed data from the 2019 Brazilian National Health Survey; the sample was older adults (≥60 years old; n = 22,726). The outcome of this study was being physically active or inactive during leisure time, and NCD was used as a moderating variable. The correlates investigated were sociodemographic and health-related variables. According to the logistic regression analysis, it was observed that being male had an association only in the group with NCDs (OR = 1.25 (1.05-1.48)), as well as residing in the northeastern region (OR = 1.26 (1.04-1.53)). On the other hand, high levels of education (OR = 4.09 (2.92-5.2); OR = 1.92 (1.48-2.49)) and income (OR = 1.64 (1.09-2.48); OR = 1.86 (1.33-2.60)) were associated with PA in both groups, as well as dietary habits (OR = 1.03 (1.01-1.05); (OR = 1.05 (1.04-1.07)). Advanced age (OR = 0.96 (0.94-0.97); OR = 0.97 (0.96-0.98)) and reporting a regular health perception (OR = 0.53 (0.43-0.66); OR = 0.61 (0.52-0.73)) were factors associated with physical inactivity in both groups. Gender, education, and income were unequally associated with an active lifestyle in both groups, and therefore, barriers to PA may arise.

Inequalities in the receipt of healthcare practitioner counseling for adults after COVID-19 in southern Brazil

Health counseling is a prevention and health promotion action, especially in the context of a pandemic, for both preventing disease and maintaining health. Inequalities may affect receipt of health counseling. The aim was to provide an overview of the prevalence of receiving counseling and to analyze income inequality in the receipt of health counseling.

METHODS

This was a cross-sectional telephone survey study with individuals aged 18 years or older with diagnosis of symptomatic COVID-19 using RT-PCR testing between December 2020 and March 2021. They were asked about receipt of health counseling. Inequalities were assessed using the Slope Index of Inequality (SII) and Concentration Index (CIX) measures. We used the Chi-square test to assess the distribution of outcomes according to income. Adjusted analyses were performed using Poisson regression with robust variance adjustment.

RESULTS

A total of 2919 individuals were interviewed. Low prevalence of health counseling by healthcare practitioner was found. Participants with higher incomes were 30% more likely to receive more counseling.

CONCLUSIONS

These results serve as a basis for aggregating public health promotion policies, in addition to reinforcing health counseling as a multidisciplinary team mission to promote greater health equity.

Prevalence and factors associated with multimorbidity in adults in Brazil, according to sex: a population-based cross-sectional survey

Introduction

Multimorbidity, defined as the coexistence of two or more chronic diseases in the same individual, represents a significant health challenge. However, there is limited evidence on its prevalence and associated factors in developing countries, such as Brazil, especially stratified by sex. Thus, this study aims to estimate the prevalence and analyze the factors associated with multimorbidity in Brazilian adults according to sex.

Methods

Cross-sectional population-based household survey carried out with Brazilian adults aged 18 years or older. The sampling strategy consisted of a three-stage conglomerate plan. The three stages were performed through simple random sampling. Data were collected through individual interviews. Multimorbidity was classified based on a list of 14 self-reported chronic diseases/conditions. Poisson regression analysis was performed to estimate the magnitude of the association between sociodemographic and lifestyle factors with the prevalence of multimorbidity stratified by sex.

Results

A total of 88,531 individuals were included. In absolute terms, the prevalence of multimorbidity was 29.4%. The frequency in men and women was 22.7 and 35.4%, respectively. Overall, multimorbidity was more prevalent among women, the older people, residents of the South and Southeast regions, urban area residents, former smokers, current smokers, physically inactive, overweight, and obese adults. Individuals with complete high school/incomplete higher education had a lower prevalence of multimorbidity than those with higher educational level. The associations between education and multimorbidity differed between sexes. In men, multimorbidity was inversely associated with the strata of complete middle school/incomplete high school and complete high school/incomplete higher education, while in women, the association between these variables was not observed. Physical inactivity was positively associated with a higher prevalence of multimorbidity only in men. An inverse association was verified between the recommended fruit and vegetable consumption and multimorbidity for the total sample and both sexes.

Conclusion

One in four adults had multimorbidity. Prevalence increased with increasing age, among women, and was associated with some lifestyles. Multimorbidity was significantly associated with educational level and physical inactivity only in men. The results suggest the need to adopt integrated strategies to reduce the magnitude of multimorbidity, specific by gender, including actions for health promotion, disease prevention, health surveillance and comprehensive health care in Brazil.

Hospitalizations for oral and oropharyngeal cancer in Brazil by the SUS: impacts of the covid-19 pandemic

OBJECTIVE

To analyze the impact of the different phases of the covid-19 pandemic on hospitalizations for oral (CaB) and oropharyngeal (CaOR) cancer in Brazil, carried out within the scope of the Brazilian Unified Health System (SUS).

METHODS

We obtained data regarding hospital admissions due to CaB and CaOR between January 2018 and August 2021 from the SUS Hospital Information System, analyzing hospital admissions as rates per 100,000 inhabitants. We divided the pandemic (January 2020 to August 2021) and pre-pandemic (January 2018 to December 2019) periods into four-month periods, comparing the pandemic period rates with analogous rates for the pre-pandemic period - for Brazil, by macro-region and by a group of procedures performed during hospitalization. We also analyzed the impact of the pandemic on the average cost of hospitalizations, expressing the results in percentage change.

RESULTS

Rates of hospitalization in the SUS due to CaB and CaOR decreased during the pandemic in Brazil. The most significant reduction occurred in the second four-month period of 2020 (18.42%), followed by decreases in the third four-month period of 2020 (17.76%) and the first and second four-month periods of 2021 (respectively, 14.64% and 17.07%), compared with 2019. The South and Southeast showed the most expressive and constant reductions between the different phases of the pandemic. Hospitalizations for clinical procedures suffered a more significant decrease than for surgical procedures. In Brazil, the average expenditure per hospitalization in the four-month pandemic periods was higher than in the reference periods.

CONCLUSION

After more than a year of the pandemic's beginning in Brazil, the SUS hospital care network for CaB and CaOR had yet to be re-established. The repressed demand for hospitalizations for these diseases, which have fast evolution, will possibly result in delays in treatment, negatively impacting the survival of these patients. Future studies are needed to monitor this situation.

Access to diabetes diagnosis in Brazil based on recent testing and consultation: The Brazilian national health survey, 2013 and 2019

BACKGROUND

Screening for undiagnosed diabetes using glucose testing is recommended globally to allow preventive action among those detected. Our aim was to evaluate the access to glucose testing to screen for diabetes in Brazil using self-reported information on recent testing and medical consultation from national surveys of Brazilian adults.

METHODS

The Pesquisa Nacional de Saúde (PNS) was conducted in 2013 and 2019 drawing probabilistic samples of Brazilians aged 18 years and above. To evaluate glucose testing among those undiagnosed, we excluded those self-reporting a previous diagnosis of diabetes. We then defined recent access to diabetes diagnosis by considering the previous two years and choosing the last blood glucose test and the proximal medical consultation reported. We used Poisson regression with robust variance to assess correlates of access, expressing them with adjusted prevalence ratios (PR) and their 95% confidence intervals.

RESULTS

Access to recent glucose testing documented that over 70% reported a recent glycemic test, 71% in 2013, and 77% in 2019. These findings are consistent with a wide recent access to medical consultation, 86% and 89% in 2013 and 2019, respectively. Reporting recent glucose testing and medical consultation may better reflect the actual access to medical diagnostic testing. When analyzing this joint outcome, diagnostic access was still wide, 67% and 74%, respectively. Greater access (p< 0.001) was seen for women (PR=1.16; 1.15-1.17), older individuals (PR=1.25; 1.22-1.28), and those with higher education (PR=1.17; 1.15-1.18), obesity (PR=1.06; 1.05-1.08), and hypertension (PR=1.12; 1.11-1.13). In contrast, lower access (p<0.001) was seen for those declaring being Black (PR=0.97; 0.95-0.99) or of mixed-race (PR=0.97; 0.96-0.98), those residing in rural areas (PR=0.89; 0.87-0.90), and not having a private health insurance plan (PR=0.85; 0.84-0.86).

CONCLUSIONS

Although access to diagnostic testing for diabetes is high in Brazil, partly due to its universal health system, social inequities are still present, demanding specific actions, particularly in rural areas and among those self-declaring as being Black or mixed-race.

Health economic impacts associated with the consumption of sugar-sweetened beverages in Brazil

Introduction

The consumption of sugar-sweetened beverages (SSBs) is among the main risk factors for non-communicable diseases (NCDs). This study aimed to estimate the financial costs of hospitalizations and procedures of high and medium complexity for NCDs attributable to the consumption of SSBs in the Brazilian Unified Health System (SUS) in 2019.

Methods

This ecological study used data from the Global Burden of Disease (GBD) 2019 and the Department of Informatics of the Unified Health System (DATASUS). The attributable costs were estimated from the population-attributable fraction (PAF) and the costs in the treatment of chronic diseases [type 2 diabetes mellitus and ischemic heart disease (IHD)], stratified by sex, age group, level of complexity of treatment, and federative units.

Results

In 2019, in Brazil, US$ 14,116,240.55 were the costs of hospitalizations and procedures of high and medium complexity in the treatment of NCDs attributable to the consumption of SSBs. These values were higher in males (US$ 8,469,265.14) and the southeast and southern regions, mainly in the state of São Paulo. However, when evaluating these results at a rate per 10,000 inhabitants, it was observed that the states of Paraná, Tocantins, and Roraima had higher costs per 10,000 inhabitants. Regarding the age groups, higher costs were observed in the older age groups.

Conclusion

This study revealed the high financial impact of the NCDs treatment attributed to the consumption of SSBs in Brazil and the variability among Brazilian macro-regions. The results demonstrate the urgency and need for the expansion of policies to reduce the consumption of SSBs in Brazil with strategies that consider regional particularities.

Factors associated with recent and regular non-use of dental services by students from a university in southeastern Brazil: a cross-sectional study

BACKGROUND

Lack of use of dental services can be a risk factor for oral health. In addition to recent visits to dental services, it is important to assess the regularity of use of these services, as well as the motivations for visiting the dentist. There is a gap in literature studies on the patterns of use of oral health services by the young university students. The goal of this study was to assess the factors associated with recent and regular non-use of dental services by young university students, using the Andersen model as a reference.

METHODS

This was a cross-sectional study with 477 university students between 18 and 24 years old, carried out as a web survey, through which predisposing, enabling and need variables were collected, according to the model proposed by Andersen, to test the factors associated with recent and regular non-use of dental services. Bivariate analyses and robust Poisson regression were performed, with estimation of crude and adjusted prevalence ratios, using confidence intervals of 95%. The variables with p < 0.05 remained in the final model.

RESULTS

The prevalence of recent non-use was of 19.5% (95% CI 16.0-23.3%), and of regular non-use, of 53.5% (95% CI 48.9-58.0%). After the adjusted analysis, the following were found to be associated with the outcome of recent non-use: type of service used (PR = 0.91; 95% CI 0.85-0.98) and perceived need for dental treatment (PR = 0.98; 95% CI 0.97-0.99); and the following variables were associated with regular non-use: father's level of education (PR = 0.86; 95% CI 0.78-0.96), area of study (PR = 1.08; 95% CI 1.02-1.15), reason for last dental appointment (PR = 0.81; 95% CI 0.75-0.88), use of dental services throughout childhood (PR = 0.92; 95% CI 0.86-0.97), self-perceived oral health (PR = 0.86; 95% CI 0.76-0.88), and toothaches over the last 2 years (PR = 0.93; 95% CI 0.87-0.99).

CONCLUSION

The motivation for young university students to use dental services are curative treatment needs, not prevention. The results point to the need to implement health prevention and promotion policies in higher education institutions and to expand access to dental services for this young population.

Impact of socioeconomic factors and health determinants on preterm birth in Brazil: a register-based study

BACKGROUND

More than 15 million children are born preterm annually. While preterm survival rates have increased in high-income countries. Low- and middle-income countries, like Brazil, continue to battle high neonatal mortality rates due to a lack of adequate postnatal care. Globally, neonatal mortality is higher for preterm infants compared to those born at term. Our study aims to map and analyze the spatial, socioeconomic, and health coverage determinants related to preterm birth in Brazil in order to understand how spatial variations in demographics and access to primary care may affect preterm birth occurrences.  METHODS: Using publicly available national-level data from the Brazilian health system for 2008-2017, we conducted an ecological study to visualize the spatial distributions of preterm birth along with socioeconomic status, the structure of health services, and primary care work process, each consisting of multiple variables reduced via principal component analysis. Regression models were created to determine predictive effects of numeric and spatial variation of these scores on preterm birth rates.

RESULTS

In Brazil, preterm birth rates increased from 2008-2017, with small and rural municipalities frequently exhibiting higher rates than urban areas. Scores in socioeconomic status and work process were significant predictors of preterm birth rates, without taking into account spatial adjustment, with more positive scores in socioeconomic status predicting higher preterm birth rates (coefficient 0.001145) and higher scores in work process predicting lower preterm birth rates (coefficient -0.002416). Geographically weighted regression showed socioeconomic status to be a more significant predictor in the North, with the work process indicators being most significant in the Northeast.

CONCLUSIONS

Results support that primary care work process indicators are more significant in estimating preterm birth rates than physical structures available for care. These results emphasize the importance of ensuring the presence of the minimum human resources needed, especially in the most deprived areas of Brazil. The association between social determinants of health and preterm birth rates raises questions regarding the importance of policies dedicated to foster equity in the accessibility of healthcare services, and improve income as protective proxies for preterm birth.

Contextual and individual factors associated with self-reported tooth loss among adults and elderly residents in rural riverside areas: A cross-sectional household-based survey

BACKGROUND

Tooth loss is an oral health condition with high prevalence and negative impact on quality of life. It is the result of the history of oral diseases and their treatment as well as provision of dental care and access to dental services. Socioeconomic characteristics are determinants of tooth loss and living in rural areas is also a risk factor for its incidence.

OBJECTIVE

To identify contextual and individual factors associated with self-reported tooth loss among adults and elderly people living in rural riverside areas.

METHODS

A cross-sectional household-based survey was conducted in 2019 with rural riverside communities on the left bank of the Rio Negro River, Manaus, Amazonas. These communities are covered by a fluvial health team and two riverside health teams. Interviews were conducted in a representative random sample of dwellers aged ≥ 18 years, using electronic forms to obtain information on oral health conditions, demographic and socioeconomic characteristics, and use of and access to health services. The outcome was self-reported tooth loss. After the descriptive analysis of the data, a multilevel Poisson regression analysis was performed to estimate the prevalence ratio for the outcome. Variables with p-value ≤0.20 in the bivariate analyses were included in the multiple analysis considering the hierarchy between individual and contextual variables in the multilevel model. Variables with p-value ≤0.10 were kept in the final model and the significance level adopted was 0.05.

RESULTS

603 individuals from 357 households were assessed (mean age 44.1 years). The average number of missing teeth was 11.2 (±11.6); 27.4% of individuals had lost more than 20 teeth (non-functional dentition) and 12.1% were completely edentulous. Contextual characteristic of primary healthcare offered was associated with the outcome. The tooth loss was lower in territories covered by riverside health teams. At individual level, tooth loss was greater in older individuals who had experienced dental pain over the past six months and whose sugar consumption was high. Black or brown individuals, individuals whose household income was higher, those who were on the Bolsa Família cash transfer program, those who consulted a dentist over the past year, and those who reported satisfaction with their teeth/oral health reported less tooth loss.

CONCLUSION

Tooth loss was associated with contextual territorial factors related to the healthcare service and individual demographic, behavioral, socioeconomic, and service-related characteristics as well as self-perceived oral health conditions. The findings suggest that actions focused on the oral health of these populations involve not only changes in the healthcare service organization, but also intersectoral policies that contribute to reducing social inequalities.

Obesity and health service utilization in Brazil: data from the National Health Survey

Background

Obesity, a complex public health problem, is generally associated with other chronic diseases. The association of obesity with health service utilization has been little investigated in low- and middle-income countries. This study aimed to analyze the association between obesity and health service utilization (considering those services related to hypertension and/or diabetes).

Methods

A cross-sectional, nationally-representative, study of Brazilians aged ≥18 years was conducted. Data from the National Health Survey (2013) for 59,402 individuals were analyzed, including measured weight and height. The association between body mass index (BMI) category (under/normal weight, overweight, and obesity) and health service utilization due to hypertension and/or diabetes was investigated using Poisson regression models (crude and adjusted). To analyze the health services utilization, the following variables were considered: 1) routine visits to a general doctor or health service; 2) referrals/consultations with a specialist; 3) prescribed exams done; and 4) hospital admission due to the disease or related complication. All analyses were stratified by sex.

Results

Compared with under/normal-weight individuals, subjects with obesity (both male and female) made roughly double the use of all health care services assessed. Men with hypertension that had obesity had a higher risk of hospital admission (adjusted PR = 2.55; 95%CI 1.81–3.61), than those with under/normal weight. Women with diabetes that had obesity had more referrals/consultations with specialists (adjusted PR = 2.56; 95%CI 1.94–3.38), than those with under/normal weight.

Conclusions

The presence of obesity was associated with increased use of health care services for hypertension and/or diabetes, indicating greater demand for human resources and materials, and a greater burden on the national health system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13906-2.

Tendência Temporal da Mortalidade por Câncer de Boca e da Cobertura de Atenção Primária no Estado do Rio de Janeiro

Introdução: O câncer de boca e comumente diagnosticado de forma tardia, comprometendo a qualidade de vida dos indivíduos ou os levando a óbito. Objetivo: Verificar a tendencia temporal da mortalidade por câncer de boca no Estado do Rio de Janeiro e da cobertura da Estratégia Saúde da Família (ESF) e de equipes de saúde bucal (ESB). Método: Estudo ecológico com análise da tendencia temporal da mortalidade por câncer de boca, entre 1999 e 2018, e da cobertura da ESF e ESB, no período de 2002 a 2018, no Estado e Regiões de Saúde. Utilizou-se a regressão linear generalizada de Prais-Winsten no cálculo das tendencias para o Estado, cada Região de Saúde, sexo, faixa etária e localização do tumor. Resultados: Houve tendencia de mortalidade por câncer de boca decrescente no Estado e nas Regiões Metropolitana I e II; nas demais Regiões de Saúde, foi estacionaria. As tendencias dos óbitos em homens, das faixas etárias 40 a 59 anos e 80 anos ou mais, foram decrescentes. Na localização do tumor, houve tendencia decrescente entre óbitos por outras partes e partes não especificadas (C06) e uma tendencia crescente na mortalidade por câncer de base de língua (C01). Na cobertura de ESF e ESB, na maioria das Regiões de Saúde e no Estado, a tendencia foi crescente. Conclusão: A tendencia decrescente na mortalidade por câncer de boca e a tendencia crescente de ESF e ESB, no Estado do Rio de Janeiro, não foram observadas em todas as Regiões de Saúde.

Performance bonuses and the quality of primary health care delivered by family health teams in Brazil: A difference-in-differences analysis

BACKGROUND

Pay-for-performance (P4P) programmes to incentivise health providers to improve quality of care have been widely implemented globally. Despite intuitive appeal, evidence on the effectiveness of P4P is mixed, potentially due to differences in how schemes are designed. We exploited municipality variation in the design features of Brazil's National Programme for Improving Primary Care Access and Quality (PMAQ) to examine whether performance bonuses given to family health team workers were associated with changes in the quality of care and whether the size of bonus mattered.

METHODS AND FINDINGS

For this quasi-experimental study, we used a difference-in-differences approach combined with matching. We compared changes over time in the quality of care delivered by family health teams between (bonus) municipalities that chose to use some or all of the PMAQ money to provide performance-related bonuses to team workers with (nonbonus) municipalities that invested the funds using traditional input-based budgets. The primary outcome was the PMAQ score, a quality of care index on a scale of 0 to 100, based on several hundred indicators (ranging from 598 to 660) of health care delivery. We did one-to-one matching of bonus municipalities to nonbonus municipalities based on baseline demographic and economic characteristics. On the matched sample, we used ordinary least squares regression to estimate the association of any bonus and size of bonus with the prepost change over time (between November 2011 and October 2015) in the PMAQ score. We performed subgroup analyses with respect to the local area income of the family health team. The matched analytical sample comprised 2,346 municipalities (1,173 nonbonus municipalities; 1,173 bonus municipalities), containing 10,275 family health teams that participated in PMAQ from the outset. Bonus municipalities were associated with a 4.6 (95% CI: 2.7 to 6.4; p < 0.001) percentage point increase in the PMAQ score compared with nonbonus municipalities. The association with quality of care increased with the size of bonus: the largest bonus group saw an improvement of 8.2 percentage points (95% CI: 6.2 to 10.2; p < 0.001) compared with the control. The subgroup analysis showed that the observed improvement in performance was most pronounced in the poorest two-fifths of localities. The limitations of the study include the potential for bias from unmeasured time-varying confounding and the fact that the PMAQ score has not been validated as a measure of quality of care.

CONCLUSIONS

Performance bonuses to family health team workers compared with traditional input-based budgets were associated with an improvement in the quality of care.

Epidemiologic Profile of Severe Acute Respiratory Infection in Brazil During the COVID-19 Pandemic: An Epidemiological Study

Background

The COVID-19 is a significant public health issue, and monitoring confirmed cases and deaths is an essential epidemiologic tool. We evaluated the features in Brazilian hospitalized patients due to severe acute respiratory infection (SARI) during the COVID-19 pandemic in Brazil. We grouped the patients into the following categories: Influenza virus infection (G1), other respiratory viruses' infection (G2), other known etiologic agents (G3), SARS-CoV-2 infection (patients with COVID-19, G4), and undefined etiological agent (G5).

Methods

We performed an epidemiological study using data from DataSUS (https://opendatasus.saude.gov.br/) from December 2019 to October 2021. The dataset included Brazilian hospitalized patients due to SARI. We considered the clinical evolution of the patients with SARI during the COVID-19 pandemic according to the SARI patient groups as the outcome. We performed the multivariate statistical analysis using logistic regression, and we adopted an Alpha error of 0.05.

Results

A total of 2,740,272 patients were hospitalized due to SARI in Brazil, being the São Paulo state responsible for most of the cases [802,367 (29.3%)]. Most of the patients were male (1,495,416; 54.6%), aged between 25 and 60 years (1,269,398; 46.3%), and were White (1,105,123; 49.8%). A total of 1,577,279 (68.3%) patients recovered from SARI, whereas 701,607 (30.4%) died due to SARI, and 30,551 (1.3%) did not have their deaths related to SARI. A major part of the patients was grouped in G4 (1,817,098; 66.3%) and G5 (896,207; 32.7%). The other groups account for &lt;1% of our sample [G1: 3,474 (0.1%), G2: 16,627 (0.6%), and G3: 6,866 (0.3%)]. The deaths related to SARI were more frequent in G4 (574,887; 34.7%); however, the deaths not related to SARI were more frequent among the patients categorized into the G3 (1,339; 21.3%) and G5 (25,829; 4.1%). In the multivariate analysis, the main predictors to classify the patients in the G5 when compared with G4 or G1-G4 were female sex, younger age, Black race, low educational level, rural place of residence, and the use of antiviral to treat the clinical signs. Furthermore, several features predict the risk of death by SARI, such as older age, race (Black, Indigenous, and multiracial background), low educational level, residence in a flu outbreak region, need for intensive care unit, and need for mechanical ventilatory support.

Conclusions

The possible COVID-19 underreporting (G5) might be associated with an enhanced mortality rate, more evident in distinct social groups. In addition, the patients' features are unequal between the patients' groups and can be used to determine the risk of possible COVID-19 underreporting in our population. Patients with a higher risk of death had a different epidemiological profile when compared with patients who recovered from SARI, like older age, Black, Indigenous, and multiracial background races, low educational level, residence in a flu outbreak region, need for intensive care unit and need for mechanical ventilatory support.

[Prevalence rates and inequalities in access to medicines by users of the Brazilian Unified National Health System in 2013 and 2019]

The study aimed to analyze and compare the prevalence of access to medicines and associated factors among users of the Brazilian Unified National Health System (SUS). The authors analyzed data from the 2013 and 2019 editions of the Brazilian National Health Survey, a nationwide health study, representative of the Brazilian population. The outcomes were: (1) obtaining from the SUS all the medicines prescribed during care received in the SUS itself in the two weeks prior to the interview (2) and obtaining all the medicines, regardless of the source. Demographic and socioeconomic characteristics were included as independent variables. In 2019, 29.7% of the interviewees obtained all the prescribed medicines from the SUS, 81.8% obtained all the medicines in general (considering all sources), and 56.4% paid some amount for the medicines. The proportion who did obtain any medicine from the SUS and that made some out-of-pocket payment increased from 2013 to 2019. The likelihood of obtaining all the medicines in the SUS was higher among the poorest, and that of obtaining the medicines regardless of source was higher among the wealthiest. Approximately two out of three persons that were unable to access all the medicines reported difficulties obtaining them in services funded by the public sector. There was an increase in out-of-pocket expenditure on medicines in Brazil and a reduction in access through the SUS, among users of the system.

Mortality from chronic respiratory disease in Brazil: time trend and forecasts

OBJECTIVE

To analyze the time trend of monthly mortality rates from chronic respiratory diseases in Brazil from 1996 to 2017, with forecasts for 2022, besides analyzing the possibility of achieving the goal of the Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas Não Transmissíveis no Brasil (Strategic Action Plan to Tackle Chronic Noncommunicable Diseases in Brazil) from 2011 to 2022.

METHODS

This is an ecological study that uses data from Sistema de Informações sobre Mortalidade (SIM - Mortality Information System), Sistema de Informações Demográficas e Socioeconômicas (Demographic and Socioeconomic Information System) and Pesquisa Nacional por Amostra de Domicílios Contínua (PNAD Contínua - Continuous National Household Sample Survey). We established the age range between 30 and 69 years old and the evolution of the rates over time was made by autoregressive integrated moving average models in R statistical tool.

RESULTS

Premature mortality rates from chronic respiratory diseases are decreasing in Brazil as a whole, mostly in state capitals. There is also a trend to reach the Ministry of Health's goal in most of the country. For capitals that tend not to reach the goal, there is an association between mortality and social indicators, healthcare network and frequency of smoking.

CONCLUSION

This study intends to improve planning of the public health system for the control of chronic respiratory diseases.

Inequalities in health care and access to health services among adults with self-reported arterial hypertension: Brazilian National Health Survey

This study compared indicators of care and access to health services by adults who self-reported hypertension in 2013 and 2019, analyzing those indicators according to gender, age group, schooling level, and race/color. This is an analytic study with data from the Brazilian National Health Survey (PNS), conducted in 2013 and 2019 in Brazil. The indicators to care and access to health services by individuals with arterial hypertension in both surveys were compared. For 2019, those indicators were analyzed according to sociodemographic characteristics. This study estimated the proportions, prevalence ratio (PR), and their respective 95% confidence intervals (95%CI). In total, 60,202 individuals were evaluated in 2013 and 88,531 in 2019, of these 24.4% reported arterial hypertension in 2013 and 23.9% in 2019. Women received more medical care for hypertension within the last year (PR = 1.07; 95%CI: 1.04; 1.11), had the last physician appointment at an basic health unit (PR = 1.11; 95%CI: 1.05; 1.17) than men. About race/color, black people had more hospitalization for hypertension or some complication (PR = 1.2; 95%CI: 1.05; 1.38) and intense or very intense degree of limitation in performing daily activities (PR = 1.37; 95%CI: 1.06; 1.76). In 2019, inequalities were evidenced and worse indicators were observed for males, black, with low education and young age. Therefore, investments in the Brazilian Unified National Health System, as well as public policies and strategic actions are essential to reduce inequalities, promote health care.

Undernutrition and short duration of breastfeeding association with child development: a population-based study

OBJECTIVE

To explore the relationship of undernutrition and the short duration of breastfeeding with child development of children 0-66 months of age residing in Ceará, Brazil.

METHODS

The authors of the present study utilized population-based data from children enrolled in the Study on Maternal and Child Health in Ceará, Brazil (PESMIC). Children's development was assessed with the Ages and Stages Questionnaire third version, validated in Brazil. Undernutrition was accessed through anthropometric measures obtained by trained staff. Breastfeeding information was obtained through the mothers' report and confirmed in the child's governmental booklet. The authors used logistic regressions adjusted for sample clusters used in PESMIC design in a theoretical model for known determinants of child development following the World Health Organization nurturing framework.

RESULTS

A total of 3,566 children were enrolled in the sixth PESMIC study and had their development assessed. The authors found that 8.2%, 3.0%, 2.1%, and 3.6% of children were stunted, underweight, or wasted, at the time of the interview, respectively. All studied factors were associated with a higher prevalence of child development impairment in at least one of the assessed domains. Underweight was the factor with the strongest effect, with an adjusted odds ratio (AOR) of 4,14 (2,26-7,58), p < 0.001. Breastfeeding for up to two months compared to more than six months (AOR 2,08 (1,38-3,12)) was also associated.

CONCLUSIONS

The authors found that undernutrition and short duration of breastfeeding are associated with development outcomes among Brazilian children. As a result, integrated nutritional programs may improve child development outcomes.

COVID-19 and outpatient care: a nationwide household survey

We aimed to assess the proportion of the population in 133 Brazilian municipalities who - from March to August 2020 - had a health problem but failed to seek care or failed to attend to a health service for routine appointment or examination. We conducted a household survey from August 24-27 in 133 Brazilian cities by asking the subjects if, since the beginning of the COVID-19 pandemic in March 2020, they had suffered from a health problem but did not seek care or failed to attend to a routine or screening examination. Poisson regression was used for the analyses. We interviewed 33,250 subjects and 11.8% (95%CI: 11.4-12.1) reported that, since March 2020, they failed to seek care despite being ill, 17.3% (95%CI: 16.9-17.7) failed to attend to a routine or screening examination and 23.9% (95%CI: 23.4-24.4) reported one or both outcomes. Health service closure and fear of the COVID-19 infection were the main reasons for not seeking care. Women and the poorest were more likely to not look for a health service, despite having a health problem or a scheduled routine appointment. On the other hand, those subjects who self-identified as white were less likely to not look for a health service. The COVID-19 pandemic is more critical for the indigenous people and the poorest, and these people are also more likely to not seek care for other health conditions during the pandemic.

Neonatal visits in the first week of life in primary care: low prevalence and related factors

OBJECTIVES

to identify the prevalence of and factors related to access to neonatal consultation in the first week of life, in Brazil.

METHODS

a secondary data analysis from a national cross-sectional survey involving 14,133 mothers from primary care services. Pearson chi-square was used to analyze the prevalence of access to appointment and Poisson regression to analyze related factors, considering prevalence ratio (PR) and confidence intervals (95%CI).

RESULTS

the prevalence of healthcare visits was 63.0% in Brazil. Children of mothers, aged 30-39 years (PR=1.065; CI=1.029-1.103), and of single mothers (PR=1.021; CI=1.00-1.042) had higher prevalence of access. Children from the northern region of Brazil had a lower prevalence of healthcare visits compared to children from other regions.

CONCLUSIONS

low prevalence of access to neonatal visits was identified in the first week of life in primary care services; the region of residence, maternal age, and marital status were identified among the related factors.

Health services utilization in the Brazilian Amazon: panel of two cross-sectional studies

OBJECTIVE

To investigate the use of health services among adults living in Manaus, Amazonas.

METHODS

This was a panel of two cross-sectional studies conducted in Manaus in 2015 and 2019. Individuals aged ≥ 18 years were selected by probabilistic sampling and interviewed at home. The study outcomes were doctor visits and hospitalizations in the previous 12 months, and unmet surgical needs. Variations between 2015 and 2019 were tested using chi-squared goodness-of-fit test. Poisson regression with robust variance was employed to calculate the prevalence ratios (PR) of the outcomes with 95% confidence intervals (95%CI).

RESULTS

The surveys included 5,800 participants in total. Visits to the doctor decreased from 2015 (78.7%) to 2019 (76.3%; p < 0.001), hospital admissions increased from 2015 (7.9%) to 2019 (11.5%; p < 0.001), and unmet surgical needs decreased in the period (15.9% to 12.1%; p < 0.001). These variations were particularly observed in vulnerable individuals – sicker; poorer; non-whites; and those belonging to lower social classes, with less access to education, formal jobs, and health insurance (p < 0.05). Doctor visits were higher in people with fair health status (PR = 1.09; 95%CI 1.06–1.12), health insurance (PR = 1.13; 95%CI 1.09–1.17), and chronic diseases (p < 0.001) but lower in men (PR = 0.87; 95%CI 0.84–0.90) and informal workers (PR = 0.89; 95%CI 0.84–0.94). Hospitalizations were higher in people with worse health statuses (p < 0.001), without partners (PR = 1.27; 95%CI 1.05–1.53), and with multimorbidity (PR = 1.68; 95%CI 1.33–2.12) but lower in men (PR = 0.55; 95%CI 0.44–0.68), older adults (p < 0.001), informal workers (PR = 0.67; 95%CI 0.51–0.89), and unemployed (PR = 0.72; 95%CI 0.53–0.97). Unmet surgical needs were higher in older adults (p < 0.001), middle-class people (PR = 1.24; 95%CI 1.01–1.55), worse health statuses (p < 0.001), and chronic diseases (p < 0.001) but lower in men (PR = 0.76; 95%CI 0.65–0.86).

CONCLUSIONS

From 2015 to 2019, less people visited the doctor, more were admitted to hospitals, and less were in need of surgery or aware of that need, potentially indicating poorer access to health services.

Multilevel Analysis of Individual and Neighborhood Characteristics Associated with Viral Suppression Among Adults with HIV in Rio de Janeiro, Brazil

Understanding the impact of neighborhood context on viral suppression outcomes may help explain health disparities and identify future interventions. We assessed the relationship between individual characteristics, neighborhood socioeconomic context, and viral suppression using multilevel logistic regression models. Adults with HIV initiating antiretroviral therapy (ART) between 2000 and 2017, who resided in Rio de Janeiro and had an HIV-1 RNA level (viral load) measured 90-270 days after ART initiation were included. Overall, 83.9% achieved viral suppression. Participants who were older, had a higher level of education, and identified as heterosexual cisgender men and cisgender men-who-have-sex-with-men had increased odds of viral suppression. Later calendar year of ART initiation carried the strongest association with viral suppression, reflecting the increased effectiveness and tolerability of ART over time. Neighborhood socioeconomic indicators did not predict viral suppression in unadjusted or adjusted analyses, which may result from the integrated care provided in our health care facility together with Brazil's universal treatment.

Dual Use of Public and Private Health Care Services in Brazil

(1) Background: Brazil has a universal public healthcare system, but individuals can still opt to buy private health insurance and/or pay out-of-pocket for healthcare. Past research suggests that Brazilians make combined use of public and private services, possibly causing double costs. This study aims to describe this dual use and assess its relationship with socioeconomic status (SES). (2) Methods: We calculated survey-weighted population estimates and descriptive statistics, and built a survey-weighted logistic regression model to explore the effect of SES on dual use of healthcare, including demographic characteristics and other variables related to healthcare need and use as additional explanatory variables using data from the 2019 Brazilian National Health Survey. (3) Results: An estimated 39,039,016 (n = 46,914; 18.6%) persons sought care in the two weeks before the survey, of which 5,576,216 were dual users (n = 6484; 14.7%). Dual use happened both in the direction of public to private (n = 4628; 67.3%), and of private to public (n = 1855; 32.7%). Higher income had a significant effect on dual use (p < 0.0001), suggesting a dose–response relationship, even after controlling for confounders. Significant effects were also found for region (p < 0.0001) and usual source of care (USC) (p < 0.0001). (4) Conclusion: A large number of Brazilians are seeking care from a source different than their regular system. Higher SES, region, and USC are associated factors, possibly leading to more health inequity. Due to its high prevalence and important implications, more research is warranted to illuminate the main causes of dual use.

Associação entre letramento em saúde, ameaça pela COVID-19 e intenção vacinal de adolescentes brasileiros

Resumo Objetivo: investigar a influência do letramento em saúde na avaliação da ameaça à saúde pela COVID-19 e sobre a intenção de não se vacinar de adolescentes brasileiros. Método: estudo transversal com 526 adolescentes brasileiros de 14 a 19 anos. Aspectos socioeconômicos, perfil saúde-doença, letramento em saúde, ameaça à saúde pela COVID-19 e intenção de não se vacinar foram analisados por associação bivariada e regressão linear múltipla com resposta Poisson. Resultados: maior pontuação de letramento em saúde (p=0,010), doença cardíaca (p=0,006), menor renda (p=0,000) e morar na região norte (p=0,007) foram fatores que contribuíram para o sentimento de maior ameaça pela COVID-19. O letramento em saúde não influenciou a intenção de não se vacinar (p=0,091), cuja prevalência foi menor entre os adolescentes do Sudeste quando comparados aos do Norte (p=0,010), entre os que cursavam o ensino superior (p=0,049) e entre aqueles com maior renda (p=0,000). Conclusão: letramento em saúde influenciou a percepção da ameaça da doença, mas não a intenção de não se vacinar. Avaliação da ameaça à saúde pela COVID-19 e a prevalência da intenção de não se vacinar foram influenciadas pela região de residência, renda e escolaridade, o que reforça a importância dos determinantes sociais da saúde nesse contexto.

Relación entre alfabetización en salud, amenaza por COVID-19 e intención de vacunación entre los adolescentes brasileños

Resumen Objetivo: investigar la influencia de la alfabetización en salud sobre la evaluación de la amenaza por COVID-19 y sobre la intención de los adolescentes brasileños de no vacunarse. Método: estudio transversal con 526 adolescentes brasileños entre 14 y 19 años. Se analizaron aspectos socioeconómicos, perfil epidemiológico, alfabetización en salud, amenaza a la salud por COVID-19 y la intención de no vacunarse mediante una relación bivariada y regresión lineal múltiple de respuesta de Poisson. Resultados: una elevada puntuación de alfabetización en salud (p=0,010), enfermedades cardiovasculares (p=0,006), menor nivel de renta (p=0,000) y vivir en la región norte (p=0,007) fueron factores que ayudaron a la sensación de mayor amenaza por COVID-19. La alfabetización en salud no influyó en la intención de no vacunarse (p=0,091), cuya prevalencia fue más baja entre los adolescentes del Sudeste en comparación con los del Norte (p=0,010), entre los que cursaban estudios superiores (p=0,049) y mayor nivel de renta (p=0,000). Conclusión: la alfabetización en salud influyó sobre la percepción de la amenaza de la enfermedad pero no en la intención de no vacunarse. La evaluación de la amenaza a la salud por COVID-19 y la prevalencia de la intención de no vacunarse fueron condicionadas por la región de residencia, nivel de renta y educación, acentuando la importancia de los determinantes sociales de la salud en este contexto.

Situação programática na perspectiva da vulnerabilidade em saúde: validação de banco de itens

RESUMO Objetivo Validar banco de itens para avaliação da situação programática na perspectiva da vulnerabilidade em saúde. Método Estudo de validação realizado em 2021. Construíram-se duas scoping reviews para identificar definições operacionais e, após, realizaram-se reuniões com os autores para formular itens. Em seguimento, enviaram-se os itens via Google Forms para especialistas com expertise na área de vulnerabilidade em saúde ou construção e validação de instrumentos. Para validar os itens, utilizou-se coeficiente de validade de conteúdo, teste binomial, além do coeficiente de correlação intraclasse para verificar confiabilidade, todos via SPSS® versão 25. Resultados Sete especialistas retornaram com avaliações dos itens nos critérios clareza da linguagem, pertinência prática e relevância teórica. Dos 88 itens organizados nos subconceitos infraestrutura e processo de trabalho, a maior parte foi modificada por sugestão dos especialistas e teve coeficiente de validade de conteúdo maior que 0,80. O coeficiente de correlação intraclasse foi 0,80 para clareza, 0,94 para pertinência e 0,92 para relevância (p < 0,05). Dois itens foram excluídos após reunião dos autores para consenso sobre os itens do banco final e dez foram mesclados. Conclusão e implicação para prática: O banco de itens foi validado internamente e houve boa confiabilidade entre os juízes, possibilitando o uso por profissionais da saúde para investigar a vulnerabilidade.

Fatores associados ao desenvolvimento infantil em crianças brasileiras: linha de base da avaliação do impacto do Programa Criança Feliz

Resumo: O objetivo deste artigo foi avaliar os fatores socioeconômicos, familiares e individuais associados ao desenvolvimento infantil no primeiro ano de vida, entre famílias em vulnerabilidade social. Trata-se de uma análise transversal, com dados da linha de base de um ensaio randomizado. O estudo incluiu 3.242 crianças < 12 meses de idade, residentes em 30 municípios de cinco regiões do Brasil. A escolha de estados e municípios foi intencional, tendo como base a implementação do Programa Criança Feliz. A amostra foi selecionada a partir de crianças elegíveis para o Programa Criança Feliz, cujo objetivo é promover a estimulação e o desenvolvimento infantil. O Ages and Stages Questionnaire (ASQ) foi utilizado para avaliação do desenvolvimento infantil. Um modelo de análise multinível em três níveis (estado, município e indivíduos), usando teste de Wald para heterogeneidade e tendência linear, estimou a média do ASQ-3 e intervalo de 95% de confiança (IC95%). Análises foram ajustadas para potenciais confundidores. Foram analisadas informações de 3.061 (94,4%) crianças com dados disponíveis para ASQ-3. Escores de desenvolvimento infantil (total e em todos os domínios) foram cerca de 12% menores em crianças nascidas pré-termo e com restrição do crescimento intrauterino (pequenas para idade gestacional). Observou-se menores escores em filhos de mães com baixa escolaridade, com sintomas de depressão, com duas ou mais crianças menores de sete anos residindo no domicílio e que não relataram autopercepção de apoio/ajuda durante a gestação. Conclui-se que características potencialmente modificáveis (escolaridade, depressão materna e prematuridade/restrição do crescimento intrauterino) apresentaram maior impacto na redução do escore de desenvolvimento em todos os domínios avaliados.

Programmatic situation from the perspective of health vulnerability: Item database validation

ABSTRACT Objective To validate an item database to assess the programmatic situation of health vulnerability. Method A validation study carried out in 2021. Two scoping reviews were elaborated to identify operational definitions and, afterwards, meetings were held with the authors to formulate items. As a follow-up, the items were sent via Google Forms to specialists with expertise in the areas of health vulnerability or construction and validation of instruments. To validate the items, we used the content validity coefficient and binomial test, in addition to the intraclass correlation coefficient to verify reliability, all via SPSS® version 25. Results Seven experts answered with item evaluations in the language clarity, practical relevance and theoretical relevance criteria. Of the 88 items organized in the infrastructure and work process sub-concepts, most were modified following the experts' suggestions and had content validity coefficients greater than 0.80. The intraclass correlation coefficient was 0.80 for clarity, 0.94 for relevance, and 0.92 for relevance (p < 0.05). Two items were excluded after the authors' meeting for consensus on the final item database and ten were merged. Conclusion and implications for the practice The items were internally validated and there was good reliability among the judges, enabling their use by health professionals to investigate vulnerability.

Association of health literacy, COVID-19 threat, and vaccination intention among Brazilian adolescents

Objective:

investigate the influence of health literacy on the assessment of COVID-19 threat to health and the intention not to be vaccinated among Brazilian adolescents.

Method:

cross-sectional study with 526 Brazilian adolescents aged 14 to 19 years. Socioeconomic aspects, health-disease profile, health literacy, health threat by COVID-19 and intention not to be vaccinated were analyzed by bivariate association and multiple linear regression with Poisson response.

Results:

higher health literacy score (p=0.010), cardiovascular disease (p=0.006), lower income (p=0.000), and living in the North region (p=0.007) were factors that contributed to feeling more threatened by COVID-19. Health literacy did not influence the intention not to be vaccinated (p=0.091), whose prevalence was lower among adolescents in the Southeast region when compared to those in the North region (p=0.010), among those who attended higher education (p=0,049) and those with higher income (p=0.000).

Conclusion:

health literacy influenced the perception of COVID-19 threat, but not the intention not to be vaccinated. Assessment of COVID-19 threat to health and prevalence of the intention not to be vaccinated were influenced by the region of residence, income, and education, which reinforces the importance of social determinants of health in this context.

[What do the national data say about the supply and performance of legal abortions in Brazil in 2019?]

Abortion is supplied by the Brazilian Unified National Health System (SUS) in cases allowed under the prevailing legislation. The current study seeks to map and characterize the supply and performance of this procedure in Brazil in 2019. Data included the Referral Services for Termination of Pregnancy Authorized by Law (SRIGCPL) recorded in the National Registry of Healthcare Establishments (SCNES) and the establishments with records of abortion for medical and legal reasons in the Outpatient Information System and Hospital Information System. Establishments were characterized by type and subtype, legal status, and contractual agreements, and georeferenced according to data from the SCNES. Next, municipalities were classified as those with and without supply of the procedure in 2019 and were presented by categories of Municipal Human Development Index (HDI-M) and population size. The data were used to calculate the rates of legally authorized abortions performed in the two groups of municipalities. In all, 290 establishments supplied the service, of which 101 SRIGCPL and 251 establishments with records of the procedure. The establishments were situated in 3.6% (200) of Brazil's municipalities. The supply was mostly in hospitals (98.6%), under the public administration (62.1%), in contractual agreements with the SUS (99.7%), in municipalities in the Southeast of Brazil (40.5%), with more than 100,000 inhabitants (59.5%), and with high or very high HDI-M (77.5%). The rate of legally authorized abortions in childbearing-age residents of municipalities without supply of the service was 4.8 times lower than in municipalities with the service. The supply of legally authorized abortions in Brazil is distributed unequally across the territory, with possible negative implications for access to the service.

Analysis of demand and access to services in the last two weeks previous to the National Health Survey 2013 and 2019

OBJECTIVE

Compare the demand and use of health services between 2013 and 2019, and analyze the associated sociodemographic and health variables in 2019.

METHODS

Cross-sectional study with data from the National Health Survey (PNS) 2013 and 2019. The prevalence and 95% confidence intervals (95% CI) for the demand and use of health services were estimated. In 2019, the differences in the indicators were analyzed according to sociodemographic variables and the crude and adjusted by sex and age prevalence ratios (RP) were estimated.

RESULTS

There was an increase of 22% in the demand for health care in the last two weeks, going from 15.3% (95%CI 15.0-15.7) in 2013 to 18.6% (95%CI 18.3-19.0) in 2019. There was a reduction in use in the last two weeks, from 97% (95%CI 96.6-97.4) in 2013 to 86.1% (95%CI 85.4-86.8) in 2019, which was observed for most Federation Units. In 2019, the demand for care was greater among women, the elderly, those with high schooling, individuals with health insurance and poor self-rated health. They obtained greater access to health services in the fifteen days prior to the survey: men, children or adolescents up to 17 years of age, people with health insurance and poor health self-assessment.

CONCLUSION

The demand for health services has grown and reduced access in the last 15 days between 2013 and 2019. These differences may have been exacerbated by the austerity measures implemented in the country.

Factors associated with cardiovascular disease in the Brazilian adult population: National Health Survey, 2019

OBJECTIVE

to estimate the prevalence and investigate the sociodemographic, health, and lifestyle factors associated with the self-reported diagnosis of Cardiovascular Disease (CVD) in the adult Brazilian population.

METHODS

Data from the National Health Survey (PNS 2019) were analyzed. The presence of CVD was self-reported through the question: "Has any doctor ever given you a diagnosis of heart disease?". Sociodemographic factors, health conditions, and lifestyle were evaluated. For data analysis, Poisson Regression with robust variance was used.

RESULTS

5.3% (95%CI 5.04-5.57) of Brazilian adults reported CVD, of which, 29.08% (95%CI 27.04-31.21) underwent coronary artery bypass surgery or angioplasty and 8.26% (95%CI 7.09-9.6) reported severe limitation in usual activities due to CVD. The factors associated with CVD were advanced age; being male; white race/color; complete middle school and incomplete high school education; have health insurance; self-assessing health as regular or bad/very bad; self-reported hypertension, high cholesterol, and diabetes; being a former smoker; consuming fruits and vegetables as recommended; not consuming alcohol in excess; and not practicing leisure-time physical activity.

CONCLUSIONS

CVD is associated with sociodemographic, health, and lifestyle factors. It is important to support public policies, programs, and goals for the reduction of cardiovascular diseases in Brazil, especially in the most vulnerable groups.

Inequalities in the use of health services by adults and elderly people with and without noncommunicable diseases in Brazil, 2019 National Health Survey

OBJECTIVE

The objective of this study was to investigate the use of health services and limitations in performing usual activities by adults and elderly people with and without noncommunicable chronic diseases (NCDs), according to sociodemographic strata.

METHODS

This is a cross-sectional study in which data from the 2019 National Health Survey were analyzed. The final sample corresponded to 88,531 households with interviews carried out, referring to individuals aged 18 years and above. The prevalence of use of services by the population with NCDs was compared with that of the population without NCDs and stratified by socioeconomic and demographic variables. Prevalence ratios (PRs) and 95% confidence intervals (95%CI) were calculated.

RESULTS

In 2019, 47.6% (95%CI 47.0-48.3) of the population reported having one or more NCDs. Population with NCDs had more medical consultations in the last 12 months (adjusted PR [APR]=1.21; 95%CI 1.20-1.23), used more health services in the last 2 weeks (APR=2.01; 95%CI 1.91-2.11), were referred to more hospitalization (APR=2.11; 95%CI 1.89-2.36), and had more limitations in performing usual activities (APR=2.52; 95%CI 2.30-2.76), compared with the population without NCDs. A positive dose-response gradient was observed between the number of comorbidities and the use of services. In all socioeconomic and demographic strata, the prevalence of indicators was higher in people with NCDs.

CONCLUSION

The presence of NCDs was associated with a higher frequency of use of health services (i.e., consultation, use of services, and hospitalization) and the restriction of usual activities in all socioeconomic and demographic strata.

The Influence of Dentists' Profile and Health Work Management in the Performance of Brazilian Dental Teams

To evaluate the association between dentists' profile and health work management with the performance of primary care dental teams in the Brazilian National Health System, both nationally and regionally. Secondary data analysis from a Brazilian National Programme that evaluated 18,114 Brazilian dental teams, working in the public sector, between 2013 and 2014. Twenty-four independent variables taken from dentists' profile and dental team management characteristics were analysed to assess their influence on reported “dental team performance.” An estimated score was generated from their performance on 20 dental procedures by an item response theory model. Multiple linear regression models were performed for each Brazilian geographical region, separately and for the whole of Brazil. p values ≤ 0.05 were considered significant. Two variables related to dentists' profile, “having graduate studies” (β = 0.151) and “undertaking continuing professional development training” (β = 0.101), were associated with enhanced dental team performance in all five Brazilian geographical regions and nationally. The dental team management variables of “having a flexible dental appointment list” (β = 0.218) and “monitoring oral health indicators” (β = 0.132) also contributed to improve team performance in each of the regions and nationally. Dentists' profile influenced the performance of dental teams from south region more than the other regions. The findings suggest that continuing professional development, including postgraduate education, and strategic management characteristics are important for primary dental care performance and should be reflected in health policy initiatives in support of quality care. Regional factors could be considered for health care management.

Traumatic brain injury hospital incidence in Brazil: an analysis of the past 10 years

Objetivo

Caracterizar os aspectos demográficos e sociais e o ônus econômico do traumatismo craniencefálico no sistema público de saúde brasileiro na última década.

Métodos

Analisaram-se os dados provenientes da base de dados do Departamento de Informática do Sistema Único de Saúde referentes ao período entre janeiro de 2008 e dezembro de 2019.

Resultados

Entre 2008 e 2019 ocorreram, em média, no Brasil, 131.014,83 internações por traumatismo craniencefálico ao ano, com incidência de 65,54 por 100 mil habitantes. Deve-se salientar a elevada incidência de traumatismo craniencefálico em adultos idosos (acima de 70 anos), acompanhada de altas taxas de mortalidade. Além disso, há também elevada incidência de traumatismo craniencefálico em adultos jovens (20 a 29 anos e 30 a 39 anos). Os dados aqui apresentados demonstram uma proporção de traumatismos craniencefálicos de 3,6 homens/mulheres.

Conclusão

Embora se acredite que os dados apresentados subestimem a incidência e mortalidade associadas com o traumatismo craniencefálico no Brasil, este estudo pode ajudar na implantação de futuras estratégias de promoção da saúde para a população brasileira e mundial, com o objetivo de diminuir a incidência, a mortalidade e os custos do traumatismo craniencefálico.

HDI, Technological and Human Resources in the Diagnosis and Treatment of Malformations of the Circulatory System in Brazil

BACKGROUND

In 2015, the number of infants with congenital malformations (CMs) per 100 000 live births (LBs) was 2368 (7.6%) worldwide, of whom 10.6% died in the first year of life, 43% due to malformations of the circulatory system (MCSs), a scenario similar to what occurs in Brazil.

OBJECTIVE

To assess, per Brazilian macroregion, whether diagnosis of MCS at birth and death due to MCS in the first year of life associate with human development index (HDI) and with technological and human resources.

METHODS

Ecological study including data available in 2000-2015. Data of LBs, deaths and availability of echocardiography devices were obtained from the DATASUS website. The HDI was obtained from the Atlas of Human Development in Brazil, while other variables were obtained from medical demographic data. Correlation measures between the variables were performed using the Kendall index.

RESULTS

The CM rate was 660.8/100 000 LBs, of which 18 444 were due to MCS (diagnosis rate, 38.55/100 000 LBs). Of all Brazilian macroregions, the Southern and Southeastern regions, with the highest HDI values and resources, had the highest MCS diagnosis rates (56.94/100 000 and 62.83/100 000 LBs, respectively). The Northern and Northeastern regions, with the lowest HDI values and resources, had the lowest MCS diagnosis rates (9.77/100 000 and 13.43/100 000 LBs, respectively). The MCS diagnosis rate was 6.4-fold higher in the Southeastern region as compared to the Northern region, but mortality rates were similar in both regions.

CONCLUSION

Of the CMs, the MCS accounted for the highest number of deaths in children under the age of 1 year in Brazil.

Integrated Care in the Community: The Case of the Programa Maior Cuidado (Older Adult Care Programme) in Belo Horizonte-Minas Gerais, BRA

Internationally, there is a large body of scientific evidence concerning the benefits of integrating health and social care to ensure that frail older people living in the community receive the assistance they need to maintain independence. In the Brazilian city of Belo Horizonte, located in the state of Minas Gerais, an integrated care intervention has been developed: the Programa Maior Cuidado – Older Adult Care Programme (PMC). This programme represents a pioneering example in Brazil of the provision of carers for highly vulnerable older people, through integrated action between public health and social service agencies. This paper draws on the first phase of a mixed method evaluation of PMC, including data from documentary sources, focus groups, empirical observation and expert workshops, to examine the processes that led to the establishment of programme. The origins of the PMC are discussed and its operational processes, with a particular emphasis on integrated activities and the roles of different actors. The paper situates PMC within comparable international experiences of integrated provision for older people and considers how it has been affected by unique context and challenging of a middle-income country.

Direct cost of systemic arterial hypertension and its complications in the circulatory system from the perspective of the Brazilian public health system in 2019

INTRODUCTION

Systemic arterial hypertension (SAH), a global public health problem and the primary risk factor for cardiovascular diseases, has a significant financial impact on health systems. In Brazil, the prevalence of SAH is 23.7%, which caused 203,000 deaths and 3.9 million DALYs in 2015.

OBJECTIVE

To estimate the cost of SAH and circulatory system diseases attributable to SAH from the perspective of the Brazilian public health system in 2019.

METHODS

A prevalence-based cost-of-illness was conducted using a top-down approach. The population attributable risk (PAR) was used to estimate the proportion of circulatory system diseases attributable to SAH. The direct medical costs were obtained from official Ministry of Health of Brazil records and literature parameters, including the three levels of care (primary, secondary, and tertiary). Deterministic univariate analyses were also conducted.

RESULTS

The total cost of SAH and the proportion of circulatory system diseases attributable to SAH was Int$ 581,135,374.73, varying between Int$ 501,553,022.21 and Int$ 776,183,338.06. In terms only of SAH costs at all healthcare levels (Int$ 493,776,445.89), 97.3% were incurred in primary care, especially for antihypertensive drugs provided free of charge by the Brazilian public health system (Int$ 363,888,540.14). Stroke accounted for the highest cost attributable to SAH and the third highest PAR, representing 47% of the total cost of circulatory diseases attributable to SAH. Prevalence was the parameter that most affected sensitivity analyses, accounting for 36% of all the cost variation.

CONCLUSION

Our results show that the main Brazilian strategy to combat SAH was implemented in primary care, namely access to free antihypertensive drugs and multiprofessional teams, acting jointly to promote care and prevent and control SAH.

Nonadherence to immunosuppressives and treatment in kidney transplant: ADHERE BRAZIL Study

OBJECTIVE

To estimate the prevalence and variability of nonadherence to immunosuppressives and nonpharmacological treatment across kidney transplantation centers and two health access-disparate regions in Brazil.

METHODS

In a cross-sectional design, a random multistage sample of 1,105 patients was included, based on center transplantation activity (low/moderate/high) and region (R1: North/Northeast/Mid-West; and R2: South/Southeast). Nonadherence to immunosuppressives (implementation phase) was assessed using the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS)^©. Self-report questionnaires assessed nonadherence to physical activity, smoking cessation, alcohol intake, and appointment keeping. We compared regions using the adjusted-χ² or t-test.

RESULTS

Most patients were men (58.5%), white (51.4%), and had a mean age of 47.5 (SD = 12.6) years. Regarding kidney transplantation centers, 75.9% were from R2 and 38.2% had low activity. The patients in R2 were older, white-majority, had more frequently steady partners, and received peritoneal dialysis. Nonadherence to immunosuppressives ranged from 11–65.2%; 44.5–90% to physical activity; 0–23.7% to appointment keeping; and 0–14% to smoking cessation. The total prevalence of nonadherence and by region (R1 versus R2) were: for immunosuppressives, 39.7% (44.9% versus 38.1%, p = 0.18); for smoking, 3.9% (1% versus 5%, p < 0.001); for physical activity, 69.1% (71% versus 69%, p = 0.48); for appointment keeping, 13% (12.7% versus 12%, p = 0.77); and for alcohol consumption, 0%.

CONCLUSION

Despite differences among centers and high variability, only the nonadherence to smoking cessation was higher in the region with greater access to kidney transplantation. We suppose that differences in healthcare access may have been overcome by other positive aspects of the post kidney transplantation treatment.

Genetic polymorphisms are associated with alterations in anxiety levels and vital signs in patients undergoing third molar extractions

OBJECTIVE

The objective of this study was to evaluate the association between SLC6A4 (rs1042173 and rs3813034), DRD2 (rs6275 and rs6276), ANKK1 (rs1800497), and COMT (rs174675) genetic polymorphisms and alterations in anxiety levels and vital signs in individuals undergoing third molar extractions.

STUDY DESIGN

One hundred sixty-eight individuals were evaluated at the pre-, trans-, and postoperative periods by checking systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate, and body temperature. Anxiety levels were assessed using the State-Trait Anxiety Inventory (STAI). Buccal mucosa cells were collected for genetic evaluation using real-time polymerase chain reaction. Statistical analysis was performed at a significance level of 5%.

RESULTS

The level of anxiety was associated with rs1800497 for STAI-Trait (P = .031) and rs174675 for STAI-State (P = .007). Considering the vital signs, there was a significant difference between the values of respiratory rate and rs1042173 (P = .029), rs3813034 (P = .024), and rs6275 (P = .025). The diastolic blood pressure values differed significantly for rs1042173 (P = .042), and the body temperature values differed significantly for rs174675 (P = .016).

CONCLUSIONS

Polymorphisms in SLC6A4, DRD2, ANKK1, and COMT genes could be associated with alterations in anxiety levels and vital signs in individuals undergoing third molar extractions.