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

Prevalence of Urinary Incontinence in a Community Sample From the City of Sao Paulo

PURPOSE: The aim of this study was to analyze the prevalence of urinary incontinence (UI) in a community sample from the city of Sao Paulo. METHODS: This epidemiological survey was conducted at a family health program in Sao Paulo, Brazil, using randomized sampling. Data were collected by interviewing residents and were analyzed by Pearson`s correlation coefficients, chi-square tests, and logistic regression analysis. RESULTS: Seventy (10.7%) of the 657 subjects currently presented UI, including 50.7% with sporadic UI and 74.3% with UI upon moderate efforts. Ninety-three percent woke up during the night, 43.7% maintained continence until the bathroom, 63.4% had a sensation of wetness, and 77.5% reported no use of any continence aids. Female gender, advanced age, gynecologic or urologic surgery, dysuria, and urinary tract infection were correlated with UI (P < .001; r(2) = 0.572). CONCLUSION: The overall prevalence of UI was found to be high and was comparable to results from multiple countries.

Access to tuberculosis diagnosis in Itaborai City, Rio de Janeiro, Brazil: the patient`s point of view

SETTING: Itaborai Municipality in Rio de Janeiro, Brazil. OBJECTIVE: To evaluate access to tuberculosis (TB) diagnosis for users of the Family Health Program (FHP) and Reference Ambulatory Units (RAUs). DESIGN : A cross-sectional study was conducted in Itaborai City, Rio de Janeiro, Brazil. Between July and October 2007, a sample of 100 TB patients registered consecutively with the TB Control Program was interviewed using the primary care assessment tool. The two highest scores, describing `almost always` and `always`, or `good` and `very good`, were used as a cut-off point to define high quality access to diagnosis. RESULTS: FHP patients were older and had less education than RAU interviewees. Sex and overcrowding did not differ in the two groups. Patient groups did not differ with regard to the number of times care was sought at a unit, transport problems, cost of attending units and availability of consultation within 24 h. Adequate access to diagnosis was identified by 62% of the FHP patients and 53% of the RAU patients (P = 0.01). CONCLUSION: In Itaborai, Rio de Janeiro, TB patients believe that the FHP units provide greater access to TB diagnosis than RAUs. These findings will be used by the Department of Health to improve access to diagnosis in Itaborai.

Stigmatization of alcohol and other drug users by primary care providers in Southeast Brazil

This study reports on the views of Primary Health Care (PHC) providers in Southeast Brazil on the use of alcohol and other drugs which reflect stigma, moralization, or negative judgment. Six hundred nine PHC professionals from the Brazilian states of Sao Paulo and Minas Gerais took part in the study. The majority (86.5%) of these professionals were female. Attitudes toward the use of alcohol and other drugs were evaluated in comparison to Hansen`s disease, obesity, depression, schizophrenia. HIV/AIDS, and tobacco use. The use of tobacco, marijuana/cocaine, and alcohol were the most negatively judged behaviors (p < 0.05). Nursing assistants and community health care workers demonstrated the severest judgment of alcohol use. In addition, marijuana/cocaine addicts and alcoholics suffered the highest rate of rejection by professionals. The hypothesis that the use of alcohol and other drugs is a behavior stigmatized by health professionals being confirmed, it is important to develop strategies for changing provider attitudes in order to provide a higher quality of service to these patients. This study is important as a first study among PHC professionals about social stigma of alcohol and other drugs users. (C) 2009 Elsevier Ltd. All rights reserved.

Common mental disorders and intimate partner violence in pregnancy

OBJECTIVE : To investigate the association between common mental disorders and intimate partner violence during pregnancy. METHODS : A cross sectional study was carried out with 1,120 pregnant women aged 18-49 years old, who were registered in the Family Health Program in the city of Recife, Northeastern Brazil, between 2005 and 2006. Common mental disorders were assessed using the Self-Reporting Questionnaire (SRQ-20). Intimate partner violence was defined as psychologically, physically and sexually abusive acts committed against women by their partners. Crude and adjusted odds ratios were estimated for the association studied utilizing logistic regression analysis. RESULTS : The most common form of partner violence was psychological. The prevalence of common mental disorders was 71.0% among women who reported all form of violence in pregnancy and 33.8% among those who did not report intimate partner violence. Common mental disorders were associated with psychological violence (OR 2.49, 95%CI 1.8;3.5), even without physical or sexual violence. When psychological violence was combined with physical or sexual violence, the risk of common mental disorders was even higher (OR 3.45; 95%CI 2.3;5.2). CONCLUSIONS : Being assaulted by someone with whom you are emotionally involved can trigger feelings of helplessness, low self-esteem and depression. The pregnancy probably increased women`s vulnerability to common mental disorders

CHEMOPROPHYLAXIS TO CONTROL LEPROSY AND THE PERSPECTIVE OF ITS IMPLEMENTATION IN BRAZIL: A PRIMER FOR NON-EPIDEMIOLOGISTS

The occurrence of leprosy has decreased in the world but the perspective of its elimination has been questioned. A proposed control measure is the use of post-exposure chemoprophylaxis (PEP) among contacts, but there are still questions about its operational aspects. In this text we discuss the evidence available in literature, explain some concepts in epidemiology commonly used in the research on this topic, analyze the appropriateness of implementing PEP in the context of Brazil, and answer a set of key questions. We argue some points: (1) the number of contacts that need to receive PEP in order to prevent one additional case of disease is not easy to be generalized from the studies; (2) areas covered by the family health program are the priority settings where PEP could be implemented; (3) there is no need for a second dose; (4) risk for drug resistance seems to be very small; (5) the usefulness of a serological test to identify a higher risk group of individuals among contacts is questionable. Given that, we recommend that, if it is decided to start PEP in Brazil, it should start on a small scale and, as new evidence can be generated in terms of feasibility, sustainability and impact, it could move up a scale, or not, for a wider intervention.

Schistosomiasis mansoni in Bananal (State of São Paulo, Brazil): I. Efficiency of diagnostic and treatment procedures

Bananal is an important focus of Schistosoma mansoni in the State of São Paulo. Accordingly, programmed active search for human cases, annual coproscopic surveys and treatment of infected cases were started in 1998, aiming at producing a sharp prevalence rate drop by the year 2000. S. mansoni eggs were searched for in two Kato-Katz slides per patient. Cases were followed up according to the routine of the local Family Health Program. In 1998, 130 samples out of 3,860 showed S. mansoni eggs; in 1999, 105 out of 3,550, and in 2000, 64 out of 3,528. Prevalence rates were 3.4%, 2.9%, and 1.8%, and average egg-counts 59, 64, and 79 eggs per gram of feces respectively. Prevalence rates decreased steadily after treatment, but persistently positive cases showed no significant decrease in parasite burdens. Egg count variation depended on sex and age bracket. Persistent residual cases admittedly preclude the eradication of this infection by only searching for and treating carriers. In addition, resistance to therapy and low sensitivity of fecal examinations, can not be ignored. Moderate to heavy worm burdens, frequently associated with hepatomegaly elsewhere, produced no serious cases in Bananal.

Reliability of current estimates of schistosomiasis prevalence in the Rainforest Zone of the state of Pernambuco, Northeastern Brazil

The Program for Schistosomiasis Control within the Unified Health System (PCE-SUS) was implemented by 1999 in the Rainforest Zone or "Zona da Mata" of Pernambuco (ZMP) aiming to carry out biennial stool surveys of whole populations through municipal health organs followed by treatment of the positives through the local units of the Family Health Program (PSF). Yearly reports from the Health Department of Pernambuco State (SES/PE) from 2002 to 2004 on the PCE-SUS surveys were assessed to evaluate whether the current estimates of prevalence in the municipalities of the ZMP are based on reliable samples so as to allow considerations on the real situation of schistosomiasis in that area. The surveys carried out in that period did not follow the major principles underlying sampling design, thus posing problems in both precision and validity of the estimates. Only 12 out of 43 municipalities had minimally reliable estimates: five with moderate prevalence (10-50%) and seven with low prevalence (< 10%). Surveys with appropriate sampling procedures aimed either at representative target groups (school-aged children) or communities are recommended for the ZMP and other endemic areas not only to provide reliable information on the current situation of schistosomiasis but also to plan adequate control strategies.

Prática e percepção do enfermeiro gestor quanto à efetivação do programa saúde da família

As políticas públicas de saúde surgem em decorrência do reconhecimento de um cenário desumano e incoerente frente às condições sociais e de saúde da população, este cenário favoreceu a inclusão da família como foco de atenção nas políticas públicas. Neste contexto o profissional enfermeiro vem se destacando como agente dinamizador das ações dentro do Programa Saúde da Família(PSF). A partir desta premissa este estudo objetivou conhecer as atividades gerenciais desenvolvidas pelo enfermeiro gestor no Programa Saúde da Família, a percepção do enfermeiro gestor sobre a efetivação das metas á serem alcançadas pelo Programa Saúde da Família, e as dificuldades encontradas na prática cotidiana deste profissional para efetivação das metas a serem alcançadas no Programa Saúde da Família. Trata-se de um estudo descritivo com abordagem qualitativa, realizado em Belém do Pará. Os dados foram obtidos por meio de entrevistas semi-estruturadas junto a 45 enfermeiros gestores de 30 unidades saúde da família na região metropolitana de Belém. As informações coletadas foram organizadas conforme preceitos à análise de conteúdo segundo Bardin (1977). Da análise dos discursos emergiram cinco categorias. Os resultados deste estudo demonstraram que são inúmeras as atividades gerenciais do enfermeiro, que sua maior dificuldade na prática cotidiana deve-se ao fato da comunidade ainda estar fortemente arraigada ao atendimento hospitalocêntrico, além da insatisfação na função de gerência, ligadas as várias dificuldades como falta de perfil do agente comunitário de saúde, infraestrutura das unidades, falta do profissional médico em algumas unidades, não adesão do tratamento e ações educativas pelas famílias adstritas , além da impossibilidade em alcançar os objetivos propostos pelo Programa Saúde da Família, de acordo a maioria dos informantes. Essa realidade tem sido vivenciada pelo enfermeiro gestor, caracterizada como forma de tensão interna do sistema, gerando a construção peculiar para enfrentar tais dificuldades. Apesar das dificuldades e limitações dos enfermeiros gestores, estes profissionais realizam suas funções com responsabilidade, buscando cada vez mais autonomia, e consideram que este programa, é o marco nas políticas públicas de saúde.

Inequalities in dental services utilization among Brazilian low-income children: the role of individual determinants

Objectives: To assess the role of the individual determinants on the inequalities of dental services utilization among low-income children living in the working area of Brazilian`s federal Primary Health Care program, which is called Family Health Program (FHP), in a big city in Southern Brazil. Methods: A cross-sectional population-based study was performed. The sample included 350 children, ages 0 to 14 years, whose parents answered a questionnaire about their socioeconomic conditions, perceived needs, oral hygiene habits, and access to dental services. The data analysis was performed according to a conceptual framework based on Andersen`s behavioral model of health services use. Multivariate models of logistic regression analysis instructed the hypothesis on covariates for never having had a dental visit. Results: Thirty one percent of the surveyed children had never had a dental visit. In the bivariate analysis, higher proportion of children who had never had a dental visit was found among the very young, those with inadequate oral hygiene habits, those without perceived need of dental care, and those whose family homes were under absent ownership. The mechanisms of social support showed to be important enabling factors: children attending schools/kindergartens and being regularly monitored by the FHP teams had higher odds of having gone to the dentist, even after adjusting for socioeconomic, demographic, and need variables. Conclusions: The conceptual framework has confirmed the presence of social and psychosocial inequalities on the utilization pattern of dental services for low-income children. The individual determinants seem to be important predictors of access.

Narrowing socioeconomic inequality in child stunting: the Brazilian experience, 1974-2007

Objective To assess trends in the prevalence and social distribution of child stunting in Brazil to evaluate the effect of income and basic service redistribution policies implemented in that country in the recent past. Methods The prevalence of stunting (height-for-age z score below 2 using the Child Growth Standards of the World Health Organization) among children aged less than 5 years was estimated from data collected during national household surveys carried out in Brazil in 1974-75 (n = 34 409), 1989 (n = 7374), 1996 (n = 4149) and 2006-07 (n = 4414). Absolute and relative socioeconomic inequality in stunting was measured by means of the slope index and the concentration index of inequality, respectively. Findings Over a 33-year period, we documented a steady decline in the national prevalence of stunting from 37.1% to 7.1%. Prevalence dropped from 59.0% to 11.2% in the poorest quintile and from 12.1% to 3.3% among the wealthiest quintile. The decline was particularly steep in the last 10 years of the period (1996 to 2007), when the gaps between poor and wealthy families with children under 5 were also reduced in terms of purchasing power; access to education, health care and water and sanitation services; and reproductive health indicators. Conclusion In Brazil, socioeconomic development coupled with equity-oriented public policies have been accompanied by marked improvements in living conditions and a substantial decline in child undernutrition, as well as a reduction of the gap in nutritional status between children in the highest and lowest socioeconomic quintiles. Future studies will show whether these gains will be maintained under the current global economic crisis.

A diretriz de hierarquização do SUS: mudando a antiga perspectiva do modelo médico-assistencial privatista

O Sistema Único de Saúde foi criado em 1988, época em que vigorava no Brasil, um modelo de saúde hospitalocêntrico. Tal modelo era curativo, centrado na doença, e distribuído geograficamente em locais-chave. O acesso dava-se de forma desordenada, causando grande insatisfação da população e enormes gastos por se tratar de complexos hospitalares de alta tecnologia. Buscando uma contrapartida a esse modelo, o SUS criou, entre outros princípios e diretrizes, a diretriz da hierarquização a qual segmentou o sistema de saúde em níveis de complexidade. Os principais objetivos foram aumentar a abrangência do atendimento médico, otimizar sua prática e proporcionar qualidade aos usuários, além de reduzir os custos para o Estado. O modelo foi bem estruturado e beneficiou enormemente a saúde pública, mas ainda enfrenta desafios como os altos custos, a ineficácia da atenção básica, a heterogeneidade do serviço e as dificuldades de fluxo pelos níveis de atenção. Estes estão em constante aprimoramento para que o SUS funcione efetivamente e garanta saúde e qualidade de vida a todos os brasileiros.

Satisfação no trabalho e rotatividade dos médicos do Programa de Saúde da Família

Um dos problemas mais graves identificados na implantação do Programa de Saúde da Família no Brasil é a rotatividade do médico generalista. Já que o modelo se fundamenta no vínculo entre profissionais da equipe e população, a alta rotatividade dos médicos pode comprometer a efetividade do modelo. Pesquisa realizada no município de São Paulo para verificar a existência de correlação entre satisfação no trabalho dos médicos do programa e a rotatividade desses profissionais confirmou a hipótese da existência de correlação negativa. O prestígio da instituição parceira do município na implantação do programa foi o fator mais importante na determinação da rotatividade dos médicos. Outros fatores de satisfação no trabalho que apresentaram correlação com a rotatividade foram: capacitação, distância das unidades de saúde e disponibilidade de materiais e equipamentos para realização das atividades profissionais.

Impacto da Estratégia Saúde da Família com equipe de saúde bucal sobre a utilização de serviços odontológicos

PEREIRA, C. R. S. et al. Impacto da estratégia saúde da família com equipe de saúde bucal sobre a utilização de serviços odontológicos. Cad. Saúde Pública, v. 25, n. 5, p.985-996. Maio, 2009. ISSN 0102-311X.