Lack of access and continuity of adult health care: a national population-based survey

OBJECTIVE To describe the lack of access and continuity of health care in adults.METHODS A cross-sectional population-based study was performed on a sample of 12,402 adults aged 20 to 59 years in urban areas of 100 municipalities of 23 states in the five Brazilian geopolitical regions. Barriers to the access and continuity of health care and were investigated based on receiving, needing and seeking health care (hospitalization and accident/emergency care in the last 12 months; care provided by a doctor, by other health professional or home care in the last three months). Based on the results obtained by the description of the sample, a projection is provided for adults living in Brazilian urban areas.RESULTS The highest prevalence of lack of access to health services and to provision of care by health professionals was for hospitalization (3.0%), whilst the lowest prevalence was for care provided by a doctor (1.1%). The lack of access to care provided by other health professionals was 2.0%; to accident and emergency services, 2.1%; and to home care, 2.9%. As for prevalences, the greatest absolute lack of access occurred in emergency care (more than 360,000 adults). The main reasons were structural and organizational problems, such as unavailability of hospital beds, of health professionals, of appointments for the type of care needed and charges made for care.CONCLUSIONS The universal right to health care in Brazil has not yet been achieved. These projections can help health care management in scaling the efforts needed to overcome this problem, such as expanding the infrastructure of health services and the workforce.

Performance evaluation of hospitals that provide care in the public health system, Brazil

OBJECTIVE To analyze if size, administrative level, legal status, type of unit and educational activity influence the hospital network performance in providing services to the Brazilian Unified Health System.METHODS This cross-sectional study evaluated data from the Hospital Information System and the Cadastro Nacional de Estabelecimentos de Saúde (National Registry of Health Facilities), 2012, in Sao Paulo, Southeastern Brazil. We calculated performance indicators, such as: the ratio of hospital employees per bed; mean amount paid for admission; bed occupancy rate; average length of stay; bed turnover index and hospital mortality rate. Data were expressed as mean and standard deviation. The groups were compared using analysis of variance (ANOVA) and Bonferroni correction.RESULTS The hospital occupancy rate in small hospitals was lower than in medium, big and special-sized hospitals. Higher hospital occupancy rate and bed turnover index were observed in hospitals that include education in their activities. The hospital mortality rate was lower in specialized hospitals compared to general ones, despite their higher proportion of highly complex admissions. We found no differences between hospitals in the direct and indirect administration for most of the indicators analyzed.CONCLUSIONS The study indicated the importance of the scale effect on efficiency, and larger hospitals had a higher performance. Hospitals that include education in their activities had a higher operating performance, albeit with associated importance of using human resources and highly complex structures. Specialized hospitals had a significantly lower rate of mortality than general hospitals, indicating the positive effect of the volume of procedures and technology used on clinical outcomes. The analysis related to the administrative level and legal status did not show any significant performance differences between the categories of public hospitals.

Advances and challenges in oral health after a decade of the “Smiling Brazil” Program

ABSTRACT OBJECTIVE To analyze oral health work changes in primary health care after Brazil’s National Oral Health Policy Guidelines were released. METHODS A literature review was conducted on Medline, LILACS, Embase, SciELO, Biblioteca Virtual em Saúde, and The Cochrane Library databases, from 2000 to 2013, on elements to analyze work changes. The descriptors used included: primary health care, family health care, work, health care policy, oral health care services, dentistry, oral health, and Brazil. Thirty-two studies were selected and analyzed, with a predominance of qualitative studies from the Northeast region with workers, especially dentists, focusing on completeness and quality of care. RESULTS Observed advances focused on educational and permanent education actions; on welcoming, bonding, and accountability. The main challenges were related to completeness; extension and improvement of care; integrated teamwork; working conditions; planning, monitoring, and evaluation of actions; stimulating people’s participation and social control; and intersectorial actions. CONCLUSIONS Despite the new regulatory environment, there are very few changes in oral health work. Professionals tend to reproduce the dominant biomedical model. Continuing efforts will be required in work management, training, and permanent education fields. Among the possibilities are the increased engagement of managers and professionals in a process to understand work dynamics and training in the perspective of building significant changes for local realities.

Health self-assessment by hemodialysis patients in the Brazilian Unified Health System

ABSTRACT OBJECTIVE To examine whether the level of complexity of the services structure and sociodemographic and clinical characteristics of patients in hemodialysis are associated with the prevalence of poor health self-assessment. METHODS In this cross-sectional study, we evaluated 1,621 patients with chronic terminal kidney disease on hemodialysis accompanied in 81 dialysis services in the Brazilian Unified Health System in 2007. Sampling was performed by conglomerate in two stages and a structured questionnaire was applied to participants. Multilevel multiple logistic regression was used for data analysis. RESULTS The prevalence of poor health self-assessment was of 54.5%, and in multivariable analysis it was associated with the following variables: increasing age (OR = 1.02; 95%CI 1.01–1.02), separated or divorced marital status (OR = 0.62; 95%CI 0.34–0.88), having 12 years or more of study (OR = 0.51; 95%CI 0.37–0.71), spending more than 60 minutes in commuting between home and the dialysis service (OR = 1.80; 95%CI 1.29–2.51), having three or more self-referred diseases (OR = 2.20; 95%CI 1.33–3.62), and reporting some (OR = 2.17; 95%CI 1.66–2.84) or a lot of (OR = 2.74; 95%CI 2.04–3.68) trouble falling asleep. Individuals in treatment in dialysis services with the highest level of complexity in the structure presented less chance of performing a self-assessment of their health as bad (OR = 0.59; 95%CI 0.42–0.84). CONCLUSIONS We showed poor health self-assessment is associated with age, years of formal education, marital status, home commuting time to the dialysis service, number of self-referred diseases, report of trouble sleeping, and also with the level of complexity of the structure of health services. Acknowledging these factors can contribute to the development of strategies to improve the health of patients in hemodialysis in the Brazilian Unified Health System.

Frequency of toxocara infection in children attended by the health public service of Maringá, south Brazil

The lack of specific laboratorial diagnosis methods and precise symptoms makes the toxocariasis a neglected disease in Public Health Services. This study aims to determine the frequency of Toxocara spp. infection in children attended by the Health Public Service of Hospital Municipal de Maringá, South Brazil. To evaluate the association of epidemiological and clinical data, an observational and cross-section study was carried out. From 14,690 attended children/year aged from seven month to 12 years old, 450 serum samples were randomly collected from September/2004 to September/2005. A questionnaire was used to evaluate epidemiological, clinical and hematological data. An ELISA using Toxocara canis larval excretory-secretory products as antigen detected 130 (28.8%) positive sera, mainly between children from seven month to five years old (p = 0.0016). Significant correlation was observed between positive serology for Toxocara, and frequent playing in sandbox at school or daycare center (p = 0.011) and the presence of a cat at home (p = 0.056). From the families, 50% were dog owners which exposed soil backyards. Eosinophilia (p = 0.776), and signs and symptoms analyzed (fever p = 0.992, pneumonia p = 0.289, cold-like symptoms p = 0.277, cough p = 0.783, gastrointestinal problems p = 0.877, migraine p = 0.979, abdominal pain p = 0.965, joint pain p = 0.686 and skin rash p = 0.105) could not be related to the presence of anti-Toxocara antibodies. Therefore, two asthmatics children showed titles of 1:10,240 and accentuated eosinophilia (p = 0.0001). The authors emphasize the needs of prevention activities.

Re-evaluation of the basic procedures involved in the storage of measles vaccine in public health units of the municipality of Niterói, state of Rio de Janeiro, Brazil

Four years after the first visit seventeen public health units were visited again and evaluated as to standards of storage recommended by the Brazilian Immunization Programme. In 100% of the units, refrigerators and proper inside location of vaccines in the refrigerator were adequatety or regularfy maintained and checked, respectively. However, when control of temperature was checked, onfy 64.7% presented adequate storage conditions. In 94.1 % of the units, health workers complained of lack of immediate technical support in emergency situations. In 55.2 % the titers vaccine samples of were under the minimal recommended potency. It is necessary that the factors concerning the cold chain be continualfy evaluated so that the quality of the vaccines that will be used is not affected.

Toxoplasmosis: an examination of knowledge among health professionals and pregnant women in a municipality of the State of Paraná

Introduction The aim of this study was to investigate the knowledge of toxoplasmosis among professionals and pregnant women in the public health services in Paraná, Brazil. Methods A cross-sectional observational and transversal study of 80 health professionals (44 nurses and 36 physicians) and 330 pregnant women [111 immunoglobulin M (IgM)- and IgG-non-reactive and 219 IgG-reactive] was conducted in 2010. An epidemiological data questionnaire was administered to the professionals and to the pregnant women, and a questionnaire about the clinical aspects and laboratory diagnosis of toxoplasmosis was administered to the professionals. Results The participants frequently provided correct responses about prophylactic measures. Regarding the clinical and laboratory aspects, the physicians provided more correct responses and discussed toxoplasmosis with the pregnant women. The professionals had difficulty interpreting the avidity test results, and the physicians stated that they referred pregnant women with high-risk pregnancies to a county reference center. Of the professionals, 53 (91.4%) reported that they instructed women during prenatal care, but only 54 (48.6%) at-risk pregnant women and 99 (45.2%) women who were not at risk reported receiving information about preventive measures. The physicians provided verbal instructions to 120 (78.4%) women, although instructional materials were available in the county. The pregnant women generally lacked knowledge about preventive measures for congenital toxoplasmosis, but the at-risk pregnant women tended to respond correctly. Conclusions This study provides data to direct public health policies regarding the importance of updating the knowledge of primary care professionals. Mechanisms should be developed to increase public knowledge because prophylactic strategies are important for preventing congenital toxoplasmosis.

Impact of nutritional counseling in reducing serum cholesterol in public health service patients

OBJECTIVE: To assess the impact of nutritional attention on the lipid profile and nutritional status of hypercholesterolemic patients attended in health centers of Belo Horizonte. METHODS: Using nutritional attendance patient record cards from two health units, the evolution of the lipid profile and the nutritional state (BMI) was monitored of 96 hypercholesterolemic patients who received diet. The patients were appraised at the following moments: initial (1st consultation), after 3 months (2nd consultation) and last consultation (variable for each patient). RESULTS: On the first attendance, 44,4% of the patients presented not only high total cholesterol and LDL-c, but also hypertriglyceridemia and 70.3% were overweight or obese, but most patients (75.6%) presented adequate HDL-c levels. There was significant reduction in the BMI, total cholesterol, LDL-c values (p < 0.01) and also in the triglyceride levels (p < 0.05) in the first three months, without alteration in the HDL-c levels. A significant reduction (p < 0.01) was observed in the frequency of individuals with high cholesterol (from 89.6% down to 47.9%), high and very high LDL-c (from 82.6% down to 45.7%), as well as high and very high triglyceride (from 43.6% down to 16.7%). The observed reduction in frequency of the low HDL-c was statistically meaningless. CONCLUSION: This study evidences the effect of the nutritional attention on lipid profile in hypercholesterolemic patients, reinforcing the need for a multiprofessional team to attend them at the public health services.

Schistosomiasis control in a primary health care system

The successful implementation of a Primary Health Care System (PHC) in any country depends primarily on the ability to adapt its concepts and principles to the country's culture and development stage. Thus, the PHC system should reflect a balanced interaction between available resources, such as health manpower capabilities, and the nature and magnitude of the health problems. In addition, PHC should be viewed as the inlet to a multi-level pyramidal health system which caters to both community and individual needs in a balanced way. The adage that Ministries of Health should "work with and for the people" in health development, is especially true in the area of PHC, and hence, the health policy should aim to integrate health services in community development and involve people in its planning, implementation and evaluation.

An interactive perspective of health education for the tropical disease control: the schistosomiasis case

Some municipalities in Brazil have been requesting orientation for the implementation of health education programs related to the control of schistosomiasis. This demand was based on experiences in the development of health education researches, strategies and materials for school-age children, involving the communities and secretaries of health and education. Motivated by this request and the recently implemented plan of health services (Unified Health System - Sistema Único de Saúde - SUS) that gives autonomy to the municipalities to utilize health resources and services in Brazil, this paper presents an interactive perspective of planning health education research and programs. The purpose of this perspective is to stimulate a reflection on the needs and actions of institutions and people involved in health education research and/or programs to obtain sustainability, commitment and effectiveness - not only in the control of schistosomiasis, but also in the improvement of environmental conditions, quality of life and personal health. This perspective comprises interaction among three levels related to health education programs: the decision level, the executive level and the beneficiary level. The needs and lines of action at each of these levels are discussed, as well as the ways in which they can interact with each other. This proposal may lead to useful interactive ways of planing, organizing, executing and evaluating health education research and/or program, not only towards the prevention and control of the disease at stake, but also to promote health in general.

The discourse of health managers on aspects related to the delay in tuberculosis diagnosis

The aim of this study was to analyze the discourse of health managers on aspects related to delay in tuberculosis diagnosis. This was a qualitative research study, conducted with 16 Family Health Unit managers. The empirical data were obtained through semi-structured interviews. The analysis was based on the theoretical framework of the French school of discourse analysis. According to the managers’ statements, the delay in tuberculosis diagnosis is related to patient and health service aspects. As for patient aspects, managers report fear, prejudice and lack of information as factors that may promote a delayed diagnosis. Regarding health service aspects, structural problems and lack of professional skills were reported. The discourse of managers should be considered to qualify tuberculosis control actions and to prevent delays in diagnosis.

Barriers in health care to breast cancer: perception of women

Identifying the barriers in the access to health care to breast cancer perceived by women undergoing chemotherapy.Method: An exploratory descriptive study. The sample consisted of 58 women with breast cancer receiving chemotherapy and registered in the public oncology ambulatory of Aracaju-Sergipe. Data collection was carried out between October 2011 and March 2012 by semistructured interviews, and data were processed using the SPSS, version 17.Results: Among the interviewed women, 37 (63.8%) reported at least a barrier in the trajectory of care for breast cancer. The organizational and health services barriers were the most reported in the periods of investigation and treatment of breast cancer.Conclusion: In face of these findings, the barriers should be considered in public health policies and programs for the control of breast cancer in Sergipe.



Management of basic health units in municipalities of different size: profile and management instruments

Objective To identify the characteristics of managers and their use of management instruments in primary care and to analyze differences in these features among municipalities of different sizes. Method The present cross-sectional descriptive study was conducted at 108 basic health units from 21 municipalities in northern Paraná, Brazil. The data were collected using a semi-structured questionnaire during the second half of 2010. Results Most managers had graduate degrees and were female and nurses. The managers from the small municipalities were younger, their payment was lower, and they had less work experience. The use of management instruments was expressive for both the organization and work management; however, the instruments were used less in the small municipalities. Conclusion The managers were committed to their role; it is recommended that policies and guidance should be formulated at the federal and state levels to support small municipalities.

Performance evaluation of primary care services for the treatment of tuberculosis

Objective Evaluating the performance of primary care services for the treatment of tuberculosis according to the assessment referential of health services (structure/process) in Cabedelo, a port city in the state of Paraíba. Method An evaluation quantitative, cross-sectional study, in which were carried out 117 interviews with health professionals using a structured instrument. The analysis was based on the construction of indicators using a standardized value for the reduced variable (z=1). Results The structural indicators showed regular performance for the following variables: professional training, access to record instruments and coordination with other services. The process indicators related to external actions and information about the disease had unsatisfactory performance. The directly observed treatment and the flows of reference/counter-reference had regular performance. Conclusion The focused professional qualification, the fragmentation of practices and the unsystematic home care constitute obstacles for carrying out actions aimed at providing expanded, continuous and resolute care.



Solvability of mental health care in the Family Health Strategy: social representation of professionals and users

Objective To aprehend the social representations about the solvability in mental health care with users of the Family Health Strategy and professionals of family health teams and of the Center for Psychosocial Care. Method A qualitative study using semi-structured interviews for data collection, and the Alceste software for analysis. This software uses the Hierarchical Descending Classification based on the examination of lexical roots, considering the words as units and providing context in the corpus. Results The representations emerge in two opposing poles: the users require satisfaction with care and the professionals realize the need for improvement of health actions. Although the matricial support in mental health and the home visits are developed, the barriers related to investment in health, continuing education and organization of care persist. Conclusion The different representations enable improvements in customer service, solvability of care and aggregate knowledge and practices in the expanded perspective of health needs in the family, social and therapeutic context.