Beliefs and attitudes about endemic dental fluorosis among adolescents in rural Brazil

OBJECTIVE: To understand beliefs and attitudes about fluorosis among young people living in a rural area. METHODOLOGICAL PROCEDURES: Qualitative study consisting of semi-structured interviews with 23 adolescents with dental fluorosis, 14 teachers and three health authorities in the city of São Francisco, Southeastern Brazil, in 2002. Content analysis and social representation theory were applied. ANALYSIS OF RESULTS: The organoleptic characteristics of carbonates that affect groundwater (salty flavor, whitish coloration, and turbidity) associated with negative aspects of household use of this water are considered a cause of mottled enamel. Even after contact with researchers who investigated this phenomenon and helped find a solution for this condition, the local population is still unwilling to accept fluoride as the cause of the problem and does not fully agree to use water from other sources because they are afraid of the quality of water. CONCLUSIONS: Misperceptions of the causes of dental fluorosis and water treatment costs compromise the implementation of uncontaminated surface water supplies. Health education strategies are required in parallel with solutions for securing water supply in drought-ravaged areas.

Association of dental enamel lead levels with risk factors for environmental exposure

OBJECTIVE: To analyze household risk factors associated with high lead levels in surface dental enamel. METHODS: A cross-sectional study was conducted with 160 Brazilian adolescents aged 14-18 years living in poor neighborhoods in the city of Bauru, southeastern Brazil, from August to December 2008. Body lead concentrations were assessed in surface dental enamel acid-etch microbiopsies. Dental enamel lead levels were measured by graphite furnace atomic absorption spectrometry and phosphorus levels were measured by inductively coupled plasma optical emission spectrometry. The parents answered a questionnaire about their children's potential early (05 years old) exposure to well-known lead sources. Logistic regression was used to identify associations between dental enamel lead levels and each environmental risk factor studied. Social and familial covariables were included in the models. RESULTS: The results suggest that the adolescents studied were exposed to lead sources during their first years of life. Risk factors associated with high dental enamel lead levels were living in or close to a contaminated area (OR = 4.49; 95% CI: 1.69;11.97); and member of the household worked in the manufacturing of paints, paint pigments, ceramics or batteries (OR = 3.43; 95% CI: 1.31;9.00). Home-based use of lead-glazed ceramics, low-quality pirated toys, anticorrosive paint on gates and/or sale of used car batteries (OR = 1.31; 95% CI: 0.56;3.03) and smoking (OR = 1.66; 95% CI: 0.52;5.28) were not found to be associated with high dental enamel lead levels. CONCLUSIONS: Surface dental enamel can be used as a marker of past environmental exposure to lead and lead concentrations detected are associated to well-known sources of lead contamination.

Hospitalization rates for pneumococcal disease in Brazil, 2004 - 2006

OBJECTIVE: To estimate hospitalization rates for pneumococcal disease based on the Brazilian Hospital Information System (SIH). METHODS: Descriptive study based on the Hospital Information System of Brazilian National Health System data from January 2004 to December 2006: number of hospitalizations and deaths for pneumococcal meningitis, pneumococcal sepsis, pneumococcal pneumonia and Streptococcus pneumoniae as the cause of diseases reported in Brazil. Data from the 2003 Brazilian National Household Survey were used to estimate events in the private sector. Pneumococcal meningitis cases and deaths reported to the Notifiable Diseases Information System during the study period were also analyzed. RESULTS: Pneumococcal disease accounted for 34,217 hospitalizations in the Brazilian National Health System (0.1% of all hospitalizations in the public sector). Pneumococcal pneumonia accounted for 64.8% of these hospitalizations. The age distribution of the estimated hospitalization rates for pneumococcal disease showed a "U"-shape curve with the highest rates seen in children under one (110 to 136.9 per 100,000 children annually). The highest hospital case-fatality rates were seen among the elderly, and for sepsis and meningitis. CONCLUSIONS: PD is a major public health problem in Brazil. The analysis based on the SIH can provide an important input to pneumococcal disease surveillance and the impact assessment of immunization programs.

Social contextual factors contributing to child and adolescent labor: an ecological analysis

OBJECTIVE: To examine the relationship between social contextual factors and child and adolescent labor. METHODS: Population-based cohort study carried out with 2,512 families living in 23 subareas of a large urban city in Brazil from 2000 to 2002. A random one-stage cluster sampling was used to select families. Data were obtained through individual household interviews using questionnaires. The annual cumulative incidence of child and adolescent labor was estimated for each district. New child and adolescent labor cases were those who had their first job over the two-year follow-up. The annual cumulative incidence of child and adolescent labor was the response variable and predictors were contextual factors such as lack of social support, social deprivation, unstructured family, perceived violence, poor school quality, poor environment conditions, and poor public services. Pearson's correlation and multiple linear regression were used to assess the associations. RESULTS: There were selected 943 families corresponding to 1,326 non-working children and adolescents aged 8 to 17 years. Lack of social support, social deprivation, perceived violence were all positively and individually associated with the annual cumulative incidence of child and adolescent labor. In the multiple linear regression model, however, only lack of social support and perceived violence in the neighborhood were positively associated to child and adolescent labor. No effect was found for poor school quality, poor environment conditions, poor public services or unstructured family. CONCLUSIONS: Poverty reduction programs can reduce the contextual factors associated with child and adolescent labor. Violence reduction programs and strengthening social support at the community level may contribute to reduce CAL.

Validity of self-reported hearing loss in adults: performance of three single questions

OBJECTIVE: To estimate the validity of three single questions used to assess self-reported hearing loss as compared to pure-tone audiometry in an adult population. METHODS: A validity study was performed with a random sub-sample of 188 subjects aged 30 to 65 years, drawn from the fourth wave of a population-based cohort study carried out in Salvador, Northeastern Brazil. Data were collected in household visits using questionnaires. Three questions were used to separately assess self-reported hearing loss: Q1, "Do you feel you have a hearing loss?"; Q2, "In general, would you say your hearing is 'excellent,' 'very good,' 'good,' 'fair,' 'poor'?"; Q3, "Currently, do you think you can hear 'the same as before', 'less than before only in the right ear', 'less than before only in the left ear', 'less than before in both ears'?". Measures of accuracy were estimated through seven measures including Youden index. Responses to each question were compared to the results of pure-tone audiometry to estimate accuracy measures. RESULTS: The estimated sensitivity and specificity were 79.6%, 77.4% for Q1; 66.9%, 85.1% for Q2; and 81.5%, 76.4% for Q3, respectively. The Youden index ranged from 51.9% (Q2) to 57.0% (Q1) and 57.9% (Q3). CONCLUSIONS: Each of all three questions provides responses accurate enough to support their use to assess self-reported hearing loss in epidemiological studies with adult populations when pure-tone audiometry is not feasible.

Survey of hearing disorders in an urban population in Rondonia, Northern Brazil

OBJECTIVE: To identify the prevalence of hearing loss for the population in the urban area. METHODS: A cross-sectional household survey based on the World Health Organization Ear and Hearing Disorders Survey Protocol was conducted in 298 households in the urban area of Monte Negro, Rondonia, Northern Brazil, from 2005 to 2007. Ear examinations, behavioral audiometry and pure tone audiometry were conducted on 577 individuals. RESULTS: The results showed that 3.8% (95%CI 2.17;5.45) of population were classified in the disabling hearing impairment category. The prevalence of moderate hearing impairment was 3.4%; severe impairment was 0.4%; and profound hearing impairment was not found. CONCLUSIONS: The impairing hearing loss prevalence found in this study is within of the international prevalence for this level of hearing loss and smaller than observed in a previous study in the South region of Brazil.

Professional and community satisfaction with the Brazilian family health strategy

OBJECTIVE: To analyze the strengths and limitations of the Family Health Strategy from the perspective of health care professionals and the community. METHODS: Between June-August 2009, in the city of Vespasiano, Minas Gerais State, Southeastern Brazil, a questionnaire was used to evaluate the Family Health Strategy (ESF) with 77 healthcare professionals and 293 caregivers of children under five. Health care professional training, community access to health care, communication with patients and delivery of health education and pediatric care were the main points of interest in the evaluation. Logistic regression analysis was used to obtain odds ratios and 95% confidence intervals as well as to assess the statistical significance of the variables studied. RESULTS: The majority of health care professionals reported their program training was insufficient in quantity, content and method of delivery. Caregivers and professionals identified similar weaknesses (services not accessible to the community, lack of healthcare professionals, poor training for professionals) and strengths (community health worker-patient communications, provision of educational information, and pediatric care). Recommendations for improvement included: more doctors and specialists, more and better training, and scheduling improvements. Caregiver satisfaction with the ESF was found to be related to perceived benefits such as community health agent household visits (OR 5.8, 95%CI 2.8;12.1), good professional-patient relationships (OR 4.8, 95%CI 2.5;9.3), and family-focused health (OR 4.1, 95%CI 1.6;10.2); and perceived problems such as lack of personnel (OR 0.3, 95%CI 0.2;0.6), difficulty with access (OR 0.2, 95%CI 0.1;0.4), and poor quality of care (OR 0.3, 95%CI 0.1;0.6). Overall, 62% of caregivers reported being generally satisfied with the ESF services. CONCLUSIONS: Identifying the limitations and strengths of the Family Health Strategy from the healthcare professional and caregiver perspective may serve to advance primary community healthcare in Brazil.

Access to medicines for acute illness in middle income countries in Central America

OBJECTIVE : To analyze the main predictors of access to medicines for persons who experienced acute health conditions. METHODS : This was a cross-sectional analytic study, based on data from household surveys. We examined the predictors of: (1) seeking care for acute illness in the formal health care system and (2) obtaining all medicines sought for the acute condition. RESULTS : The significant predictors of seeking health care for acute illnesses were urban geographic location, head of household with secondary school education or above, age under 15, severity of illness perceived by the respondent, and having health insurance. The most important predictor of obtaining full access to medicines was seeking care in the formal health care system. People who sought care in the formal system were three times more likely to receive all the medicines sought (OR 3.0, 95%CI 2.3;4.0). For those who sought care in the formal health system, the strongest predictors of full access to medicines were seeking care in the private sector, having secondary school education or above, and positive perceptions of quality of health care and medicines in public sector health facilities. For patients who did not seek care in the formal health system, full access to medicines was more likely in Honduras or Nicaragua than in Guatemala. Urban geographic location, higher economic status, and male gender were also significant predictors. CONCLUSIONS : A substantial part of the population in these three countries sought and obtained medicines outside of the formal health care system, which may compromise quality of care and pose a risk to patients. Determinants of full access to medicines inside and outside the formal health care system differ, and thus may require different strategies to improve access to medicines. 

Prevalence and determinants of child undernutrition and stunting in semiarid region of Brazil

OBJECTIVE : To analyze the evolution in the prevalence and determinants of malnutrition in children in the semiarid region of Brazil. METHODS : Data were collected from two cross-sectional population-based household surveys that used the same methodology. Clustering sampling was used to collect data from 8,000 families in Ceará, Northeastern Brazil, for the years 1987 and 2007. Acute undernutrition was calculated as weight/age < -2 standard deviation (SD); stunting as height/age < -2 SD; wasting as weight/height < -2 SD. Data on biological and sociodemographic determinants were analyzed using hierarchical multivariate analyses based on a theoretical model. RESULTS : A sample of 4,513 and 1,533 children under three years of age, in 1987 and 2007, respectively, were included in the analyses. The prevalence of acute malnutrition was reduced by 60.0%, from 12.6% in 1987 to 4.7% in 2007, while prevalence of stunting was reduced by 50.0%, from 27.0% in 1987 to 13.0% in 2007. Prevalence of wasting changed little in the period. In 1987, socioeconomic and biological characteristics (family income, mother’s education, toilet and tap water availability, children’s medical consultation and hospitalization, age, sex and birth weight) were significantly associated with undernutrition, stunting and wasting. In 2007, the determinants of malnutrition were restricted to biological characteristics (age, sex and birth weight). Only one socioeconomic characteristic, toilet availability, remained associated with stunting. CONCLUSIONS : Socioeconomic development, along with health interventions, may have contributed to improvements in children’s nutritional status. Birth weight, especially extremely low weight (< 1,500 g), appears as the most important risk factor for early childhood malnutrition.

Social protection systems in vulnerable families: their importance for the public health

OBJECTIVE To analyze the effectiveness of the Chilean System of Childhood Welfare in transferring benefits to socially vulnerable families. METHODS A cross-sectional study with a sample of 132 families from the Metropolitan Region, Chile, stratified according to degree of social vulnerability, between September 2011 and January 2012. Semi-structured interviews were conducted with mothers of the studied families in public health facilities or their households. The variables studied were family structure, psychosocial risk in the family context and integrated benefits from the welfare system in families that fulfill the necessary requirements for transfer of benefits. Descriptive statistics to measure location and dispersion were calculated. A binary logistic regression, which accounts for the sample size of the study, was carried out. RESULTS The groups were homogenous regarding family size, the presence of biological father in the household, the number of relatives living in the same dwelling, income generation capacity and the rate of dependency and psychosocial risk (p ≥ 0.05). The transfer of benefits was low in all three groups of the sample (≤ 23.0%). The benefit with the best coverage in the system was the Single Family Subsidy, whose transfer was associated with the size of the family, the presence of relatives in the dwelling, the absence of the father in the household, a high rate of dependency and a high income generation capacity (p ≤ 0.10). CONCLUSIONS The effectiveness of benefit transfer was poor, especially in families that were extremely socially vulnerable. Further explanatory studies of benefit transfers to the vulnerable population, of differing intensity and duration, are required in order to reduce health disparities and inequalities.

Socioeconomic inequality in catastrophic health expenditure in Brazil

OBJECTIVE To analyze the evolution of catastrophic health expenditure and the inequalities in such expenses, according to the socioeconomic characteristics of Brazilian families.METHODS Data from the National Household Budget 2002-2003 (48,470 households) and 2008-2009 (55,970 households) were analyzed. Catastrophic health expenditure was defined as excess expenditure, considering different methods of calculation: 10.0% and 20.0% of total consumption and 40.0% of the family’s capacity to pay. The National Economic Indicator and schooling were considered as socioeconomic characteristics. Inequality measures utilized were the relative difference between rates, the rates ratio, and concentration index.RESULTS The catastrophic health expenditure varied between 0.7% and 21.0%, depending on the calculation method. The lowest prevalences were noted in relation to the capacity to pay, while the highest, in relation to total consumption. The prevalence of catastrophic health expenditure increased by 25.0% from 2002-2003 to 2008-2009 when the cutoff point of 20.0% relating to the total consumption was considered and by 100% when 40.0% or more of the capacity to pay was applied as the cut-off point. Socioeconomic inequalities in the catastrophic health expenditure in Brazil between 2002-2003 and 2008-2009 increased significantly, becoming 5.20 times higher among the poorest and 4.17 times higher among the least educated.CONCLUSIONS There was an increase in catastrophic health expenditure among Brazilian families, principally among the poorest and those headed by the least-educated individuals, contributing to an increase in social inequality.

Social capital, social participation and life satisfaction among Chilean older adults

OBJECTIVE To examine factors associated with social participation and their relationship with self-perceived well-being in older adults. METHODS This study was based on data obtained from the National Socioeconomic Characterization (CASEN) Survey conducted in Chile, in 2011, on a probability sample of households. We examined information of 31,428 older adults living in these households. Descriptive and explanatory analyses were performed using linear and multivariate logistic regression models. We assessed the respondents’ participation in different types of associations: egotropic, sociotropic, and religious. RESULTS Social participation increased with advancing age and then declined after the age of 80. The main finding of this study was that family social capital is a major determinant of social participation of older adults. Their involvement was associated with high levels of self-perceived subjective well-being. We identified four settings as sources of social participation: home-based; rural community-based; social policy programs; and religious. Older adults were significantly more likely to participate when other members of the household were also involved in social activities evidencing an intergenerational transmission of social participation. Rural communities, especially territorial associations, were the most favorable setting for participation. There has been a steady increase in the rates of involvement of older adults in social groups in Chile, especially after retirement. Religiosity remains a major determinant of associativism. The proportion of participation was higher among older women than men but these proportions equaled after the age of 80. CONCLUSIONS Self-perceived subjective well-being is not only dependent upon objective factors such as health and income, but is also dependent upon active participation in social life, measured as participation in associations, though its effects are moderate.

Factors associated with vaccination coverage in children < 5 years in Angola

OBJECTIVE To analyze vaccination coverage and factors associated with a complete immunization scheme in children < 5 years old. METHODS This cross-sectional household census survey evaluated 1,209 children < 5 years old living in Bom Jesus, Angola, in 2010. Data were obtained from interviews, questionnaires, child immunization histories, and maternal health histories. The statistical analysis used generalized linear models, in which the dependent variable followed a binary distribution (vaccinated, unvaccinated) and the association function was logarithmic and had the children’s individual, familial, and socioeconomic factors as independent variables. RESULTS Vaccination coverage was 37.0%, higher in children < 1 year (55.0%) and heterogeneous across neighborhoods; 52.0% of children of both sexes had no immunization records. The prevalence rate of vaccination significantly varied according to child age, mother’s level of education, family size, ownership of household appliances, and destination of domestic waste. CONCLUSIONS Vulnerable groups with vaccination coverage below recommended levels continue to be present. Some factors indicate inequalities that represent barriers to full immunization, indicating the need to implement more equitable policies. The knowledge of these factors contributes to planning immunization promotion measures that focus on the most vulnerable groups.

Access to continued-use medication among older adults, Brazil

OBJECTIVE To determine the prevalence and associated access factors for all continued-use prescription drugs and the ways in which they can be obtained.METHODS Data was obtained from the 2008 Household National Survey. The sample comprised 27,333 individuals above 60 years who reported that they used continued-use prescription drugs. A descriptive analysis and binary and multiple multinomial logistic regressions were performed.RESULTS 86.0% of the older adults had access to all the medication they needed, and among them, 50.7% purchased said medication. Those who obtained medication from the public health system were younger (60-64 years), did not have health insurance plans, and belonged to the lower income groups. It is remarkable that 14.0% of the subjects still had no access to any continued-use medication, and for those with more than four chronic diseases, this amount reached 22.0%. Those with a greater number of chronic diseases ran a higher risk of not having access to all the medication they needed.CONCLUSIONS There are some groups of older adults with an increased risk of not obtaining all the medication they need and of purchasing it. The results of this study are expected to contribute to guide programs and plans for access to medication in Brazil.

Trends in healthy life expectancy among older Brazilian women between 1998 and 2008

OBJECTIVE To analyze conditional and unconditional healthy life expectancy among older Brazilian women.METHODS This cross-sectional study used the intercensal technique to estimate, in the absence of longitudinal data, healthy life expectancy that is conditional and unconditional on the individual’s current health status. The data used were obtained from the Pesquisa Nacional por Amostra de Domicílios (National Household Sample Survey) of 1998, 2003, and 2008. This sample comprised 11,171; 13,694; and 16,259 women aged 65 years or more, respectively. Complete mortality tables from the Brazilian Institute of Geography and Statistics for the years 2001 and 2006 were also used. The definition of health status was based on the difficulty in performing activities of daily living.RESULTS The remaining lifetime was strongly dependent on the current health status of the older women. Between 1998 and 2003, the amount of time lived with disability for healthy women at age 65 was 9.8%. This percentage increased to 66.2% when the women already presented some disability at age 65. Temporal analysis showed that the active life expectancy of the women at age 65 increased between 1998-2003 (19.3 years) and 2003-2008 (19.4 years). However, life years gained have been mainly focused on the unhealthy state.CONCLUSIONS Analysis of conditional and unconditional life expectancy indicated that live years gained are a result of the decline of mortality in unhealthy states. This pattern suggests that there has been no reduction in morbidity among older women in Brazil between 1998 and 2008.