Utilization of dental services by rural riverside populations covered by a Fluvial Family Health Team in Brazil

INTRODUCTION

Rural riverside populations of Brazil face several difficulties to access health services. The Brazilian National Primary Care Policy implemented the Fluvial Family Health Teams (FFHT), which is a specific primary care team arrangement for these territories. The aim of the study was to assess the use of dental services by adults living in rural riverside areas covered by a FFHT.

METHODS

A household-based cross-sectional survey was carried out with a rural riverside population of 38 localities on the left bank of the Rio Negro, Manaus, Amazonas, representative of the area covered by the FFHT. Stratified random sampling was calculated based on the number of adults and households in each riverside locality. An electronic questionnaire was used to obtain information on sociodemographic and oral health conditions, and the utilization of dental services. After descriptive analysis, logistic regression analyses were performed to estimate the odds ratios for the outcome 'use of dental health services over the past 12 months'.

RESULTS

A total of 492 individuals, aged 18 years or more, from 38 rural riverside areas were assessed. The mean age of participants was 43.5 years (standard deviation 17.0), ranging from 18.0 to 90.7 years. Of these participants, 3.1% had never been to a dentist and 21.9% had been to a dentist more than 3 years ago. Among those who attended the dental service, 77.4% of appointments occurred in public health services. Dental pain over the previous 6 months (odds ratio (OR)=2.44; 95% confidence interval (CI) 1.51-3.96), higher education (OR=2.62; 95%CI 1.23-5.56), most recent appointment in public health services (OR=1.86; 95%CI 1.19-2.93), edentulism (OR=0.38; 95%CI 0.17-0.85) and dissatisfaction with oral health (OR=0.59; 95%CI 0.38-0.93) were associated with the dental services utilization.

CONCLUSION

The study results revealed that approximately a quarter of the individuals did not use dental services over the previous 3 years or have never used them. Despite the increase in access provided by the FFHT, edentulous individuals, individuals dissatisfied with their oral health, and those with lower levels of education were less likely to use dental services, while individuals who experienced dental pain sought dental services more frequently. These findings suggest that the healthcare model offered to this population must be rearranged.

Prevalence of concomitant hypertension and diabetes among adults and elderly living in rural riverside areas in the Amazon

INTRODUCTION

Considering the scarcity of information on the assessment of chronic diseases in traditional Amazonian populations, as well as public health policies focused on their specificities, this study aimed to estimate the prevalence of at least one of the chronic diseases (systemic arterial hypertension (SAH) or diabetes mellitus (DM)) and their concomitant occurrence in a rural riverside population of the Amazon, and determine the associated factors.

METHODS

A household-based cross-sectional survey was conducted with a sample of adults and elderly people living in rural riverside locations along the left bank of the Negro River, in the municipality of Manaus, Amazonas, Brazil. The outcomes evaluated were the presence of at least one of the evaluated chronic diseases and the concomitant occurrence, based on the self-reported medical diagnosis of SAH and DM. Analysis of associated factors (sociodemographic, behavioral, and access to health services variables) was performed by Poisson regression with robust variance.

RESULTS

The sample consisted of 495 individuals (young adults (n=257; 51.9%), middle-aged (n=132; 26.7%), and elderly (n=106; 21.4%)), of whom 51.5% were women (n=255), mean age 43.3±17.1 years. The monthly household income was on average R$1100±902 (A$345±283). The diagnosis of any chronic disease was reported by 18.8% of the sample, with a preponderance of SAH (17.4%). The occurrence of at least one of the chronic diseases was associated with higher average age and worse health self-assessment. Regarding concomitant occurrence of SAH and DM, prevalent in 4.4% of the sample, the same associations were observed.

CONCLUSION

The data for the occurrence of chronic diseases in the studied Amazon rural riverside populations are worrying, because these people live in areas of socioeconomic vulnerability, with a lack of basic sanitation infrastructure, difficult geographic access, and limited access to health care. Health policies fail to recognize the specificities of these populations, which implies deficiencies in the provision of necessary regular care. The findings also reinforce the need to strengthen health promotion and chronic disease prevention strategies in the context of primary care.

Association of physical performance and sarcopenia with use of health services in elderly people living in rural riverside areas in the Amazon: a cross-sectional study

INTRODUCTION

Access is considered one of the necessary conditions for achieving effectiveness and quality in health services. However, it represents a complex construct, with several interpretations, and can be understood as the ease or degree of difficulty with which people obtain effective and timely care. Barriers to access can be related to individual characteristics and those of health systems and services. Regarding elderly people living in rural riverine localities, these limitations are exacerbated due to the territorial dispersion of households and the difficulty of obtaining the necessary care near their homes. The aim of this study was to describe and test the association of sarcopenia and physical performance with primary healthcare attributes and the use of health services by elderly people living in rural riverside areas in the Amazon, Brazil.

METHODS

This cross-sectional observational study was carried out in households with individuals aged 60 years or older living in nine communities located on the left bank of the Negro River, in the rural riverside area of the municipality of Manaus, Amazonas, Brazil. The study evaluated socioeconomic and demographic conditions, health services utilization and the primary care attributes related to the use of and access to services, assessed by components of the Primary Care Assessment Tool instrument (PCATool-Brazil), a reduced version validated for Brazilian adult users. Physical performance was assessed using the Short Physical Performance Battery scale, and handgrip strength was also assessed, according to a dynamometer. The Sarcopenia Formulary (SARC-F) and calf circumference (CC) were used to assess sarcopenia (SARC-CalF). The association of sarcopenia and physical performance with the study outcomes was evaluated using hierarchical logistic regression for health services utilization (having had a medical consultation in the last year), and hierarchical linear regression for the continuous outcomes of the PCATool-Brazil (total score and each of the domains). The sociodemographic variables were inserted in model 1 and the clinical variables in model 2. Variables with p<0.20 were kept in the models.

RESULTS

A total of 98 elderly people (55.1% men; mean age 70±7.4 years) were included in the study. Low physical performance and suggestive signs of sarcopenia were observed in 52.5% and 28.9% of the study participants, respectively. Elderly with better physical performance reported more health services utilization (odds ratio (OR)=1.37; 95% confidence interval (CI)=1.03-1.81) and higher scores in the affiliation (β=1.67; 95%CI=0.37-2.98), utilization (β=1.19; 95%CI=0.06-2.33) and longitudinality (β=0.99; 95%CI=0.09-1.90) domains of the PCATool-Brazil.

CONCLUSION

The study findings showed high prevalence of impairment in physical performance and suggestive signs of sarcopenia in elderly people living in the studied rural riverside localities. Better physical performance was associated with use of health services in the previous year and with better evaluation of some primary care attributes.

Institutional support for the management and delivery of health services by a mobile river clinic unit in the Amazon

O estudo analisou o processo de trabalho do apoiador institucional ao atendimento ofertado em Unidade Básica de Saúde Fluvial. Neste estudo qualitativo, foi entrevistada 100% da equipe de gestão das unidades móveis fluviais que atendem à população rural residente entre Manaus e Novo Airão. Resultados evidenciaram baixa institucionalidade do trabalho de apoiador, em paralelo à importância da imersão nas atividades itinerantes desenvolvidas no meio rural e à centralidade do trabalho vivo cotidianamente realizado. A carência de suporte administrativo às atividades da unidade fluvial obriga o apoiador a desenvolver amplo leque de ações logísticas, requeridas pelo regime de trabalho itinerante rural. Práticas verticalizadas de tomada de decisão e restrições de investimento em infraestrutura e logística fragilizam a interveniência do apoiador e das equipes multiprofissionais, em que pese a contribuição delas à extensão de cobertura provida pelas unidades móveis fluviais rurais.

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.

Barriers to Access the Pap Smear Test for Cervical Cancer Screening in Rural Riverside Populations Covered by a Fluvial Primary Healthcare Team in the Amazon

Cervical cancer is a major public health problem, especially in the north region of Brazil. The aim of the study was to identify the factors associated with not undergoing the cervical cancer screening test in rural riverside populations in the Amazon. A cross-sectional home-based survey was carried out in 38 locations covered by a fluvial primary healthcare team, and the administrative records of the screening tests from January 2016 to May 2019 were analyzed. After the descriptive analysis, logistic regression was performed considering the outcome of having undergone cervical cancer screening within the past three years. Of the 221 women assessed, 8.1% had never undergone the test, and 7.7% had undergone it more than three years ago. Multiparity (OR = 0.76 (95%CI = 0.64-0.90)), occupation in domestic activities (OR = 0.31 (95%CI = 0.11-0.89)), and lack of knowledge of the healthcare unit responsible for the service (OR = 0.18 (95%CI = 0.04-0.97)) were associated with not undergoing the cervical cancer screening test. The administrative records revealed that the screening test was performed outside the recommended age range (24%), performed needlessly (9.6%) with undue repetitions (3.2%), and a high percentage of the samples collected were unsatisfactory (23.5%). The findings revealed the existence of barriers for riverside women to access cervical cancer screening tests.

Self-reported chronic back pain in the elderly living in rural riverine areas in the Amazon

INTRODUCTION

The present study aimed to estimate the prevalence of self-reported chronic low back pain and to identify the associated factors in elderly people living in rural riverside areas in the Amazon.

METHODS

Data from a cross-sectional home-based survey performed in 38 riverside rural locations along the left bank of the Negro River, in the municipality of Manaus, Amazonas, Brazil, were analyzed. The selected elderly people answered a questionnaire comprising items related to the living conditions, socioeconomic and demographic characteristics, health status and utilization of health services. The outcome was self-reported chronic back pain or problem. The association between the outcome and the independent variables was assessed using logistic regression, estimating the odds ratios and respective 95% confidence intervals (CIs).

RESULTS

One hundred and six residents aged 60 years or older out of a total of 277 were included in the study. The prevalence of chronic back pain among the elderly residents was 57.5% (63.3% among men and 50.0% among women). Most of them did not have any treatment related to their chronic condition (77.0%). Occupation in activities other than agricultural activities was protective for the outcome (odds ratio (OR)=0.1, 95%CI=0.0-0.9). The chronic low back pain was also associated with worse self-perceived health (OR=10.3, 95%CI=1.6-67.5).

CONCLUSION

The high prevalence of chronic low back pain in elderly people living in rural riverside areas, along with limited access to treatment and the different impacts on the performance of daily activities and the quality of life, reveals the relevance of this condition as a public health problem.

Vacinação contra a influenza autorreferida por idosos de áreas rurais ribeirinhas: implicação potencial dos achados frente à pandemia de covid-19 no Amazonas

Resumo Objetivo Avaliar a proporção de pessoas idosas não vacinadas e os motivos que interferem na imunização contra influenza em localidades rurais ribeirinhas, discutindo as potenciais implicações na vacinação contra a infecção por SARS-CoV-2. Método Inquérito epidemiológico de base domiciliar realizado em 38 localidades rurais ribeirinhas de Manaus (AM), Brasil, assistidas por uma Unidade Básica de Saúde Fluvial. Os participantes responderam a um questionário que investigou condições de vida, saúde e acesso aos serviços de saúde. Para este estudo foram avaliados os desfechos relacionados à imunização contra a Influenza nos últimos 12 meses e o principal motivo alegado para a não vacinação. Foi realizada análise descritiva dos dados, seguida por análise de regressão logística para identificar fatores associados à não vacinação. Resultados Das 102 pessoas idosas incluídas no estudo, 28 (27,5%) referiram não vacinação contra a Influenza no ano anterior. Os principais motivos foram a falta de informação sobre a vacinação (60,7%) e barreiras de acesso aos serviços de saúde (28,6%). Foi identificada maior chance de não vacinação entre aqueles que não consultaram o médico no último ano (RC=4,18; IC95%=1,57-11,11) e com maior renda domiciliar (RC=1,08; IC95%=1,02-1,14). Conclusão Verificou-se elevada proporção de pessoas idosas autorreferindo não imunização contra Influenza. Os motivos identificados para a não vacinação podem também representar barreiras à vacinação desse grupo populacional contra a covid-19. Dessa forma, faz-se necessário adequar o planejamento da vacinação em contextos rurais ribeirinhos, desenvolvendo estratégias mais contextualizadas para garantia de cobertura a essa população com maior vulnerabilidade aos efeitos de doenças respiratórias.

Providing Antivenom Treatment Access to All Brazilian Amazon Indigenous Areas: 'Every Life Has Equal Value'

Snakebites are more frequent in the Brazilian Amazon than in other parts of Brazil, representing a high cost for the health system since antivenoms are only available through medical prescription from central municipal hospitals in most cases. The need for a cold chain and physicians usually restricts access to the only effective treatment of a snakebite, the antivenom. The complex topography of the rivers contributes to delays in treatment, and consequently increases the risk of severe complications, chronic sequelae and death. Thus, decentralization of antivenom treatment to primary healthcare facilities in the interior would increase access by indigenous population groups to proper healthcare. To standardize and evaluate the decentralization to low complexity indigenous healthcare units, we suggest the (i) development and validation of standardized operational procedures, (ii) training of professionals in the validated protocol in a referral health unit, (iii) implementation of the protocol in an indigenous healthcare unit, (iv) assessment of perceptions towards and acceptability of the protocol, and (v) estimation of the impact of the protocol's implementation. We expect that antivenom decentralization would shorten the time between diagnosis and treatment and, as such, improve the prognosis of snakebites. As health cosmology among indigenous populations has an important role in maintaining their way of life, the introduction of a new therapeutic strategy to their customs must take into account the beliefs of these peoples. Thus, antivenom administration would be inserted as a crucial therapeutic tool in a world of diverse social, natural and supernatural representations. The information presented here also serves as a basis to advocate for support and promotion of health policy initiatives focused on evidence-based care in snakebite management.

Barriers to access and organization of primary health care services for rural riverside populations in the Amazon

BACKGROUND

The ways of life in the Amazon are diverse and not widely known. In addition, social inequities, large geographic distances and inadequate health care network noticeably limit access to health services in rural areas. Over the last decades, Brazilian health authorities have implemented fluvial mobile units (FMU) as an alternative to increase access and healthcare coverage. The aim of the study was to identify the strategies of access and utilization of primary health care (PHC) services by assessing the strengths and limitations of the healthcare model offered by the FMU to reduce barriers to services and ensure the right to healthcare.

METHODS

Qualitative and ethnographic research involving participant observation and semi-structured interviews. Data collection consisted of interviews with users and health professionals and the observation of service organization and healthcare delivered by the FMU, in addition to the therapeutic itineraries that determine demand, access and interaction of users with healthcare services.

RESULTS

Primary care is offered by the monthly locomotion of the FMU that serves approximately 20 rural riverside communities. The effectiveness of the actions of the FMU proved to be adequate for conditions such as antenatal care for low-risk pregnancy, which require periodic consultations. However, conditions that require continued attention are not adequately met through the organization of care established in the FMU. The underutilization of the workforce of community health workers and disarrangement between their tasks and those of the rest of the multi-professional team are some of the reasons pointed out, making the healthcare continuity unfeasible within the intervals between the trips of the FMU. From the users' perspective, although the presence of the FMU provides healthcare coverage, the financial burden generated by the pursuit for services persists, since the dispersed housing pattern requires the locomotion of users to reach the mobile unit services as well as for specialized care in the urban centers.

CONCLUSIONS

The implementation of the FMU represents an advance in terms of accessibility to PHC. However, the organization of their activity uncritically replicates the routines adopted in the daily routine of health services located in urban spaces, proving to be inadequate for providing healthcare strategies capable of mitigating social and health inequalities faced by the users.

Avaliação da atenção pré-natal ofertada às mulheres indígenas no Brasil: achados do Primeiro Inquérito Nacional de Saúde e Nutrição dos Povos Indígenas

Resumo: Este estudo avalia a atenção pré-natal de mulheres indígenas com idades entre 14-49 anos, com filhos menores de 60 meses no Brasil. O Primeiro Inquérito Nacional de Saúde e Nutrição dos Povos Indígenas avaliou 3.967 mulheres que atendiam a tais requisitos, sendo 41,3% da Região Norte; 21,2% do Centro-oeste; 22,2% do Nordeste; e 15% do Sul/Sudeste. O pré-natal foi ofertado a 3.437 (86,6%) delas. A Região Norte registrou a maior proporção de mulheres que não fizeram pré-natal. A cobertura alcançada foi de 90,4%, mas somente cerca de 30% iniciaram o pré-natal no 1º trimestre e apenas 60% das elegíveis foram vacinadas contra difteria e tétano. Somente 16% das gestantes indígenas realizaram 7 ou mais consultas de pré-natal. Ter acesso a pelo menos um cuidado clínico-obstétrico foi observado em cerca de 97% dos registros, exceto exame de mamas (63%). Foi baixa a solicitação de exames (glicemia 53,6%, urina 53%, hemograma 56,9%, citologia oncótica 12,9%, teste de sífilis 57,6%, sorologia para HIV 44,2%, hepatite B 53,6%, rubéola 21,4% e toxoplasmose 32,6%) e prescrição de sulfato ferroso (44,1%). No conjunto, a proporção de solicitações de exames laboratoriais preconizados não ultrapassou 53%. Os percentuais de realização das ações do pré-natal das indígenas são mais baixos que os encontrados para mulheres não indígenas no conjunto do território nacional, e até mesmo para as residentes em regiões de elevada vulnerabilidade social e baixa cobertura assistencial como a Amazônia Legal e o Nordeste. Os resultados reafirmam a persistência de desigualdades étnico-raciais que comprometem a saúde e o bem-estar de mães indígenas.

Acesso e cobertura da Atenção Primária à Saúde para populações rurais e urbanas na região norte do Brasil

RESUMO Iniquidades de acesso ao Sistema Único de Saúde comprometem a garantia de cuidados primários de saúde para populações rurais e para outros grupos em situação de vulnerabilidade. Estudo transversal que avaliou acesso de usuários e cobertura assistencial de Equipes de Saúde da Família (EqSF) dos sete estados da região norte do Brasil e que aderiram à avaliação externa do segundo ciclo Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB). Os dados do PMAQ-AB foram relacionados a indicadores demográficos, socioeconômicos e de saúde, por meio do coeficiente de correlação de Spearman. Para o conjunto da região, a cobertura assistencial de equipes sediadas em área rural, urbana e urbana que declararam atender a populações rurais foi de 83,3%. Coberturas entre 90-100% foram encontradas para o Acre, o Amapá, Roraima e o Tocantins. Menores percentuais foram encontrados no Pará (50,5%) e no Amazonas (60,5%). A extensão de cobertura encobre barreiras de acesso geográfico ligadas à concentração de equipes da Estratégia Saúde da Família nos espaços urbanos, situação que se estende a 451 (25,3%) unidades e a 494 (22,9%) equipes encarregadas do atendimento de populações rurais, mas que atuam em espaço urbano, adicionando barreiras à chegada dos usuários às unidades. Dificuldades no acolhimento à demanda espontânea, agendamento de consulta e disponibilidade de transporte para o atendimento também foram reportadas.

AVALIAÇÃO DA ORGANIZAÇÃO DO CUIDADO EM SAÚDE MENTAL NA ATENÇÃO BÁSICA À SAÚDE DO BRASIL

Resumo Este artigo resultou de um estudo transversal sobre o cuidado em saúde mental com 29.778 equipes da Estratégia Saúde da Família de todo o Brasil (87,1% do total), incluindo avaliação normativa dos dados do segundo ciclo do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (2013-2014) nas dimensões perfil dos profissionais, promoção da saúde mental, gestão e oferta do cuidado. Os resultados mostraram que 33,8% dos entrevistados tinham vínculo trabalhista precário e 60,3% deles se sentiam despreparados para atuar em saúde mental. A oferta do conjunto de ações avaliadas só ocorreu em 9,5% das equipes em todo o Brasil (2,2% na região Norte). Cerca de metade não desenvolvia estratégias de promoção da saúde e apenas 9,8% efetivavam a gestão do cuidado. Concluiu-se que os baixos percentuais de implantação em nível nacional coexistem com expressivas desigualdades regionais, com piores resultados no Norte. Fazem-se necessários o fortalecimento de ações de promoção da saúde, a qualificação das equipes, a desprecarização de vínculos e o reordenamento da gestão do cuidado.

[Access to prenatal care and quality of care in the Family Health Strategy: infrastructure, care, and management]

This study focuses on access to prenatal care and quality of care in the Family Health Strategy in Brazil as a whole and in the North region, through evaluation of infrastructure characteristics in the health units, management, and supply of care provided by the teams, from the perspective of regional and state inequalities. A cross-sectional evaluative and normative study was performed, drawing on the external evaluation component of the second round of the Program for Improvement of Access and Quality of Primary Care, in 2013-2014. The results revealed the inadequacy of the primary healthcare network's infrastructure for prenatal care, low adequacy of clinical actions for quality of care, and the teams' low management capacity to guarantee access and quality of care. In the distribution according to geopolitical regions, the findings pertaining to the units' infrastructure indicate a direct relationship between the infrastructure's adequacy and social contexts with higher municipal human development indices and income. For the clinical actions in patient care, the teams in all the regions scored low on adequacy, with slightly better results in the North and South regions of the country. There were important differences between the states of the North, and the states with higher mean income and human development scored higher on adequacy. The results indicate important organizational difficulties in both access and quality of care provided by the health teams, in addition to visible insufficiency in management activities aimed to improve access and quality of prenatal care.

[The differentiated care model in the Special Indigenous Health Districts: reflections based on Alto Rio Negro in Amazonia State, Brazil]

The implementation of the National Policy for Healthcare of Indigenous Peoples (Pnaspi) in the Alto Rio Negro Amazon region was analyzed based on the principles of the differentiated care model. This theme was investigated from three perspectives, namely the formulation of the guidelines, the therapeutic itineraries in indigenous villages, and the work routines of the Indigenous Community Health Agents (AIS). It involved qualitative research based on the anthropological perspective of Eduardo Menéndez. The techniques used were participant observation, interviews, and, document analysis. The formulation of the guidelines of differentiated care emphasizes the adaptation of technologies and professionals, minimizing the coexistence and disputes among healthcare models. Menéndez's perspective focused on the viewpoint of the subjects was crucial for identifying the coexistence and articulation among different forms of care in the villages through the healthcare itineraries. Nevertheless, it was not possible to identify the inclusion of indigenous health practices and representations through the work routines of the Indigenous Community Health Agents (AIS). The focus was on self-care developed and practiced by the subjects and their families.

Cross-sectional study about impact of parental smoking on rhinitis symptoms in children

OBJECTIVE

Assess the prevalence of rhinitis and exposure to environmental tobacco smoke (ETS) of children in our community and its relationship with symptoms of rhinitis METHODS (DESIGN, SETTING, PARTICIPANTS, MAIN OUTCOME MEASURES): Cross-sectional study using questionnaire on rhinitis of the International Study of Asthma and Allergies in Childhood, in children (6-7 years) and adolescents (13-14 years). Categories: "rhinitis ever", "recent rhinitis", "recent rhinoconjunctivitis", "severe rhinoconjunctivitis". Parental smoking: (i) neither parent smokes; (ii) only the mother smokes; (iii) only the father smokes; and (iv) both parents smoke. Odds ratio of the prevalence of symptoms of rhinitis according to ETS exposure was calculated using logistic regression.

RESULTS

10 690 children and 10 730 adolescents. The prevalence of "rhinitis ever" in children: 29.4%, "recent rhinitis" 24%, "recent rhinoconjunctivitis" 11.5% and "severe rhinoconjunctivitis" 0.1%. In adolescents: 46.2%, 34.5%, 16.2% and 0.2%, respectively. Environmental tobacco smoke exposure in the home occurred in 51% of cases. Parental smoking was associated with a higher prevalence of forms of rhinitis in adolescents when only the mother was a smoker. In children when both parents were smokers.

CONCLUSION

Rhinitis is highly prevalent in our community. Environmental tobacco smoke exposure is still very common. The relationship between ETS and rhinitis symptoms in children of this community is not as robust as that found for asthma.

Regionalização em Saúde no Amazonas: avanços e desafios

Resumo O artigo analisa o processo de regionalização em saúde no estado do Amazonas por meio de estudo de caso da regional em Saúde Entorno de Manaus. Pesquisa qualitativa, descritivo-analítica, cujos dados foram coletados através de entrevistas, revisão de documentos e de páginas de internet, tomando como conceito guia a regionalização em saúde. Os achados do estudo mostram uma cena social onde predominam a assimetria, a verticalidade, a competitividade e a fragilidade das relações multilaterais entre municípios, associados a um perfil cartorial das instituições que atuam na região de saúde sob estudo. Os agentes políticos envolvidos no processo têm limitado reconhecimento das condições sociopolíticas e institucionais em que atuam. Tendem a atribuir os problemas de gestão e operacionalização das redes de assistência à configuração dos espaços naturais-geográficos amazônicos, mas seu financiamento, governança e capacidade técnica são insuficientes para superá-los.

Regional health network in the Amazonian context: the case in Manaus, Entorno and Alto Rio Negro

Abstract Objectives: to analyze the dimensions of policy, structure and organization in the construction of Redes de Atenção à Saúde (RAS) (healthcare networks) in the health region of Manaus, Entorno and Alto Rio Negro, focusing on Atenção Primária à Saúde (APS) (primary healthcare) and Rede de Urgência e Emergência (RUE) (urgency and emergency network). Methods: a case study with multidimensional analysis using quantitative and qualitative approach carried out in the first semester of 2016. Results: 37 interviewed key informants, such as managers (States, Cities and Regionals), providers and civil society. The reality was marked by the difficulties in the implementation of RAS's with centralized decision-making powers of State level. Perception of insufficient human resources of limited installed capacity, particularly in the APS, with insufficient priority given to this level of care. Concentration of services in Manaus, priority for urgency and emergency actions expressed in the greatest investment in human resources and mate-rials allocated at this level of care, lack of proposals for promoting equity. Conclusions: the Region was unable to implement RAS to respond to the health demands in the region. The necessity to overcome the dependency relation with the cities and the State and to strengthen its protagonism and fulfillits roles in management network, instituting a plan capable of strengthening APS to be committed in reducing iniquities and with adequate responses in health needs.

Anemia among indigenous women in Brazil: findings from the First National Survey of Indigenous People's Health and Nutrition

BACKGROUND

Anemia is recognized as a major public health problem that disproportionately affects vulnerable populations. Indigenous women of reproductive age in Brazil are thought to be at high risk, but lack of nationwide data limits knowledge about the burden of disease and its main determinants. This study aimed to assess the prevalence of anemia and associated factors in this population using data from The First National Survey of Indigenous People's Health and Nutrition in Brazil.

METHODS

Data were collected from Indigenous women between 15 and 49 years old based on a nationwide sample of villages. The outcomes of interest were hemoglobin levels (g/dL) and anemia (< 12 g/dL for nonpregnant and < 11 g/dL for pregnant women). Multilevel models were used to explore associations with contextual (village) and individual (household/woman) level variables.

RESULTS

Based on data for 6692 Indigenous women, the nationwide mean hemoglobin level was 12.39 g/dL (95% CI: 12.29-12.50). Anemia prevalence was high (33.0%; 95% CI: 30.40-35.61%) and showed pronounced regional disparities. No village-level characteristics were associated with anemia or hemoglobin levels in the multilevel model. Even after controlling for upper level variables, socioeconomic status, parity, body mass index, and having been treated for malaria were associated with anemia and hemoglobin levels.

CONCLUSION

The prevalence of anemia in Brazilian Indigenous women was 12% greater than the national estimates for women of reproductive age. Anemia prevalence and mean hemoglobin levels among Indigenous women appear to be partly explained by some previously recognized risk factors, such as socioeconomic status, body mass index, and malaria; however, part of the variability in these outcomes remains unexplained. Knowledge of health status and its potential determinants is essential to guide public policies aimed at controlling anemia burden in Indigenous communities.

La formación y el trabajo del agente indígena de salud en el Subsistema de Salud Indígena en Brasil

Objetivo. Reflexionar sobre la figura del agente indígena de salud en Brasil y sobre el papel que éste ejerce en el modelo de atención diferenciada o intercultural. Material y métodos. Se revisó la bibliografía de investigaciones existentes en el área del trabajo y la formación de los agentes indígenas de salud, del subsistema de salud indígena en Brasil. Resultados. Existe subordinación del agente al modelo médico hegemónico. Los agentes carecen de procesos formativos iniciales, los cursos ocurren con irregularidad y los contenidos se enfocan en la biomedicina. Hay conflictos con el equipo y con la comunidad, lo que genera su desvalorización. El agente no ejerce la función de mediación que se espera entre saberes y prácticas. Conclusiones. La discusión sobre la atención diferenciada debe partir de la relación entre el sector salud y la autoatención.

[Professional education and work of indigenous health agents in the Brazilian health system]

OBJECTIVE

To discuss the role of indigenous health agents in the implementation of the model of differentiated attention or intercultural health in Brazil.

MATERIALS AND METHODS

We revised the scientific literature about the work and professional education of indigenous health agents in the Brazilian indigenous health system.

RESULTS

There is a subordination of the agents to the hegemonic medical model. With regards to professional education, we observe the absence and irregularity of these processes, with a general emphasis the biomedicine. There are conflicts with the health team and community, with devaluation of the agents. The agent does not plays the role of mediator between the different health knowledge and practices.

CONCLUSIONS

We suggest that the discussion of the model of differentiated attention should strengthen the relationship between the health system and the selfcare.

Obesity and asthma: an association modified by age

BACKGROUND

Some studies indicate some causal relationship between obesity and asthma, while others show inconsistent results. Our objective was to evaluate the prevalence of asthma according to obesity in children.

METHODS

A cross-sectional study, following the ISAAC study methodology, was conducted on two randomly selected groups consisting of 6-7 year-old children (n=7485) and 13-14 year-old adolescents (n=8496). The asthma symptoms and potential risk factors were determined from the questionnaire. Overweight and obesity were defined based on the body mass index. Multiple logistic regression was used to obtain adjusted prevalence odds ratios (OR) and 95% confidence intervals.

RESULTS

Obesity was associated with an increase in wheezing ever (OR: 1.35) and exercise-induced asthma (OR: 1.62) in the 6-7 year-old group. No significant relationship was observed in the adolescent population.

CONCLUSION

Obesity was associated with a higher prevalence of asthma in young children, but not in adolescents.

Truck traffic related air pollution associated with asthma symptoms in young boys: a cross-sectional study

OBJECTIVES

The aim of this study was to evaluate the influence of intensity of truck traffic on asthma symptomatology, and its relationship with age and gender.

STUDY DESIGN

A cross-sectional study was conducted on children and adolescents from Galicia (North-West Spain).

METHODS

Following the methodology of the International Study of Asthma and Allergies in Childhood (ISAAC): children from schools randomly selected, answered a self-administered questionnaire included questions on asthma symptoms and some risk factors. The association between self-reported truck traffic on the street of residence and symptoms of asthma were investigated by logistic regression adjusted for body mass index, maternal education and parental smoking.

RESULTS

Almost 40% of children in Galicia are exposed to the frequent and constant passing of heavy goods vehicles. The odds of 6-7 year-old boys having severe or exercise induced asthma is tripled when they live in streets with the constant passing of heavy goods vehicles, compared with those living in streets where these vehicles never pass. In adolescents and 6-7 year-old girls, no relationship was observed between truck traffic and asthma symptoms.

CONCLUSIONS

The results of this study appear to support a distinct effect of truck traffic on asthma symptoms depending on the age and sex of the exposed population, being more harmful for young males.

The First National Survey of Indigenous People's Health and Nutrition in Brazil: rationale, methodology, and overview of results

Background

Although case studies indicate that indigenous peoples in Brazil often suffer from higher morbidity and mortality rates than the national population, they were not included systematically in any previous national health survey. Reported here for the first time, the First National Survey of Indigenous People’s Health and Nutrition in Brazil was conducted in 2008–2009 to obtain baseline information based on a nationwide representative sample. This paper presents the study’s rationale, design and methods, and selected results.

Methods

The survey sought to characterize nutritional status and other health measures in indigenous children less than 5 years of age and indigenous women from 14 to 49 years of age on the basis of a survey employing a representative probabilistic sample of the indigenous population residing in villages in Brazil, according to four major regions (North, Northeast, Central-West, and South/Southeast). Interviews, clinical measurements, and secondary data collection in the field addressed the major topics: nutritional status, prevalence of hypertension and diabetes mellitus in women, child hospitalization, prevalence of tuberculosis and malaria in women, access to health services and programs, and characteristics of the domestic economy and diet.

Results

The study obtained data for 113 villages (91.9% of the planned sample), 5,305 households (93.5%), 6,692 women (101.3%), and 6,128 children (93.1%). Multiple household variables followed a pattern of greater economic autonomy and lower socioeconomic status in the North as compared to other regions. For non-pregnant women, elevated prevalence rates were encountered for overweight (30.3%), obesity (15.8%), anemia (32.7%), and hypertension (13.2%). Among children, elevated prevalence rates were observed for height-for-age deficit (25.7%), anemia (51.2%), hospitalizations during the prior 12 months (19.3%), and diarrhea during the prior week (23.6%).

Conclusions

The clinical-epidemiological parameters evaluated for indigenous women point to the accentuated occurrence of nutrition transition in all regions of Brazil. Many outcomes also reflected a pattern whereby indigenous women’s and children’s health indicators were worse than those documented for the national Brazilian population, with important regional variations. Observed disparities in health indicators underscore that basic healthcare and sanitation services are not yet as widely available in Brazil’s indigenous communities as they are in the rest of the country.

[Sociocultural aspects of vaccination in an indigenous region]

The article analyzes interactions between the Baniwa, an indigenous group from the Alto Rio Negro region, and the multi-disciplinary healthcare teams that conduct vaccination there. Approaching from the perspectives of the anthropology of disease, studies of Rio Negro ethnology, and the theory of social representations, the study endeavors to comprehend indigenous interpretations of vaccination and the diseases these seek to prevent. Results show that biomedical ideas about vaccines are re-interpreted through Baniwa cosmology. It is concluded that the vigor of Baniwa thought encourages these indigenes to interpret biomedical action in accord with cultural features and that the clash between Baniwa outlooks and those of healthcare providers has negative repercussions on the vaccination process.

Mediterranean diet and asthma in Spanish schoolchildren

There is still debate on the effect of dietetic factors on the prevalence or severity of asthma, as well as the interaction with other factors. We have analysed the prevalence and severity of asthma according to adherence to the Mediterranean diet (MD), its association with obesity and family life style. We performed a cross-sectional study on 14,700 children and adolescents in six health areas in our region. We used the International Study of Asthma and Allergies in Childhood questionnaire to collect asthma symptoms, dietary habits, anthropometric parameters, parental smoking habits and maternal education level. The diet pattern was analysed using a Mediterranean Diet Score. In the logistic regression we analysed the influence of adhering to the MD on the prevalence and severity of asthma, adjusted for the other parameters included. Greater adherence to the MD is associated with a higher risk of severe asthma (odds ratios = 2.26, 95% CI: 1.21-4.22) in girls of 6-7 yr. There was no significant relationship for the other asthma categories in the population studied. The results of our study do not support a protective effect of the MD on the prevalence or severity of asthma.

Extensão de Cobertura ou Reorganização da Atenção Básica? A trajetória do Programa de Saúde da Família de Manaus-AM

Este trabalho analisa sete anos de implantação do Programa de Saúde da Família (PSF) de Manaus, procurando identificar mudanças no sistema municipal de saúde a ele relacionadas e capazes de contribuir para a redução de desigualdades em saúde. Contextualiza a gênese do PSF no município, suas características, contradições e limitações, investigando se o programa construiu apenas uma trajetória de extensão de cobertura ou contribuiu efetivamente para a reorganização do modelo de atenção básica à saúde. As categorias de análise priorizaram princípios específicos de gestão do PSF: caráter substitutivo, integração com instituições e organizações sociais, territorialização, planejamento situacional com base na família e na comunidade, participação popular e controle social. A metodologia utilizada foi quali-quantitativa, compreendendo a análise dos dados de duas pesquisas avaliativas da implementação do PSF no município, realizadas em 2001 e em 2006. Os resultados mostram que, em Manaus, o PSF se constitui em uma estratégia de extensão de cobertura, com parcial superposição à estrutura assistencial de atenção básica (AB) preexistente e paralelismo de ações. Dadas as condições de sua implantação, conclui-se que o PSF se expressa como um programa isolado dentro do sistema municipal de saúde, com potencialidade para se converter em estratégia reestruturadora da AB em Manaus. A confluência com a implantação dos Distritos Sanitários poderá contribuir para um caminho de reorientação do modelo assistencial que garanta atenção integral e concretize o direito à saúde.

[Ways of life and ways to drink of young indigenous in a transformation context]

The interactions among the ways of life and drink of youths indigenous of a populous place of Upper Rio Negro were analyzed through an ethnographic research. It was used a theoretical model that allowed to decompose and to articulate the social reality in different levels. It was observed that there was a multiplication of the situations in which is possible to drink, that are associated to mechanisms as much of belonging demarcation as of exposition of differences inter-group. Nowadays, youths insert themselves in multiple interaction networks. Through these networks they can create juvenile atmospheres of alcohol consumption, drink far away from the parents and buy industrialized drinks. With the introduction of the school and the abandonment of the initiation rituals, the youth status became uncertain, and it occurs in an ambiguous way the social norms of alcohol consumption, in a context in which there is no consensus in daily practice respect of the possible strategies to regulate juvenile drinking. Through this research, theoretical-methodological alternatives could be suggested to investigate the relationships that are established between the ways of life and the production of the health and disease, incorporating in this analysis the culture (and its transformation), the daily life (and its contradictions), the people (and its subjectivities).

Formação técnica de agente comunitário indígena de saúde: uma experiência em construção no Rio Negro

Este relato descreve a experiência de formação técnica profissionalizante de 250 agentes comunitários indígenas de saúde vinculados ao Distrito Sanitário Especial Indígena do Rio Negro, no estado do Amazonas. A iniciativa promove a elevação da escolaridade e o respeito às especificidades culturais dos alunos. Os eixos pedagógicos 'cultura', 'território', 'política', 'cuidado', 'informação', 'educação' e 'planejamento em saúde' estruturam uma matriz curricular operacionalizada por meio do ensino pela pesquisa, multilinguismo, multidisciplinaridade e intersetorialidade, em consonância com os princípios da educação escolar indígena, da atenção diferenciada à saúde dos povos indígenas e dos referenciais curriculares de formação técnica de agente comunitário de saúde. O processo pedagógico estimula a obtenção de habilidades e competências para diagnosticar e monitorar a situação de saúde e condições de risco e vulnerabilidade das populações indígenas rionegrinas, para subsidiar ações de prevenção, promoção, tratamento e reabilitação nas diversas fases da vida e desenvolver ação política e comunitária nas lutas pela melhoria da saúde. Resultados preliminares da experiência mostram o reconhecimento e fortalecimento do trabalho dos agentes indígenas de saúde, a melhoria da qualidade do trabalho em saúde na comunidade e a maior satisfação dos líderes do movimento indígena pela ampliação do acesso à educação qualificada e diferenciada.

Desigualdade social, crescimento urbano e hanseníase em Manaus: abordagem espacial

OBJETIVO: Analisar a epidemiologia de hanseníase segundo a distribuição espacial e condições de vida da população. MÉTODOS: Estudo ecológico baseado na espacialização da hanseníase em Manaus (AM), entre 1998 e 2004. Os 4.104 casos obtidos do Sistema de Informações de Agravos de Notificação foram georreferenciados de acordo com a localização dos endereços em 1.536 setores censitários urbanos, por meio de quatro técnicas: correios (73,7% dos endereços encontrados); Programa de Cadastro de Logradouros (7,3%); Programa Saúde da Família (2,1%) e folhas de coleta do Instituto Brasileiro de Geografia e Estatística (1,5%). Para cálculo do coeficiente de detecção utilizou a população de 2001. Na análise espacial foi aplicado o método bayesiano empírico local para produzir uma estimativa do risco da hanseníase, suavizando o efeito da flutuação das taxas, quando calculadas para pequenas áreas. Para análise da associação entre espacialização e fatores de risco empregou-se a regressão logística, tendo como variáveis explicativas a ocorrência de casos em menores de 15 anos (indicador de gravidade) e o Índice de Carência Social construído a partir das variáveis do Censo 2000. RESULTADOS: O coeficiente de detecção apresentou-se hiperendêmico em 34,0% dos setores e muito alto em 26,7%. A medida de associação (odds ratio) referente às variáveis explicativas foi significativa. A combinação de baixa condição de vida e ocorrência em menores de 15 anos foi adotada para identificar as áreas prioritárias para intervenção. CONCLUSÕES: A análise espacial da hanseníase mostrou que a distribuição da doença é heterogênea, atingindo mais intensamente as regiões habitadas por grupos em situação de maior vulnerabilidade.

Epidemiological profile of leprosy in children under 15 in Manaus (Northern Brazil), 1998-2005

OBJECTIVE

To describe the epidemiological status of leprosy in children living in a metropolitan area.

METHODS

There were studied 474 leprosy cases detected in children under 15 living in the metropolitan area of the city of Manaus, Northern Brazil, between 1998 and 2005. The endemic profile and quality of care services were assessed based on data from the Notifiable Diseases Information System using epidemiological and operational indicators of the National Leprosy Elimination Program.

RESULTS

Of all leprosy cases detected in the period studied, 10.4% were found in children under 15. The detection rates in this age group remained at hyperendemic levels between 1998 and 2003, and decreased from 2004 onwards but keeping on very high endemic levels. The most common clinical form was tuberculoid followed by dimorphous. Paucibacillary forms were seen in 70.7% of the cases. The level of disability at the time of diagnosis was assessed in 94.7% of patients and 2.9% of them had physical disabilities. Most children (99.4%) were treated with the multiple drug regimen recommended by the World Health Organization.

CONCLUSIONS

Despite its decrease, detection rate of leprosy in children in the city of Manaus remains at a very high endemic level.

Hanseníase em populações indígenas do Amazonas, Brasil: um estudo epidemiológico nos municípios de Autazes, Eirunepé e São Gabriel da Cachoeira (2000 a 2005)

O Estado do Amazonas, Brasil, apresentou, em 2005, coeficientes hiperendêmicos de detecção de hanseníase e prevalência de média endemicidade. O estado detém a maior população indígena no país, mas inexistem informações sobre o perfil da hanseníase nesses grupos. O estudo objetivou a descrição e análise das características epidemiológicas das notificações de hanseníase nos municípios de Autazes, Eirunepé e São Gabriel da Cachoeira, comparando achados entre indígenas e não indígenas, segundo variáveis de interesse. Foram analisados os casos notificados no SINAN, no período de 2000 a 2005. Do total de 386 casos notificados, verificaram-se coeficientes médios de detecção de 3,55, 14,94 e 2,13/10 mil (entre os não indígenas) e de 10,95, 1,93 e 0,78/10 mil (para os indígenas), para Autazes, Eirunepé e São Gabriel da Cachoeira, respectivamente. Houve predomínio de casos paucibacilares em indígenas e em não indígenas, no entanto, a forma dimorfa representou 1/3 das notificações. Apesar das limitações de cobertura e do sub-registro, os achados sugerem que a hanseníase representa importante problema de saúde pública para os indígenas no Amazonas. A classificação segundo "raça/etnicidade" se constituiu em ferramenta útil para elucidar desigualdades em saúde.

Cárie dentária e necessidade de tratamento odontológico entre os índios Baniwa do Alto Rio Negro, Amazonas

Pesquisas epidemiológicas em comunidades indígenas no Brasil têm evidenciado forte relação entre a deterioração da saúde bucal e o consumo de itens industrializados (e do açúcar refinado em particular), aliados à precariedade da atenção odontológica. Este estudo abordou a população Baniwa do pólo-base de Tunuí-Cachoeira, São Gabriel da Cachoeira, Amazonas, Brasil. Foi realizado inquérito transversal sobre as condições de saúde bucal, de acordo com critérios da OMS. Foram observadas as condições dentárias e a necessidade de tratamento, examinando-se 590 indivíduos (49,2% da população > 2 anos). A média de dentes atacados pela doença cárie foi 6,0, 8,2 e 22,1 nas faixas etárias 12-14, 15-19 e mais de 50 anos, respectivamente. O maior valor de ceo-d (5,3) foi encontrado na idade de 5 anos. Do total de pessoas examinadas, 73,6% apresentaram alguma necessidade de tratamento cirúrgico-restaurador. Os indivíduos entre 15-19 anos apresentam as mais elevadas freqüências de restaurações. O CPO-D da população Baniwa é elevado, o que deve estar relacionado a processos recentes de mudanças socioeconômicas, particularmente na dieta. Enfatiza-se a necessidade de ampliação da atenção à saúde bucal, considerando-se a complexidade da questão sociocultural dos povos indígenas.

[When, how, and what to drink: alcoholism among Indian peoples in the Upper Rio Negro, Brazil]

This paper analyzes the development of alcoholism among Indian peoples in the Upper Rio Negro, Amazonas State, Brazil. Based on a comprehensive approach to what, how, and when individuals drink, this ethnography emphasizes the socio-cultural and historical context in which alcohol is consumed and interpretation of the issue by Indian people themselves. The article discusses historical transformations in the forms of drinking and their correlations with the status quo and changes in social standards of living. The article concludes that current forms of alcohol consumption are linked to the behaviors and values emerging on the frontier of interethnic relations and the resignification of the traditional culture, currently experiencing difficulties in offering parameters for action and symbolization of social life by the younger generations as they deal with challenges from the modern world.

[Cosmology, environment, and health: Baniwa food myths and rites]

The Baniwa people, a member of the Aruak group which lives in the northwestern Amazon, has a rich mythic tradition that influences how the political, ethical, and practical dimensions of their social life are expressed and that guides the ancestral knowledge that guarantees the group's survival under adverse environmental conditions. The article analyzes myths and rites built around fish as a food source; these have an intimate relationship with cosmological explanations of the origin of the gods, water bodies, and the micro-ecosystems that foster the reproduction of aquatic fauna. Baniwa mythology draws an association between the reproductive processes of fish and a set of social relations involving human and nonhuman societies. Predation and edibility--notions underlying food rites--are viewed as part of a set of practices meant to produce and maintain kinship alliances, ease the food/prey peril, and maintain the cosmic balance that sustains life.

Taxonomias das doenças entre os índios Baniwa (arawak) e desana (tukano oriental) do alto rio negro (Brasil)

O presente artigo estuda as taxonomias de doenças de dois povos indígenas da região do Alto Rio Negro, Noroeste amazônico (Brasil): os Baniwa, da família lingüística arawak, e os Desana, da família lingüística tukano oriental. Tomando como base explicativa a produção mítica dessas etnias, as autoras comparam seus sistemas de doença e cura e demonstram que as circunstâncias ligadas ao surgimento de uma doença particular, as representações de pessoa e do mundo natural, e as modalidades de relação entre os grupos humanos, a natureza e o cosmos, participam da interpretação da doença. Essa ênfase na causalidade social e/ou com a ordem do mundo traduz-se na terminologia vernacular e na classificação das doenças em ambos os grupos estudados. A produção do processo patogênico liga-se a uma "economia simbólica da alteridade" (Viveiros de Castro, 2002). Promover a saúde e evitar a doença exigem cooperação, reciprocidade, diligência, controle das ações predatórias e do apetite alimentar e sexual.

[Globalization and environmentalism: polyphonic ethnicities in the Amazon]

The article examines the issue of globalization, along with its contradictions and the ways in which it guides and shapes specific situations within the Amazon's present-day reality, while simultaneously engendering the uniformization of economic production and the valorization of cultural differences. The discussion explores the nuances of implementing a massified, standardized productive base that paradoxically fosters the valorization of cultural differences and favors alliances between, on the one hand, ethno-political leaders from indigenous Amazon groups and, on the other, environmentalists and other transworld actors who wield strong decision-making power. The article analyzes the indigenous movement's network of alliances and highlights the polyphony of the different political agents that come to clash with each other within this post-modern geopolitical setting.

Dimensões e potencialidades dos sistemas de informação geográfica na saúde indígena

OBJETIVO: Discutir as potencialidades do sistema de informação geográfico na análise do perfil epidemiológico, sociodemográfico e da organização dos serviços de saúde dirigidos aos povos indígenas. MÉTODOS: Foi efetuada a análise georreferenciada das notificações de tuberculose, malária e da mortalidade de 374.123 indígenas distribuídos em 36 Distritos Sanitários Especiais Indígenas em todo o Brasil. Definiu-se um gradiente da intensidade do risco de adoecimento indígena por tuberculose, malária e mortalidade infantil nos anos de 2000 a 2002, comparando-os com os coeficientes encontrados na população não indígena no mesmo período. RESULTADOS: O estudo mostrou que os dados previamente disponíveis são fragmentários, não possibilitando uma visão de conjunto das condições de vida e da situação de saúde dos grupos étnicos. A construção de gradientes de risco evidenciou coeficientes de incidência de tuberculose superiores em mais de 1.000 vezes àqueles encontrados para a população geral brasileira. O Índice Parasitário Anual médio de malária na população indígena superou em até 10 vezes os valores médios encontrados para a população não-indígena e o Coeficiente de Mortalidade Infantil variou entre 74,7/1.000 nascidos vivos em 2000 e 56,5/1.000 em 2001, superando em mais de 100% a média nacional para o período. CONCLUSÕES: O Sistema de Informação Geográfica se revela uma ferramenta útil para a gestão, possibilitando análises de situações sanitárias, avaliação de risco populacional, construção de cenários que viabilizem o planejamento de estratégias de intervenção nos diversos níveis, transitando com rapidez e eficiência entre macro e micro realidades.

Organizações indígenas e distritalização sanitária: os riscos de "fazer ver" e "fazer crer" nas políticas de saúde

O trabalho se propõe a analisar repercussões etnopolíticas, éticas e sanitárias nas práticas das organizações indígenas, conveniadas com o Ministério da Saúde, ligadas ao processo de implantação dos Distritos Sanitários Especiais Indígenas (DSEI) no Estado do Amazonas, Brasil. Os DSEI escolhidos para análise foram o de Manaus e do Rio Negro. As informações trabalhadas são retiradas de relatórios de encontros, reuniões de planejamento e de gestão das convenentes indígenas, da observação participante em eventos de avaliação do processo de distritalização e entrevistas com gerentes indígenas e não indígenas dos DSEI. É discutida a ambigüidade das organizações indígenas de ter que exercer o seu papel político e ao mesmo tempo de executoras de uma política do Estado, assumindo como uma forma de superação do estigma de incapacidade de estar à frente do processo de implantação dos DSEI.