An Hp-Adaptive Hierarchical Formulation for the Boundary Element Method Applied to Elasticity in Two Dimensions

This paper presents an HP-Adaptive Procedure with Hierarchical formulation for the Boundary Element Method in 2-D Elasticity problems. Firstly, H, P and HP formulations are defined. Then, the hierarchical concept, which allows a substantial reduction in the dimension of equation system, is introduced. The error estimator used is based on the residual computation over each node inside an element. Finally, the HP strategy is defined and applied to two examples.

A blockmodel study of managerial hierarchies, verbal networks, and organizational culture in four hospitals

This study demonstrates and applies a social network methodology for studying the dynamics of hierarchies in organizations. Social network (blockmodel) analysis of verbal networks in four hospitals contrasted hierarchical and structurally equivalent partitions of the sociomatrices of frequent ties and perceptions of organizational culture. It was found that the verbal networks in these organizations follow a center periphery pattern rather than a hierarchical logic and that perceptions of culture vary more by verbal network than by formal hierarchy. The perceptions of culture of central groups in one organization are much like those of peripheral groups in another. In all four hospitals, structurally equivalent social networks are more important in predicting subcultures than are hierarchical groupings and hierarchy has a limited impact on the development of verbal networks. These findings suggest the value of an amoeba rather than a pyramid metaphor in interpreting the cultures and relational structures of organizations.

Confiabilidade das aferições de estudo sobre violência familiar e desnutrição severa na infância

INTRODUÇÃO: Como parte do programa de investigação sobre violência familiar e desnutrição severa na infância, especificamente um estudo do tipo caso-controle foi avaliada a confiabilidade dos instrumentos utilizados no processo de obtenção de dados. Estudou-se a confiabilidade de quatro componentes do instrumento principal: (a) as Escalas sobre Táticas de Conflitos (Conflicts Tactics Scales - CTS) que medem o grau de conflito/violência familiar; (b) o instrumento CAGE (Cut-down; Annoyed; Guilty & Eye-opener) usado para indicar suspeição de alcoolismo; (c) o NSDUQ (Non-student Drugs Use Questionnaire) que visa aferir o uso de drogas ilícitas; e (d) a medida antropométrica de comprimento. MÉTODO: Para os três primeiros componentes citados foram avaliadas a estabilidade (confiabilidade intra-observador ou teste-reteste) e a equivalência (confiabilidade inter-observador), usando-se os 50 primeiros sujeitos captados no estudo caso-controle de fundo. Para a análise, usou-se o índice Kappa (k) com ajustamento (pseudo-Bayes) para lidar com problemas de estimabilidade. Em relação ao componente "d", foi estudada somente a equivalência (n=73), usando-se o Coeficiente de Correlação Intraclasse (Intra-class Correlation Coefficient - ICC) como estimador. RESULTADOS: Todos os componentes mostraram estabilidade e equivalência aceitáveis. Quanto à estabilidade das CTS, CAGE e NSDUQ, as estimações de k foram em torno de 0,70, 0,78 e 0,85, respectivamente. Em relação à equivalência, encontrou-se os valores de 1,0 para as CTS e NSDUQ e 0,75 para CAGE. A equivalência estimada através do ICC para comprimento foi de 0,99. Algumas situações desviantes foram observadas. Os resultados apontam para uma adequada padronização dos observadores e refletem a boa qualidade do processo de aferição referente ao estudo de fundo, encorajando a equipe de pesquisa a prosseguir com maior segurança.

Aplicação de modelo bayesiano empírico na análise espacial da ocorrência de hanseníase

OBJETIVO: Analisar a distribuição espacial da hanseníase, identificar áreas de possível sub-registro de casos ou de provável alta transmissão (risco) e verificar a associação dessa distribuição à existência de casos de formas multibacilares. MÉTODOS: O estudo foi realizado em Recife, PE, de acordo com 94 bairros analisados. A fonte de coleta de dados foi o Sistema de Informações sobre Agravos de Notificação do Ministério da Saúde. Foi adotada uma abordagem ecológica com utilização do método bayesiano empírico para suavização local de taxas, a partir de informações de bairros vizinhos por adjacência. RESULTADOS: A ocorrência média anual foi de 17,3% de casos novos em menores de 15 anos (28,3% de formas multibacilares), indicando um processo de intensa transmissão da doença. A análise da distribuição espacial de hanseníase apontou três áreas onde se concentram bairros com taxas de detecção elevadas e que possuem baixa condição de vida. CONCLUSÕES: O emprego do modelo bayesiano, baseado em informações de unidades espaciais vizinhas, permitiu estimar novamente indicadores epidemiológicos. Foi possível identificar áreas prioritárias para o programa de controle de hanseníase no município, tanto pelo elevado número de ocorrências correlacionado à presença de formas multibacilares de doença em menores de 15 anos quanto pela existência de subnotificação.

Voluntary HIV counseling and testing during prenatal care in Brazil

OBJECTIVE: Voluntary HIV counseling and testing are provided to all Brazilian pregnant women with the purpose of reducing mother-to-child HIV transmission. The purpose of the study was to assess characteristics of HIV testing and identify factors associated with HIV counseling and testing. METHODS: A cross-sectional study was carried out comprising 1,658 mothers living in Porto Alegre, Brazil. Biological, reproductive and social variables were obtained from mothers by means of a standardized questionnaire. Being counseling about HIV testing was the dependent variable. Confidence intervals, chi-square test and hierarchical logistic model were used to determine the association between counseling and maternal variables. RESULTS: Of 1,658 mothers interviewed, 1,603 or 96.7% (95% CI: 95.7-97.5) underwent HIV testing, and 51 or 3.1% (95% CI: 2.3-4.0) were not tested. Four (0.2%) refused to undergo testing after counseling. Of 51 women not tested in this study, 30 had undergone the testing previously. Of 1,603 women tested, 630 or 39.3% (95% CI: 36.9-41.7) received counseling, 947 or 59.2% (95% CI: 56.6-61.5) did not, and 26 (1.6%) did not inform. Low income, lack of prenatal care, late beginning of prenatal care, use of rapid testing, and receiving prenatal in the public sector were variables independently associated with a lower probability of getting counseling about HIV testing. CONCLUSIONS: The study findings confirmed the high rate of prenatal HIV testing in Porto Alegre. However, women coming from less privileged social groups were less likely to receive information and benefit from counseling.

Blood glucose control in diabetes patients seen in primary health care centers

OBJECTIVE: To identify factors associated to poor glycemic control among diabetic patients seen at primary health care centers. METHODS: A cross-sectional study was carried out in a sample of 372 diabetic patients attending 32 primary health care centers in southern Brazil. Data on three hierarchical levels of health unit infrastructure, medical care and patient characteristics were collected. RESULTS: The frequency of poor glycemic control was 50.5%. Multivariate analysis (multilevel method) showed that patients with body mass indexes below 27 kg/m², patients on oral hypoglycemic agents or insulin, and patients diagnosed as diabetic over five years prior to the interview were more likely to present poor glycemic control when compared to their counterparts. CONCLUSIONS: Given the hierarchical data structuring, all associations found suggest that factors associated to hyperglycemia are related to patient-level characteristics.

Risk-factors for antepartum fetal deaths in the city of São Paulo, Brazil

OBJECTIVE: To assess risk factors for antepartum fetal deaths. METHODS: A population-based case-control study was carried out in the city of São Paulo from August 2000 to January 2001. Subjects were selected from a birth cohort from a linked birth and death certificate database. Cases were 164 antepartum fetal deaths and controls were drawn from a random sample of 313 births surviving at least 28 days. Information was collected from birth and death certificates, hospital records and home interviews. A hierarchical conceptual framework guided the logistic regression analysis. RESULTS: Statistically significant factors associated with antepartum fetal death were: mother without or recent marital union; mother's education under four years; mothers with previous low birth weight infant; mothers with hypertension, diabetes, bleeding during pregnancy; no or inadequate prenatal care; congenital malformation and intrauterine growth restriction. The highest population attributable fractions were for inadequacy of prenatal care (40%), hypertension (27%), intrauterine growth restriction (30%) and absence of a long-standing union (26%). CONCLUSIONS: Proximal biological risk factors are most important in antepartum fetal deaths. However, distal factors - mother's low education and marital status - are also significant. Improving access to and quality of prenatal care could have a large impact on fetal mortality.

Modelagem Bayesiana do risco de infecção tuberculosa para estudos com perdas de seguimento

OBJETIVO: Desenvolver um modelo estatístico baseado em métodos Bayesianos para estimar o risco de infecção tuberculosa em estudos com perdas de seguimento, comparando-o com um modelo clássico determinístico. MÉTODOS: O modelo estocástico proposto é baseado em um algoritmo de amostradores de Gibbs, utilizando as informações de perdas de seguimento ao final de um estudo longitudinal. Para simular o número desconhecido de indivíduos reatores ao final do estudo e perdas de seguimento, mas não reatores no tempo inicial, uma variável latente foi introduzida no novo modelo. Apresenta-se um exercício de aplicação de ambos os modelos para comparação das estimativas geradas. RESULTADOS: As estimativas pontuais fornecidas por ambos os modelos são próximas, mas o modelo Bayesiano apresentou a vantagem de trazer os intervalos de credibilidade como medidas da variabilidade amostral dos parâmetros estimados. CONCLUSÕES: O modelo Bayesiano pode ser útil em estudos longitudinais com baixa adesão ao seguimento.

Factors related to inadequate cervical cancer screening in two Brazilian state capitals

OBJECTIVE:To analyze factors associated with cervical cancer screening failure. METHODS:Population-based cross-sectional study with self-weighted two-stage cluster sampling conducted in the cities of Fortaleza (Northeastern Brazil) and Rio de Janeiro (Southeastern Brazil) in 2002. Subjects were women aged 25-59 years in the last three years prior to the study. Data were analyzed through Poisson regression using a hierarchical model. RESULTS: The proportion of women who did not undergo the Pap smear test in Fortaleza and Rio de Janeiro was 19.1% (95% CI: 16.1;22.1) and 16.5% (95% CI: 14.1;18.9), respectively. Higher prevalence ratios of cervical cancer screening failure in both cities were seen among women with low education and low per capita income, old age, unmarried, who never underwent mammography, clinical breast examination, and blood glucose and cholesterol level testing. Smokers also had lower screening rates compared to non-smoker women and this difference was only statistically significant in Rio de Janeiro. CONCLUSIONS:The study findings point to the need of intervention focusing particularly women in worse socioeconomic conditions and access to healthcare, old-aged and unmarried. Education activities must prioritize screening of asymptomatic women and early diagnosis for symptomatic women and access to adequate diagnostic methods and treatment should be provided.

Socioeconomic inequities in the health and nutrition of children in low/middle income countries

OBJECTIVE: To describe the effects of social inequities on the health and nutrition of children in low and middle income countries. METHODS: We reviewed existing data on socioeconomic disparities within-countries relative to the use of services, nutritional status, morbidity, and mortality. A conceptual framework including five major hierarchical categories affecting inequities was adopted: socioeconomic context and position, differential exposure, differential vulnerability, differential health outcomes, and differential consequences. The search of the PubMed database since 1990 identified 244 articles related to the theme. Results were also analyzed from almost 100 recent national surveys, including Demographic Health Surveys and the UNICEF Multiple Indicator Cluster Surveys. RESULTS: Children from poor families are more likely, relative to those from better-off families, to be exposed to pathogenic agents; once they are exposed, they are more likely to become ill because of their lower resistance and lower coverage with preventive interventions. Once they become ill, they are less likely to have access to health services and the quality of these services is likely to be lower, with less access to life-saving treatments. As a consequence, children from poor family have higher mortality rates and are more likely to be undernourished. CONCLUSIONS: Except for child obesity and inadequate breastfeeding practices, all the other adverse conditions analyzed were more prevalent in children from less well-off families. Careful documentation of the multiple levels of determination of socioeconomic inequities in child health is essential for understanding the nature of this problem and for establishing interventions that can reduce these differences.

Physical activity during pregnancy and fetal outcomes: a case-control study

OBJECTIVE: To investigate the relationship between physical activity during the second trimester pregnancy and low birth weight, preterm birth, and intrauterine growth restriction. METHODS: Case-control study including 273 low birth weight newborns and 546 controls carried out in the city of São Paulo, Southeastern Brazil, in 2005. Low birth weight cases were grouped into two subsamples: preterm birth (n=117) and intrauterine growth restriction (n=134), with their related controls. Information was collected by means of interviews with mothers shortly after birth and transcription of medical records. Data were analyzed using conditional multiple and hierarchical logistic regression. RESULTS: Light physical activity for over 7 hours per day was shown to be protective against low birth weight (adjusted OR=0.61; 95% CI 0.39-0.94) with a dose-response relationship (p-value for trend=0.026). A similar trend was found for intrauterine growth restriction (adjusted OR=0.51; 95% CI 0.26-0.97). Homemaking activities were associated as a protective factor for both low birth weight and preterm birth (p-value for trend=0.013 and 0.035, respectively). Leisure-time walking was found to be protective against preterm birth. CONCLUSIONS: Mild physical activity during the second trimester of pregnancy such as walking has an independent protective effect on low birth weight, preterm birth, and intrauterine growth restriction.

Growth patterns in early childhood and the onset of menarche before age twelve

OBJECTIVE: To examine the relationship between growth patterns in early childhood and the onset of menarche before age 12. METHODS: The study included 2,083 women from a birth cohort study conducted in the city of Pelotas, Southern Brazil, starting in 1982. Anthropometric, behavioral, and pregnancy-related variables were collected through home interviews. Statistical analyses were performed using Pearson's chi-square and chi-square test for linear trends. A multivariable analysis was carried out using Poisson regression based on a hierarchical model. RESULTS: Mean age of menarche was 12.4 years old and the prevalence of menarche before age 12 was 24.3%. Higher weight-for-age, height-for-age, and weight-for-height z-scores at 19.4 and 43.1 months of age were associated with linear tendencies of increased prevalence and relative risks of the onset of menarche before age 12. Girls who experienced rapid growth in weight-for-age z-score from birth to 19.4 months of age and in weight-for-age or height-for-age z-scores from 19.4 to 43.1 months of age also showed higher risk of menarche before age 12. Higher risk was seen when rapid growth in weight-for-age z-score was seen during these age intervals and the highest risk was found among those in the first tertile of Williams' curve at birth. Rapid growth in weight-for-height z-score was not associated with menarche before age 12. CONCLUSIONS: Menarche is affected by nutritional status and growth patterns during early childhood. Preventing overweight and obesity during early childhood and keeping a "normal" growth pattern seem crucial for the prevention of health conditions during adulthood.

Factors associated to medicine use among children from the 2004 Pelotas Birth Cohort (Brazil)

OBJECTIVE: To identify factors associated to medicine use among children from the 2004 Pelotas Birth Cohort, Brazil. METHODS: Prospective study to evaluate medicine use in children aged 3, 12 and 24 months regardless of the reasons, therapeutic indication or class. The study included 3,985 children followed up at three months of age, 3,907 at 12 months, and 3,868 at the last follow-up time of 24 months. Mothers were interviewed to collect information on medicine use during the recall period of 15 days prior to the interview. The outcome was studied according to sociodemographic and perinatal variables, mother's perception of child's health and breastfeeding status. Crude and adjusted analyses were performed by Poisson regression following a hierarchical model. RESULTS: The prevalence of medicine use ranged from 55% to 65% in the three follow-ups. After controlling for confounders, some variables remained associated to medicine use only at the three-month follow-up with greatest use among children of younger mothers, those children who had intrapartum complications, low birthweight, were never breastfed and were admitted to a hospital. Greatest medicine use was also associated with being a firstborn child at 3 and 12 months; mother's perception of their child health as fair or poor and children whose mothers have private health insurance at 12 and 24 months; highest maternal education level at all follow-up times. CONCLUSIONS: Different variables influence medicine use among children during the first two years of life and they change as the child ages especially maternal factors and those associated to the child's health problems.

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.