Health in Brazil 2 Maternal and child health in Brazil: progress and challenges

In the past three decades, Brazil has undergone rapid changes in major social determinants of health and in the organisation of health services. In this report, we examine how these changes have affected indicators of maternal health, child health, and child nutrition. We use data from vital statistics, population censuses, demographic and health surveys, and published reports. In the past three decades, infant mortality rates have reduced substantially, decreasing by 5.5% a year in the 1980s and 1990s, and by 4.4% a year since 2000 to reach 20 deaths per 1000 livebirths in 2008. Neonatal deaths account for 68% of infant deaths. Stunting prevalence among children younger than 5 years decreased from 37% in 1974-75 to 7% in 2006-07. Regional differences in stunting and child mortality also decreased. Access to most maternal-health and child-health interventions increased sharply to almost universal coverage, and regional and socioeconomic inequalities in access to such interventions were notably reduced. The median duration of breastfeeding increased from 2.5 months in the 1970s to 14 months by 2006-07. Official statistics show stable maternal mortality ratios during the past 10 years, but modelled data indicate a yearly decrease of 4%, a trend which might not have been noticeable in official reports because of improvements in death registration and the increased number of investigations into deaths of women of reproductive age. The reasons behind Brazil`s progress include: socioeconomic and demographic changes (economic growth, reduction in income disparities between the poorest and wealthiest populations, urbanisation, improved education of women, and decreased fertility rates), interventions outside the health sector (a conditional cash transfer programme and improvements in water and sanitation), vertical health programmes in the 1980s (promotion of breastfeeding, oral rehydration, and immunisations), creation of a tax-funded national health service in 1988 (coverage of which expanded to reach the poorest areas of the country through the Family Health Program in the mid-1990s); and implementation of many national and state-wide programmes to improve child health and child nutrition and, to a lesser extent, to promote women`s health. Nevertheless, substantial challenges remain, including overmedicalisation of childbirth (nearly 50% of babies are delivered by caesarean section), maternal deaths caused by illegal abortions, and a high frequency of preterm deliveries.

Inequalities in dental services utilization among Brazilian low-income children: the role of individual determinants

Objectives: To assess the role of the individual determinants on the inequalities of dental services utilization among low-income children living in the working area of Brazilian`s federal Primary Health Care program, which is called Family Health Program (FHP), in a big city in Southern Brazil. Methods: A cross-sectional population-based study was performed. The sample included 350 children, ages 0 to 14 years, whose parents answered a questionnaire about their socioeconomic conditions, perceived needs, oral hygiene habits, and access to dental services. The data analysis was performed according to a conceptual framework based on Andersen`s behavioral model of health services use. Multivariate models of logistic regression analysis instructed the hypothesis on covariates for never having had a dental visit. Results: Thirty one percent of the surveyed children had never had a dental visit. In the bivariate analysis, higher proportion of children who had never had a dental visit was found among the very young, those with inadequate oral hygiene habits, those without perceived need of dental care, and those whose family homes were under absent ownership. The mechanisms of social support showed to be important enabling factors: children attending schools/kindergartens and being regularly monitored by the FHP teams had higher odds of having gone to the dentist, even after adjusting for socioeconomic, demographic, and need variables. Conclusions: The conceptual framework has confirmed the presence of social and psychosocial inequalities on the utilization pattern of dental services for low-income children. The individual determinants seem to be important predictors of access.

Narrowing socioeconomic inequality in child stunting: the Brazilian experience, 1974-2007

Objective To assess trends in the prevalence and social distribution of child stunting in Brazil to evaluate the effect of income and basic service redistribution policies implemented in that country in the recent past. Methods The prevalence of stunting (height-for-age z score below 2 using the Child Growth Standards of the World Health Organization) among children aged less than 5 years was estimated from data collected during national household surveys carried out in Brazil in 1974-75 (n = 34 409), 1989 (n = 7374), 1996 (n = 4149) and 2006-07 (n = 4414). Absolute and relative socioeconomic inequality in stunting was measured by means of the slope index and the concentration index of inequality, respectively. Findings Over a 33-year period, we documented a steady decline in the national prevalence of stunting from 37.1% to 7.1%. Prevalence dropped from 59.0% to 11.2% in the poorest quintile and from 12.1% to 3.3% among the wealthiest quintile. The decline was particularly steep in the last 10 years of the period (1996 to 2007), when the gaps between poor and wealthy families with children under 5 were also reduced in terms of purchasing power; access to education, health care and water and sanitation services; and reproductive health indicators. Conclusion In Brazil, socioeconomic development coupled with equity-oriented public policies have been accompanied by marked improvements in living conditions and a substantial decline in child undernutrition, as well as a reduction of the gap in nutritional status between children in the highest and lowest socioeconomic quintiles. Future studies will show whether these gains will be maintained under the current global economic crisis.

Fortified food made by the extrusion of a mixture of chickpea, corn and bovine lung controls iron-deficiency anaemia in preschool children

A fortified food that was rich in protein, vitamins and iron made of chickpea, bovine lung and corn was developed with the aim of controlling iron-deficiency anaemia in children from poorer areas. It was tested in Teresina, State of Piaui, Northeastern Brazil, on a population with high anaemia prevalence. Two local daycare units with similar characteristics were selected and the children at one of them received a 30 g pack three times a week, representing a total iron daily intake of 6.96 mg. The other daycare unit was followed as a control. The capillary haemoglobin concentration was determined for the children at both daycare units, at the beginning of the study and after a two-month intervention period. The mean haemoglobin concentration in the test group at the beginning of the intervention was 11.8 g/dL, which increased to 13.1 g/dL at the end of the intervention. In the control group these figures remained practically constant (11.6-11.8 g/dL). These represented a dramatic and significant drop in anaemia prevalence, from 61.5% to 11.5% in the test group, and an insignificant reduction (63.1-57.7%) in the control group. The acceptance of the fortified snack was excellent and no undesirable effects were observed. (C) 2007 Published by Elsevier Ltd.

Impact of a nutritional counseling program on prevention of HAART-related metabolic and morphologic abnormalities

The advent of highly active antiretroviral therapy (HAART) improved HIV infection prognosis. However, adverse metabolic and morphologic effects emerged, highlighting a lack of investigation into the role of nutritional interventions among this population. The present study evaluated the impact of a nutritional counseling program on prevention of morphologic and metabolic changes in patients living with HIV/AIDS receiving HAART. A 12-month randomized clinical trial was conducted with 53 adults of both genders in use of HAART. Subjects were allocated to either an intervention group (IG) or a control group (CG). Nutritional counseling was based on the promotion of a healthy diet pattern. Anthropometrical, biochemical, blood pressure, and food intake variables were assessed on four separate occasions. Sub scapular skin-fold results showed a significant tendency for increase between time 1 (Mean IG = 14.9 mm; CG = 13.6 mm), time 3 (Mean IG = 16.7 mm; CG = 18.2 mm), and time 4 (Mean IG = 16.4 mm; CG = 17.7 mm). Lipid percentage intake presented a greater increase among controls (time 1 mean = 26.3%, time 4 mean = 29.6%) than among IG subjects (time 1 mean = 29.1%, time 4 mean = 28.9%). Moreover, participants allocated to the IG presented an increase in dietetic fiber intake of almost 10 grams. The proposed nutritional counseling program proved to be effective in improving diet by reducing fat consumption and increasing fiber intake.

Health in Brazil 6 Health conditions and health-policy innovations in Brazil: the way forward

Brazil is a large complex country that is undergoing rapid economic, social, and environmental change In this Series of six articles, we have reported important improvements in health status and life expectancy, which can be ascribed largely to progress in social determinants of health and to implementation of a comprehensive national health system with strong social participation. Many challenges remain, however. Socioeconomic and regional disparities are still unacceptably large, reflecting the fact that much progress is still needed to improve basic living conditions for a large proportion of the population. New health problems arise as a result of urbanisation and social and environmental change, and some old health issues remain unabated. Administration of a complex, decentralised public-health system, in which a large share of services is contracted out to the private sector, together with many private insurance providers, inevitably causes conflict and contradiction. The challenge is ultimately political, and we conclude with a call for action that requires continuous engagement by Brazilian society as a whole in securing the right to health for all Brazilian people.

Nutritional information of meals supplied by companies, participating in the workers` meal program in Sao Paulo, Brazil

Objective. To compare the nutritional value of meals provided by companies participating in the Workers` Meal Program in the city of Sao Paulo, Brazil, to the nutritional recommendations and guidelines established by the Ministry of Health for the Brazilian population. Methods. The 72 companies studied were grouped according to economic sector (industrial, services, or commerce), size (micro, small, medium, or large), meal preparation modality (prepared on-site by the company itself, on-site by a hired caterer, or off-site by a hired caterer), and supervision by a dietitian (yes or no). The per capita amount of food was determined based on the lunch, dinner, and supper menus for three days. The nutritional value of the meals was defined by the amount of calories, carbohydrates, protein, total fat, polyunsaturated fat, saturated fat, trans fat, sugars, cholesterol, and fruits and vegetables. Results. Most of the menus were deficient in the number of fruits and vegetables (63.9%) and amount of polyunsaturated fat (83.3%), but high in total fat (47.2%) and cholesterol (62.5%). Group 2, composed of mostly medium and large companies, supervised by a dietician, belonging to the industrial and/or service sectors, and using a hired caterer, on averaged served meals with higher calorie content (P < 0.001), higher percentage of polyunsaturated fat (P < 0.001), more cholesterol (P = 0.015), and more fruits and vegetables (P < 0.001) than Group 1, which was composed of micro and small companies from the commercial sector, that prepare the meals themselves on-site, and are not supervised by a dietitian. Regarding the nutrition guidelines set for the Brazilian population, Group 2 meals were better in terms of fruit and vegetable servings (P < 0.001). Group I meals were better in terms of cholesterol content (P = 0.05). Conclusions. More specific action is required targeting company officers and managers in charge of food and nutrition services, especially in companies without dietitian supervision.