The Epidemiology and Health Economics of Ankle Injuries

Thesis (Ph.D, Community Health & Epidemiology) -- Queen's University, 2016-10-03 22:59:05.858

Evaluation of an intervention focusing on children to promote physical activity in the entire community: Feasibility, effectiveness and sustainability over time.

Regular physical activity (PA) during childhood is associated with physical, mental, emotional and social health benefits. The constant practice of PA is considered one of the best buys available in public health. The World Health Organization (WHO) recommends to perform at least 60 minutes per day of moderate to vigorous PA for children and adolescents in order to obtain health benefits. However, globally, this level of PA is hardly achieved. Children and adolescent who do not reach the recommended levels of PA are defined as physically inactive and nowadays physical inactivity constitutes a new type of pandemic. For this reason, the WHO launched a global action plan addressing physical activity with a goal of reducing physical inactivity in children and youth. The plan also included recommendation to improve individual and community health and contribute to the social, cultural and economic development of all nations. Worldwide, children and adolescents spend a significant amount of time in school and for this reason the school represents a fundamental educational setting that can play a pivotal role increasing students’ PA. Opportunities to be physically active should not be considered purely in relation to when children attend physical education classes but also making physical activity available during the school day, such as physically active lessons, and multicomponent PA interventions. Since school-based PA interventions are quite numerous, the present thesis focused on interventions delivered during school hours and that integrate small doses of PA as part of routine instruction. This type of intervention is called “Active Breaks.” Active Breaks consists of brief 5–15 minutes sessions of PA led by teachers who introduce short bursts of PA into the academic lesson. In light of this the present thesis aims to evaluate the feasibility, efficacy and sustainability of an Active Breaks intervention targeting children to promote PA.

Percepção dos usuários, profissionais de saúde e gestores sobre o modelo de atendimento oftalmológico no Hospital Regional de Divinolândia - São Paulo

Purpose: This study aimed to evaluate the assistance quality through the perception of the users and municipal health managers (mayors, health secretaries and screening team). Methods: A transversal and descriptive study was carried out. Results: The sample was comprised by 359 users and 48 managers. Medical assistance was considered excellent by 79.6% of the users, 93.7% of the managers, 87.5% of the health secretaries and 100% of the screening team. Reception received a great evaluation by 73.8% of the users and 93.8% of the selectors. Conclusion: The assistance model used at the Ophthalmologic Clinic of Divinolândia obtained a high level of satisfaction pleasing both users and managers.

Self-perception and malocclusion and their relation to oral appearance and function

The aim of this study was to evaluate the relationship between malocclusion and self-perception of oral appearance/function, in 12/15-year-old Brazilian adolescents. The cluster sample consisted of 717 teenagers attending 24 urban public (n=611) and 5 rural public (n=107) schools in Maringá/PR. Malocclusion was measured using the Dental Aesthetic Index (DAI), in accordance with WHO recommendations. A parental questionnaire was applied to collect information on esthetic perception level and oral variables related to oral health. Univariate and multiple logistic regression analyses were performed. Multiple logistic regression confirmed that for 12-year-old, missing teeth (OR=2.865) and presence of openbite (open occlusal relationship) (OR=2.865) were risk indicators for speech capability. With regard to 15-year-old, presence of mandibular overjet (horizontal overlap) (OR=4.016) was a risk indicator for speech capability and molar relationship (OR=1.661) was a risk indicator for chewing capability. The impact of malocclusion on adolescents' life was confirmed in this study. Speech and chewing capability were associated with orthodontic deviations, which should be taken into consideration in oral health planning, to identify risk groups and improve community health services.

A percepção do usuário do Programa Saúde da Família sobre a privacidade e a confidencialidade de suas informações

Trata-se de estudo que procurou conhecer como o usuário do Programa Saúde da Família (PSF) percebe o direito à privacidade e à confidencialidade de suas informações reveladas ao agente comunitário de saúde (ACS) e como relaciona a visita domiciliar ao seu direito à privacidade. Estudo qualitativo, de natureza exploratória e como instrumento de investigação elaborou-se um roteiro de entrevistas semiestruturadas, com questões abertas, realizadas com usuários de uma Unidade do PSF do município de São Paulo. Os resultados mostraram que os usuários não consideram a entrada do ACS em suas residências como uma invasão à sua privacidade e que esse profissional é visto, muitas vezes, apenas como um facilitador do acesso ao serviço de saúde. Constatou-se tendência em se admitir que as informações dadas em sigilo podem ser reveladas pelo ACS. Notou-se a importância das relações de gênero e do cuidado quando da revelação de determinadas condições de saúde. Enfermidades como AIDS, tuberculose, câncer, doenças da próstata e o diabetes apareceram como doenças que podem causar preconceito e, nesse sentido, não deveriam ser reveladas ao ACS, a não ser pela necessidade do acesso mais rápido às consultas médicas. Pareceu, ainda, haver certa passividade do usuário em relação à percepção da falta de respeito ao sigilo das suas informações.

A visita domiciliária realizada pelo agente comunitário de saúde sob a ótica de adultos e idosos

A visita domiciliária constitui o principal instrumento de trabalho dos agentes comunitários na Estratégia Saúde da Família. O objetivo deste estudo foi descrever a percepção de adultos e idosos em relação à visita domiciliária realizada pelo agente comunitário de saúde. Como referencial metodológico foi utilizada a abordagem qualitativa embasada em algumas figuras metodológicas do Discurso do Sujeito Coletivo. Os dados foram coletados em maio de 2007, em uma Unidade de Saúde da Família de Botucatu-SP, por meio de formulário sociodemografico e entrevista semiestruturada aplicada a 14 usuários. A análise dos dados permitiu identificar dois temas: "Sentimentos e percepções em relação à visita e ao agente comunitário" e "O reconhecimento das ações do agente comunitário". Apesar de os entrevistados sentirem-se satisfeitos e gratos diante da visita, o fato de perceberem a frequência mensal como insuficiente e de alegarem desconhecer o conteúdo das anotações realizadas pelo agente no momento da visita sinalizam a necessidade de o enfermeiro investir de maneira mais intensa em atividades educativas junto a esses profissionais, priorizando questões que envolvem os processos de comunicação. Acredita-se que com essa medida será possível otimizar, qualitativamente, a realização da atividade.

Retardo estatural em menores de cinco anos: um estudo "baseline"

OBJETIVO: Descrever a prevalência e analisar fatores associados ao retardo estatural em menores de cinco anos. MÉTODOS: Estudo “baseline”, que analisou 2.040 menores de cinco anos, verificando possíveis associações entre o retardo estatural (índice altura/idade ≤ 2 escores Z) e variáveis hierarquizadas em seis blocos: socioeconômicas, do domicílio, do saneamento, maternas, biológicas e de acesso aos serviços de saúde. A análise multivariada foi realizada por regressão de Poisson, com opção de erro padrão robusto, obtendo-se as razões de prevalência ajustadas, com IC 95por cento e respectivos valores de significância. RESULTADOS: Entre as variáveis não dicotômicas, houve associação positiva com tipo de teto e número de moradores por cômodo e associação negativa com renda, escolaridade da mãe e peso ao nascer. A análise ajustada indicou ainda como variáveis significantes: abastecimento de água, visita do agente comunitário de saúde, local do parto, internação por diarréia e internação por pneumonia. CONCLUSÃO: Os fatores identificados como de risco para o retardo estatural configuram a multicausalidade do problema, implicando na necessidade de intervenções multisetoriais e multiníveis para o seu controle

Poder de agir e sofrimento: estudo de caso sobre Agentes Comunitários de Saúde

Os Agentes Comunitários de Saúde (ACS) possuem uma missão de grande importância na implementação da Estratégia de Saúde da Família: devem criar o vínculo entre a população e os serviços de atenção básica, combinando ações de promoção da saúde, assistência básica e prevenção. A equipe do Cerest de Piracicaba realizou, no período de 2004-2006, análise ergonômica do trabalho em uma unidade de saúde de família cujos objetivos foram compreender a relação entre queixas de sofrimento e as condições de trabalho das ACS e propor medidas para modificá-las. Os resultados da AET mostram que, a despeito do engajamento visando resolver os problemas de saúde das famílias, o limitado “poder de agir” das ACS, devido às limitações da unidade e da rede de serviços, expunham-nas a situações nas quais se encontravam incapazes de adotar ações efetivas e nas quais não podiam se prevenir do sofrimento

Efetividade de programa de agentes comunitários na promoção da saúde bucal

OBJETIVO:Avaliar mudanças em conhecimentos, atitudes e acesso/utilização de serviços odontológicos decorrentes de um programa de promoção da saúde bucal com agentes comunitários de saúde. MÉTODOS:Um projeto de capacitação combinando ensino-aprendizagem, apoio e supervisão, foi desenvolvido entre os meses de julho de 2003 a agosto de 2004. As mudanças foram avaliadas por meio de entrevistas estruturadas em que participaram 36 agentes comunitários de saúde e uma amostra de 91 mulheres e mães, representativa de donas de casa com 25 a 39 anos de idade, alfabetizadas e residentes em domicílios de três a seis cômodos no município de Rio Grande da Serra (SP). Foram colhidos dados sobre conhecimentos de saúde-doença bucal, práticas e capacidades auto-referidas em relação ao auto-exame, higiene bucal, número de residentes e de escovas dentais individuais e coletivas em cada domicílio e acesso e uso de serviços odontológicos. Por meio do teste t de Student pareado, foram comparadas as médias dos valores obtidos antes e depois do programa para cada um dos grupos estudados. As respostas foram analisadas adotando-se um nível de significância de 5%. RESULTADOS: Foram observadas diferenças estatisticamente significativas para questões relativas ao conhecimento de saúde bucal entre os agentes e entre as mulheres antes e depois da capacitação (p<0,05). Desequilíbrio entre o número de escovas e de indivíduos em cada família diminuiu. A freqüência da escovação e do uso do fio dental se elevou depois da atuação dos agentes. Os valores de auto-avaliação da higiene bucal aumentaram. Modificação nas práticas e capacidades auto-referidas mostrou significativa elevação da auto-confiança. O acesso ao serviço foi mais fácil (p<0,000) e seu uso mais regular (p<0,000) entre mulheres. CONCLUSÕES: Houve mudanças positivas na percepção em relação a aspectos de saúde bucal, na auto-confiança e no acesso e uso de serviços odontológicos. Tais mudanças po

Urban air pollution and chronic obstructive pulmonary disease-related emergency department visits

Background: Patients with chronic obstructive pulmonary disease (COPD) can have recurrent disease exacerbations triggered by several factors, including air pollution. Visits to the emergency respiratory department can be a direct result of short-term exposure to air pollution. The aim of this study was to investigate the relationship between the daily number of COPD emergency department visits and the daily environmental air concentrations of PM(10), SO(2), NO(2), CO and O(3) in the City of Sao Paulo, Brazil. Methods: The sample data were collected between 2001 and 2003 and are categorised by gender and age. Generalised linear Poisson regression models were adopted to control for both short-and long-term seasonal changes as well as for temperature and relative humidity. The non-linear dependencies were controlled using a natural cubic spline function. Third-degree polynomial distributed lag models were adopted to estimate both lag structures and the cumulative effects of air pollutants. Results: PM(10) and SO(2) readings showed both acute and lagged effects on COPD emergency department visits. Interquartile range increases in their concentration (28.3 mg/m(3) and 7.8 mg/m(3), respectively) were associated with a cumulative 6-day increase of 19% and 16% in COPD admissions, respectively. An effect on women was observed at lag 0, and among the elderly the lag period was noted to be longer. Increases in CO concentration showed impacts in the female and elderly groups. NO(2) and O(3) presented mild effects on the elderly and in women, respectively. Conclusion: These results indicate that air pollution affects health in a gender-and age-specific manner and should be considered a relevant risk factor that exacerbates COPD in urban environments.

Impact of outdoor biomass air pollution on hypertension hospital admissions

Background This study aimed to evaluate the association between the total suspended particles (TSP) generated from burning sugar cane plantations and the incidence of hospital admissions from hypertension in the city of Araraquara. Methods The study was an ecological time-series study. Total daily records of hypertension (ICD 10th I10-15) were obtained from admitted patients of all ages in a hospital in Araraquara, Sao Paulo State, Brazil, from 23 March 2003 to 27 July 2004. The daily concentration of TSP (mu g/m(3)) was obtained using a Handi-Vol sampler placed in downtown Araraquara. The local airport provided daily measures of temperature and humidity. In generalised linear Poisson regression models, the daily number of hospital admissions for hypertension was considered to be the dependent variable and the daily TSP concentration the independent variable. Results TSP presented a lagged effect on hypertension admissions, which was first observed 1 day after a TSP increase and remained almost unchanged for the following 2 days. A 10 mu g/m(3) increase in the TSP 3 day moving average lagged in 1 day led to an increase in hypertension-related hospital admissions during the harvest period (12.5%, 95% CI 5.6% to 19.9%) that was almost 30% higher than during non-harvest periods (9.0%, 95% CI 4.0% to 14.3%). Conclusions Increases in TSP concentrations were associated with hypertension-related hospital admissions. Despite the benefits of reduced air pollution in urban cities achieved by using ethanol produced from sugar cane to power automobiles, areas where the sugar cane is produced and harvested were found to have increased public health risk.

Opportunity for catch-up HPV vaccination in young women after first delivery

Background Early age at first delivery has been identified as a risk factor for high-risk HPV-type infection and cervical cancer development. Methods A cross-sectional study was carried out in a large public maternity hospital in Sao Paulo, Brazil. During June 2006 to February 2007, 301 women aged 15-24 years who gave birth to their first child were recruited between 43 and 60 days after delivery. Detection of HPV DNA in cervical specimens was performed using a standardised PCR protocol with PGMY09/11 primers. The association of selected factors with HPV infection was assessed by using a Generalised Linear Model. Results HPV DNA was detected in 58.5% (95% CI 52.7% to 64.0%) of the enrolled young women. The most common types of HPV found were: HPV16, HPV51, HPV52, HPV58 and HPV71. The overall prevalence of HPV types targeted by the HPV prophylactic vaccines was: HPV 16-12.0%, HPV 18-2.3% and HPV 6 and 11 4.3%. In the multivariate analysis, only age (inversely, p for trend=0.02) and smoking habits were independently associated with HPV infection. Conclusions The findings show that these young primiparous women had high cervical HPV prevalence, suggesting that this is a high-risk group for cervical cancer development. Nevertheless, 17.3% were positive for any of the four HPV types included in HPV vaccines (HPV6, 11, 16 or 18), with 13.3% positive for HPV 16 or 18 and only 1.0% having both vaccine related-oncogenic HPV types. Thus, young primiparous women could benefit from catch-up HPV vaccination programmes.

Cardiac arrhythmia emergency room visits and environmental air pollution in Sao Paulo, Brazil

Objectives: Air-pollution exposure has been associated with increased cardiovascular hospital admissions and mortality in time-series studies. We evaluated the relation between air pollutants and emergency room (ER) visits because of cardiac arrhythmia in a cardiology hospital. Methods: In a time-series study, we evaluated the association between the emergency room visits as a result of cardiac arrhythmia and daily variations in SO2, CO, NO2, O-3 and PM10, from January 1998 to August 1999. The cases of arrhythmia were modelled using generalised linear Poisson regression models, controlling for seasonality (short-term and long-term trend), and weather. Results: Interquartile range increases in CO (1.5 ppm), NO2 (49,5 mu g/m(3)) and PM10 (22.2 mu g/m(3)) on the concurrent day were associated with increases of 12.3% (95% CI: 7.6% to 17.2%), 10.4% (95% CI: 5.2% to 15.9%) and 6.7% (95% CI: 1.2% to 12.4%) in arrhythmia ER visits, respectively. PM10, CO and NO2 effects were dose-dependent and gaseous pollutants had thresholds. Only CO effect resisted estimates in models with more than one pollutant. Conclusions: Our results showed that air pollutant effects on arrhythmia are predominantly acute starting at concentrations below air quality standards, and the association with CO and NO2 suggests a relevant role for pollution caused by cars.

Relatedness and HLA-DRB1 typing may discriminate the magnitude of the genetic susceptibility to tuberculosis using a household contact model

Background Tuberculosis clusters in families may be due to increased household exposure, shared genetic factors, or both. Household contact studies are useful to control exposure because socioeconomic and environmental conditions are similar to all subjects, allowing the evaluation of the contribution of relatedness to disease development. Methods In this study, the familial aggregation of tuberculosis using relatedness and a specific inherited marker (HLA-DRB1) was evaluated. Fifty families, which had at least two cases of tuberculosis diagnosed within the past 5 years, were selected from a cohort of tuberculosis carried out in Recife, Brazil. The first case diagnosed was considered to be a primary case. The secondary attack rate of tuberculosis in household contacts was estimated according to the degree of relatedness. The relative risk of having tuberculosis based on the degree of relatedness household and the population attributable fraction to relatedness were also estimated. HLA-DRB1 typing and attributable etiologic/preventive fractions were calculated among sick and healthy household contacts. Results Compared to unrelated contacts, the relative risk for tuberculosis adjusted for age was 1.38 (95% CI 0.86 to 2.21). Relatedness contributed 23% to the development of tuberculosis at the population levels. The HLA-DRB1*04 allele group (OR = 2.44; p =0.0324; etiologic fraction =0.15) was overrepresented and the DRB1*15 allele group (OR=0.48; p=0.0488; protective fraction=0.19) was underrepresented among household contacts exhibiting tuberculosis. The presence of DRB1 shared alleles between primary cases and their contacts was a risk factor for tuberculosis (p=0.0281). Conclusion This household contact model together with the utilisation of two genetic variables permitted the evaluation of genetic factors contributing towards tuberculosis development.