Mid-point for open-ended income category and the effect of equivalence scales on the income-health relationship

To estimate the mid-point of an open-ended income category and to assess the impact of two equivalence scales on income-health associations. Data were obtained from the 2010 Brazilian Oral Health Survey ( Pesquisa Nacional de Saúde Bucal – SBBrasil 2010). Income was converted from categorical to two continuous variables ( per capita and equivalized) for each mid-point. The median mid-point was R$ 14,523.50 and the mean, R$ 24,507.10. When per capita income was applied, 53% of the population were below the poverty line, compared with 15% with equivalized income. The magnitude of income-health associations was similar for continuous income, but categorized equivalized income tended to decrease the strength of association.

Screening for depressive symptoms in older adults in the Family Health Strategy, Porto Alegre, Brazil

OBJECTIVE To analyze the prevalence of depression in older adults and associated factors. METHODS Cross-sectional study using a stratified random sample of 621 individuals aged ≥ 60 from 27 family health teams in Porto Alegre, RS, Southern Brazil, between 2010 and 2012. Community health agents measured depression using the 15-item Geriatric Depression Scale. Scores of ≥ 6 were considered as depression and between 11 and 15 as severe depression. Poisson regression was used to search for independent associations of sociodemographic and self-perceived health with both depression and its severity. RESULTS The prevalence of depression was 30.6% and was significantly higher in women (35.9% women versus 20.9% men, p < 0.001). The variables independently associated with depression were: female gender (PR = 1.4, 95%CI 1.1;1.8); low education, especially illiteracy (PR = 1.8, 95%CI 1.2;2 6); regular self-rated health (OR = 2.2, 95%CI 1.6;3.0); and poor/very poor self-rated health (PR = 4.0, 95%CI 2.9;5.5). Except for education, the strength of association of these factors increases significantly in severe depression. CONCLUSIONS A high prevalence of depression was observed in the evaluations conducted by community health agents, professionals who are not highly specialized. The findings identified using the 15-item Geriatric Depression Scale in this way are similar to those in the literature, with depression more associated with low education, female gender and worse self-rated health. From a primary health care strategic point of view, the findings become still more relevant, indicating that community health agents could play an important role in identifying depression in older adults.

Brazilian physical activity guidelines as a strategy for health promotion

Public health actions endorsed by the federal government, for instance, health promotion initiatives, usually have greater impact at population level compared to other types of initiatives. This commentary aims to instigate debate on the importance and necessity of producing federally endorsed brazilian physical activity guidelines as a strategy for health promotion.

Incidence and risk factors for intimate partner violence during the postpartum period

OBJECTIVE To estimate the incidence and identify risk factors for intimate partner violence during postpartum.METHODS This prospective cohort study was conducted with women, aged between 18-49 years, enrolled in the Brazilian Family Health Strategy in Recife, Northeastern Brazil, between 2005 and 2006. Of the 1.057 women interviewed during pregnancy and postpartum, 539 women, who did not report violence before or during pregnancy, were evaluated. A theoretical-conceptual framework was built with three levels of factors hierarchically ordered: women’s and partners’ sociodemografic and behavioral characteristics, and relationship dynamics. Incidence and risk factors of intimate partner violence were estimated by Poisson Regression.RESULTS The incidence of violence during postpartum was 9.3% (95%CI 7.0;12.0). Isolated psychological violence was the most common (4.3%; 95%CI 2.8;6.4). The overlapping of psychological with physical violence occurred at 3.3% (95%CI 2.0;5.3) and with physical and/or sexual in almost 2.0% (95%CI 0.8;3.0) of cases. The risk of partner violence during postpartum was increased for women with a low level of education (RR = 2.6; 95%CI 1.3;5.4), without own income (RR = 1.7; 95%CI 1.0;2.9) and those who perpetrated physical violence against their partner without being assaulted first (RR = 2.0; 95%CI 1.2;3.4), had a very controlling partner (RR = 2.5; 95%CI 1.1;5.8), and had frequent fights with their partner (RR = 1.7; 95%CI 1.0;2.9).CONCLUSIONS The high incidence of intimate partner violence during postpartum and its association with aspects of the relationship’s quality between the couple, demonstrated the need for public policies that promote conflict mediation and enable forms of empowerment for women to address the cycle of violence.

Institutional and matrix support and its relationship with primary healthcare

OBJECTIVE To analyze whether the level of institutional and matrix support is associated with better certification of primary healthcare teams.METHODS In this cross-sectional study, we evaluated two kinds of primary healthcare support – 14,489 teams received institutional support and 14,306 teams received matrix support. Logistic regression models were applied. In the institutional support model, the independent variable was “level of support” (as calculated by the sum of supporting activities for both modalities). In the matrix support model, in turn, the independent variables were the supporting activities. The multivariate analysis has considered variables with p < 0.20. The model was adjusted by the Hosmer-Lemeshow test.RESULTS The teams had institutional and matrix supporting activities (84.0% and 85.0%), respectively, with 55.0% of them performing between six and eight activities. For the institutional support, we have observed 1.96 and 3.77 chances for teams who had medium and high levels of support to have very good or good certification, respectively. For the matrix support, the chances of their having very good or good certification were 1.79 and 3.29, respectively. Regarding to the association between institutional support activities and the certification, the very good or good certification was positively associated with self-assessment (OR = 1.95), permanent education (OR = 1.43), shared evaluation (OR = 1.40), and supervision and evaluation of indicators (OR = 1.37). In regards to the matrix support, the very good or good certification was positively associated with permanent education (OR = 1.50), interventions in the territory (OR = 1.30), and discussion in the work processes (OR = 1.23).CONCLUSIONS In Brazil, supporting activities are being incorporated in primary healthcare, and there is an association between the level of support, both matrix and institutional, and the certification result.

Strategies for price reduction of HIV medicines under a monopoly situation in Brazil

ABSTRACT OBJECTIVE To analyze Government strategies for reducing prices of antiretroviral medicines for HIV in Brazil. METHODS Analysis of Ministry of Health purchases of antiretroviral medicines, from 2005 to 2013. Expenditures and costs of the treatment per year were analyzed and compared to international prices of atazanavir. Price reductions were estimated based on the terms of a voluntary license of patent rights and technology transfer in the Partnership for Productive Development Agreement for atazanavir. RESULTS Atazanavir, a patented medicine, represented a significant share of the expenditures on antiretrovirals purchased from the private sector. Prices in Brazil were higher than international references, and no evidence was found of a relationship between purchase volume and price paid by the Ministry of Health. Concerning the latest strategy to reduce prices, involving local production of the 200 mg capsule, the price reduction was greater than the estimated reduction. As for the 300 mg capsule, the amounts paid in the first two years after the Partnership for Productive Development Agreement were close to the estimated values. Prices in nominal values for both dosage forms remained virtually constant between 2011 (the signature of the Partnership for Productive Development Agreement), 2012 and 2013 (after the establishment of the Partnership). CONCLUSIONS Price reduction of medicines is complex in limited-competition environments. The use of a Partnership for Productive Development Agreement as a strategy to increase the capacity of local production and to reduce prices raises issues regarding its effectiveness in reducing prices and to overcome patent barriers. Investments in research and development that can stimulate technological accumulation should be considered by the Government to strengthen its bargaining power to negotiate medicines prices under a monopoly situation.

Relationship of health workers with their organization and work: a cross-cultural study

ABSTRACT We analyzed the differences, by Student’s t-test and ANOVA, between nurses and physicians from Portugal, Poland, Spain, and United Kingdom regarding their relationship with their work and organization. In total, 1,401 professionals answered the HSA-QHPR questionnaire. There are different levels of connection between physicians and nurses. The United Kingdom has the lowest levels of connection with the work while Portugal has the highest levels of relationship with the organization. The results provide guidelines for the development of policies and differential strategies aimed at improving the quality of healthcare service.

Relationship between the prevalence of antibodies to arbovirus and hepatitis B virus in the Vale do Ribeira region, Brazil

280 students, between 6 and 14 years old, residents in the Iguape county, southern coast of the State of São Paulo, were studied in order to identify the existence of a possible association between the prevalence of specific antibodies to the hepatitis B virus and the exposure to haematophagous mosquitoes, evaluated indirectly through the prevalence of antibodies to 17 arboviruses isolated in Brazil. The children were from 4 areas with different topographical characteristics: 89 of the children were from the urban zone of the town of Iguape, 89 were from the periurban zone, 30 were from the rural area with extensive banana plantations, and 72 were from the jungle zone. Previous studies had shown significantly higher prevalence of antibodies to different arboviruses in the cultivated zone and the jungle zone, when compared to the urban and periurban zones of Iguape. The detection of antibodies to the HBV surface antigen (HBs Ag) was done through the radioimmunoassay (Ausab, Abbott Laboratory). The cases considered positive were confirmed through the presence of anti-core HBV antibodies (anti-HBc-EIA Roche). A significantly higher prevalence of anti-HBV antibodies was observed in children from the jungle zone (26/72 = 36,1% ) when compared to those from the urban zone (5/89 = 5,6%), peri-urban (6/89 = 6,7%) or from the cultivated zone (0/30 = 0%). The result suggest the existence of a common factor in the dissemination of the arboviruses and the hepatitis B virus, supporting the hypothesis that mosquitoes may play an important role in the HBV transmission in tropical forested region.

Relationship between the prevalence of antibodies to hepatitis B core antigen and arbovirus in fishermen from the Ribeira Valley, Brazil

Sera from 299 fishermen 16 to 80 years old, residents in Cananeia and Iguape counties, southern cost of São Paulo State, Brazil, were studied in order to identify a possible association between the prevalence of specific antibodies to the hepatitis B virus (HBV) and exposure to haematophagus mosquitoes evaluated by the prevalence of arbovirus antibodies. This professional group presented the highest prevalence of arbovirus antibodies (54.1%) in past investigations carried out in this heavily forested region. Detection of antibody to hepatitis B core antigen (anti-HBc) in the sera was done by enzyme immunoassay (Roche). Prevalence of anti-HBc antibodies in this group was 31.4% (94/299) which is very high compared with 7.2% to 15.0% for different groups of healthy adults in State of São Paulo. No significant difference is observed between the prevalences of HBV antibodies in Iguape and Cananeia. Prevalence of anti-HBc and anti-arbovirus antibodies increases with age. There is a concordance in the distribution according to age groups of the frequency of anti-HBc and anti-arbovirus positive sera. Ag HBs was detected in 4% of the studied sera. These results support the hypothesis that the transmission of the hepatitis B virus and the arboviruses may be due to the same factor, one of the possibilities would be by anthropophilic mosquitoes.

A multivariate analysis of the relationship between work ability and S. japonicum infection in Dongting Lake Region, in China

A cross-sectional case-control study on the association between the reduced work ability and S. japonicum infection was carried out in a moderate endemic area for schistosomiasis japonica in the southern part of Dongting lake in China. A total of 120 cases with reduced work ability and 240 controls paired to the case by age, sex, occupation and without reduced work ability, participated in the study. The mean age for individuals was 37.6 years old (21-60), the ratio of male: female was 60:40, the prevalence of S. japonicum in the individuals was 28.3%. The results obtained in this study showed that the infection of S. japonicum in case and control groups was 49.2% (59/120) and 17.9% (43/240), respectively. Odds ratio for reduced work ability among those who had schistosomiasis was 4.34 (95%), confidence interval was 2.58-7.34, and among those who had S. japonicum infection (egg per gram > 100) was up to 12.67 (95%), confidence interval was 3.64-46.39. After odds ratio was adjusted by multiple logistic regression, it was confirmed that heavier intensity of S. japonicum infection and splenomegaly due to S. japonicum infection were the main risk factors for reduced work ability in the population studied.

Identification of factors and groups at risk of infection with Schistosoma mansoni: a strategy for the implementation of control measures?

A fourteen year schistosomiasis control program in Peri-Peri (Capim Branco, MG) reduced prevalence from 43.5 to 4.4%; incidence from 19.0 to 2.9%, the geometric mean of the number of eggs from 281 to 87 and the level of the hepatoesplenic form cases from 5.9 to 0.0%. In 1991, three years after the interruption of the program, the prevalence had risen to 19.6%. The district consists of Barbosa (a rural area) and Peri-Peri itself (an urban area). In 1991, the prevalence in the two areas was 28.4% and 16.0% respectively. A multivariate analysis of risk factors for schistosomiasis indicated the domestic agricultural activity with population attributive risk (PAR) of 29.82%, the distance (< 10 m) from home to water source (PAR = 25.93%) and weekly fishing (PAR = 17.21%) as being responsible for infections in the rural area. The recommended control measures for this area are non-manual irrigation and removal of homes to more than ten meters from irrigation ditches. In the urban area, it was observed that swimming at weekly intervals (PAR = 20.71%), daily domestic agricultural activity (PAR = 4.07%) and the absence of drinking water in the home (PAR=4.29%) were responsible for infections. Thus, in the urban area the recommended control measures are the substitution of manual irrigation with an irrigation method that avoids contact with water, the creation of leisure options of the population and the provision of a domestic water supply. The authors call attention to the need for the efficacy of multivariate analysis of risk factors to be evaluated for schistosomiasis prior to its large scale use as a indicator of the control measures to be implemented.

Immunological status of ENL (Erythema Nodosum Leprosum) patients: its relationship to bacterial load and levels of circulanting IL-2R

Recent data suggest that the clinical course of reactional states in leprosy is closely related to the cytokine profile released locally or systemically by the patients. In the present study, patients with erythema nodosum leprosum (ENL) were grouped according to the intensity of their clinical symptoms. Clinical and immunological aspects of ENL and the impact of these parameters on bacterial load were assessed in conjunction with patients' in vitro immune response to mycobacterial antigens. In 10 out of the 17 patients tested, BI (bacterial index) was reduced by at least 1 log from leprosy diagnosis to the onset of their first reactional episode (ENL), as compared to an expected 0.3 log reduction in the unreactional group for the same MDT (multidrug therapy) period. However, no difference in the rate of BI reduction was noted at the end of MDT among ENL and unreactional lepromatous patients. Accordingly, although TNF-alpha (tumor necrosis factor) levels were enhanced in the sera of 70.6% of the ENL patients tested, no relationship was noted between circulating TNF-alpha levels and the decrease in BI detected at the onset of the reactional episode. Evaluation of bacterial viability of M. leprae isolated from the reactional lesions showed no growth in the mouse footpads. Only 20% of the patients demonstrated specific immune response to M. leprae during ENL. Moreover, high levels of soluble IL-2R (interleukin-2 receptor) were present in 78% of the patients. Circulating anti-neural (anti-ceramide and anti-galactocerebroside antibodies) and anti-mycobacterial antibodies were detected in ENL patients' sera as well, which were not related to the clinical course of disease. Our data suggest that bacterial killing is enhanced during reactions. Emergence of specific immune response to M. leprae and the effective role of TNF-alpha in mediating fragmentation of bacteria still need to be clarified.

Relationship between acute diarrhoea and low plasma levels of vitamin A and retinol binding protein

The objective of this study was to assess vitamin A status and association between acute diarrhoea and plasma levels of vitamin A through cross-sectional comparison in children. Plasma vitamin A was measured by colorimetric method of Neeld & Pearson and RBP by radial immunodiffusion technique. Seventy eight children (aged 18-119 months), 26 with current history of diarrhoea and 52 children as controls (outpatient from the Santa Casa de Misericórdia Hospital in metropolitan area of São Paulo City, Brazil) were studied. Children with history of diarrhoea showed significant low levels (mean ± s.e.) as compared to controls, vitamin A (15.87 ± 1.4 µg/dl vs. 21.14 ± 1.15 µg/dl, p < 0.007) and RBP (1.70 ± 0.2 mg/dl vs. 2.52 ±0.11 mg/dl). Multivariate logistic regression adjusted by sex, age, nutritional status and mother education revealed association between diarrhoea and inadequate levels of vitamin A and RBP.

CHRONIC CHAGASIC CARDIOPATHY: THE PRODUCT OF A TURBULENT HOST-PARASITE RELATIONSHIP

The pathogenesis of chronic chagasic cardiopathy is still a debated matter. In this review, the main theories raised about it since the first description of the disease in 1909 by Carlos Chagas, are considered. The scarcity of T.cruzi parasites into the myocardium and the apparent lack of correlation between their presence and the occurrence of myocardial inflammatory infiltrate, have originated many theories indicating that chronic Chagas' cardiopathy is an autoimmune disease. Recently however, papers using immunohistochemical technique or PCR have demonstrated a strong association between moderate or severe myocarditis and presence of T.cruzi Ags, indicating a direct participation of the parasite in the genesis of chronic chagasic myocarditis. Different patterns of cytokine production seem to have important role in the outcome of the disease. Participation of the microcirculatory alterations and fibrosis as well as the relationship with the parasite are also emphasized. Finally, the author suggests that the indeterminate form of the disease occurs when the host immunological response against the parasite is more efficient while the chronic cardiopathy occurs in patients with hyperergic and inefficient immune response