Análisis político del Programa de Control del dengue en Morelos, México

OBJETIVO: Analizar medidas municipales implementadas para el control de la epidemia del dengue, sobretodo las de coordinación sectorial, gobernanza y participación de grupos sociales. MÉTODOS: Estudio de observación, realizado en Morelos, México, 2007. Los datos colectados en entrevistas y observaciones directas fueron sometidos a análisis de contenido y mapeo político. El software Policy Marker fue utilizado para evaluar los pesos atribuidos a los datos de desempeño (e.g. criterios alto, medio y bajo) y el papel de actores (acciones realizadas sean ellas de vigilancia, control o administrativas). Se realizó análisis estratégico de las oportunidades y desafíos en el cumplimiento de las políticas públicas y control del dengue. RESULTADOS: Las bases jurídicas indican que la respuesta a la epidemia es una tarea multisectorial. Sin embargo, la respuesta está centrada en actividades de los servicios de la salud, que están forzados a dar mayor apoyo financiero y derivar los recursos humanos necesarios, en contraste con la contribución de otros sectores (e.g. agua y saneamiento básico), que desconocen sus responsabilidades. El sector de la salud presenta alto nivel de factibilidad para la vinculación intra?institucional, en términos de optimización de recursos y cumplimiento de objetivos, particularmente entre autoridades de salud en los niveles estatal, jurisdiccional, municipal y local. CONCLUSIONES: El abordaje multidisciplinario y el fortalecimiento de las responsabilidades políticas permitirán la respuesta eficaz ante la epidemia del dengue, sustentada en la coordinación sectorial e involucramiento activo de la población afectada.

The AIDS epidemic in the Amazon region: a spatial case-control study in Rondonia, Brazil

OBJECTIVE To analyze spatial changes in the risk of AIDS and the relationship between AIDS incidence and socioeconomic variables in the state of Rondonia, Amazon region. METHODS A spatial, population case-control study in Rondonia, Brazil, based on 1,780 cases reported to the Epidemiological Surveillance System and controls based on demographic data from 1987 to 2006. The cases were grouped into five consecutive four-year periods. A generalized additive model was adjusted to the data; the dependent variable was the status of the individuals (case or control), and the independent variables were a bi-dimensional spline of the geographic coordinates and some municipality-level socioeconomic variables. The observed values of the Moran’s I test were compared to a reference distribution of values generated under conditions of spatial randomness. RESULTS AIDS risk shows a marked spatial and temporal pattern. The disease incidence is related to socioeconomic variables at the municipal level in Rondônia, such as urbanization and human capital. The highest incidence rates of AIDS are in municipalities along the BR-364 highway and calculations of the Moran’s I test show positive spatial correlation associated with proximity of the municipality to the highway in the third and fourth periods (p = 0.05). CONCLUSIONS Incidence of the disease is higher in municipalities of greater economic wealth and urbanization, and in those municipalities bisected by Rondônia’s main roads. The rapid development associated with the opening up of once remote regions may be accompanied by an increase in these risks to health.

Cross-cultural validity of the demand-control questionnaire: Swedish and Brazilian workers

OBJECTIVE To evaluate the cross-cultural validity of the Demand-Control Questionnaire, comparing the original Swedish questionnaire with the Brazilian version. METHODS We compared data from 362 Swedish and 399 Brazilian health workers. Confirmatory and exploratory factor analyses were performed to test structural validity, using the robust weighted least squares mean and variance-adjusted (WLSMV) estimator. Construct validity, using hypotheses testing, was evaluated through the inspection of the mean score distribution of the scale dimensions according to sociodemographic and social support at work variables. RESULTS The confirmatory and exploratory factor analyses supported the instrument in three dimensions (for Swedish and Brazilians): psychological demands, skill discretion and decision authority. The best-fit model was achieved by including an error correlation between work fast and work intensely (psychological demands) and removing the item repetitive work (skill discretion). Hypotheses testing showed that workers with university degree had higher scores on skill discretion and decision authority and those with high levels of Social Support at Work had lower scores on psychological demands and higher scores on decision authority. CONCLUSIONS The results supported the equivalent dimensional structures across the two culturally different work contexts. Skill discretion and decision authority formed two distinct dimensions and the item repetitive work should be removed.

Tuberculosis Control Program and patient satisfaction, Rio de Janeiro, Brazil

OBJECTIVE To evaluate factors associated with users’ satisfaction in the Tuberculosis Control Program. METHODS A cross-sectional study of 295 patients aged ≥ 18 years, with two or more outpatient visits in the Tuberculosis Control Program, in five cities in the metropolitan region of Rio de Janeiro, RJ, Southeastern Brazil, in 2010. Considering an estimated population of 4,345 patients, the sampling plan included 15 health care units participating in the program, divided into two strata: units in Rio de Janeiro City, selected with probability proportional to the monthly average number of outpatient visits, and units in the other four cities. In the units, four temporal clusters of five patients each were selected with equal probability, totaling 300 patients. A questionnaire investigating the users’ clinical and sociodemographic variables and aspects of care and service in the program relevant to user satisfaction was applied to the patients. Descriptive statistics about users and their satisfaction with the program were obtained, and the effects of factors associated with satisfaction were estimated. RESULTS Patients were predominantly males (57.7%), with a mean age of 40.9 and with low level of schooling. The mean treatment time was 4.1 months, mostly self-administered (70.4%). Additionally, 25.8% had previously been treated for tuberculosis. There was a high level of satisfaction, especially regarding medication provision, and respect to patients by the health professionals. Patients who were younger (≤ 30), those on self-administered treatment, and with graduate level, showed less satisfaction. Suggestions to improve the services include having more doctors (70.0%), and offering exams in the same place of attendance (55.1%). CONCLUSIONS Patient satisfaction with the Tuberculosis Control Program was generally high, although lower among younger patients, those with university education and those on self-administered treatment. The study indicates the need for changes to structural and organizational aspects of care, and provides practical support for its improvement.

Self-reported diabetes in older people: comparison of prevalences and control measures

OBJECTIVE The objective of this study was to analyze the prevalence of diabetes in older people and the adopted control measures.METHODS Data regarding older diabetic individuals who participated in the Health Surveys conducted in the Municipality of Sao Paulo, SP, ISA-Capital, in 2003 and 2008, which were cross-sectional studies, were analyzed. Prevalences and confidence intervals were compared between 2003 and 2008, according to sociodemographic variables. The combination of the databases was performed when the confidence intervals overlapped. The Chi-square (level of significance of 5%) and the Pearson’s Chi-square (Rao-Scott) tests were performed. The variables without overlap between the confidence intervals were not tested.RESULTS The age of the older adults was 60-69 years. The majority were women, Caucasian, with an income of between > 0.5 and 2.5 times the minimum salary and low levels of schooling. The prevalence of diabetes was 17.6% (95%CI 14.9;20.6) in 2003 and 20.1% (95%CI 17.3;23.1) in 2008, which indicates a growth over this period (p at the limit of significance). The most prevalent measure adopted by the older adults to control diabetes was hypoglycemic agents, followed by diet. Physical activity was not frequent, despite the significant differences observed between 2003 and 2008 results. The use of public health services to control diabetes was significantly higher in older individuals with lower income and lower levels of education.CONCLUSIONS Diabetes is a complex and challenging disease for patients and the health systems. Measures that encourage health promotion practices are necessary because they presented a smaller proportion than the use of hypoglycemic agents. Public health policies should be implemented, and aimed mainly at older individuals with low income and schooling levels. These changes are essential to improve the health condition of older diabetic patients.

Visceral leishmaniasis in Brazil: rationale and concerns related to reservoir control

The control of zoonotic visceral leishmaniasis is a challenge, particularly in Brazil, where the disease has been gradually spreading across the country over the past 30 years. Strategies employed for decreasing the transmission risk are based on the control of vector populations and reservoirs; since humans are considered unnecessary for the maintenance of transmission. Among the adopted strategies in Brazil, the sacrifice of infected dogs is commonly performed and has been the most controversial measure. In the present study, we provide the rationale for the implementation of different control strategies targeted at reservoir populations and highlight the limitations and concerns associated with each of these strategies.