Regional governance: strategies and disputes in health region management

OBJECTIVE To analyze the regional governance of the health systemin relation to management strategies and disputes.METHODOLOGICAL PROCEDURES A qualitative study with health managers from 19 municipalities in the health region of Bahia, Northeastern Brazil. Data were drawn from 17 semi-structured interviews of state, regional, and municipal health policymakers and managers; a focus group; observations of the regional interagency committee; and documents in 2012. The political-institutional and the organizational components were analyzed in the light of dialectical hermeneutics.RESULTS The regional interagency committee is the chief regional governance strategy/component and functions as a strategic tool for strengthening governance. It brings together a diversity of members responsible for decision making in the healthcare territories, who need to negotiate the allocation of funding and the distribution of facilities for common use in the region. The high turnover of health secretaries, their lack of autonomy from the local executive decisions, inadequate technical training to exercise their function, and the influence of party politics on decision making stand as obstacles to the regional interagency committee’s permeability to social demands. Funding is insufficient to enable the fulfillment of the officially integrated agreed-upon program or to boost public supply by the system, requiring that public managers procure services from the private market at values higher than the national health service price schedule (Brazilian Unified Health System Table). The study determined that “facilitators” under contract to health departments accelerated access to specialized (diagnostic, therapeutic and/or surgical) services in other municipalities by direct payment to physicians for procedure costs already covered by the Brazilian Unified Health System.CONCLUSIONS The characteristics identified a regionalized system with a conflictive pattern of governance and intermediate institutionalism. The regional interagency committee’s managerial routine needs to incorporate more democratic devices for connecting with educational institutions, devices that are more permeable to social demands relating to regional policy making.

Mammography in asymptomatic women aged 40-49 years

OBJECTIVE To assess findings of mammography of and interventions resulting from breast cancer screening in women aged 40-49 years with no increased risk (typical risk) of breast cancer. METHODS This cross-sectional study evaluated women aged 40-49 years who underwent mammography screening in a mastology reference center in Recife, PE, Northeastern Brazil, between January 2010 and October 2011. Women with breast-related complaints, positive findings in the physical examination, or high risk of breast cancer were excluded. RESULTS The 1,000 mammograms performed were classified into the following Breast Imaging-Reporting and Data System (BI-RADS) categories BI-RADS 0, 232; BI-RADS 1, 294; BI-RADS 2, 294; BI-RADS 3, 16; BI-RADS 4A, 2; BI-RADS 5, 1. There was one case of grade II invasive ductal carcinoma and various interventions, including 469 ultrasound scans, 53 referrals to mastologists, 11 cytological examinations, and 8 biopsies. CONCLUSIONS Mammography screening in women aged 40-49 years with typical risk of breast cancer led to the performance of other interventions. However, it also resulted in increased costs without demonstrable efficacy in decreasing mortality.

Intimate partner violence after the diagnosis of sexually transmitted diseases

OBJECTIVE To assess the prevalence and factors associated with intimate partner violence after the diagnosis of sexually transmitted diseases.METHODS This cross-sectional study was conducted in Fortaleza, CE, Northeastern Brazil, in 2012 and involved 221 individuals (40.3% male and 59.7% female) attended to at reference health care units for the treatment of sexually transmitted diseases. Data were collected using a questionnaire applied during interviews with each participant. A multivariate analysis with a logistic regression model was conducted using the stepwise technique. Only the variables with a p value < 0.05 were included in the adjusted analysis. The odds ratio (OR) with 95% confidence interval (CI) was used as the measure of effect.RESULTS A total of 30.3% of the participants reported experiencing some type of violence (27.6%, psychological; 5.9%, physical; and 7.2%, sexual) after the diagnosis of sexually transmitted disease. In the multivariate analysis adjusted to assess intimate partner violence after the revelation of the diagnosis of sexually transmitted diseases, the following variables remained statistically significant: extramarital relations (OR = 3.72; 95%CI 1.91;7.26; p = 0.000), alcohol consumption by the partner (OR = 2.16; 95%CI 1.08;4.33; p = 0.026), history of violence prior to diagnosis (OR = 2.87; 95%CI 1.44;5.69; p = 0.003), and fear of disclosing the diagnosis to the partner (OR = 2.66; 95%CI 1.32;5.32; p = 0.006).CONCLUSIONS Individuals who had extramarital relations, experienced violence prior to the diagnosis of sexually transmitted disease, feared disclosing the diagnosis to the partner, and those whose partner consumed alcohol had an increased likelihood of suffering violence. The high prevalence of intimate partner violence suggests that this population is vulnerable and therefore intervention efforts should be directed to them. Referral health care services for the treatment of sexually transmitted diseases can be strategic places to identify and prevent intimate partner violence.

Postpartum depression among women with unintended pregnancy

OBJECTIVE To analyze the association between unintended pregnancy and postpartum depression.METHODS This is a prospective cohort study conducted with 1,121 pregnant aged 18 to 49 years, who attended the prenatal program devised by the Brazilian Family Health Strategy, Recife, PE, Northeastern Brazil, between July 2005 and December 2006. We interviewed 1,121 women during pregnancy and 1,057 after childbirth. Unintended pregnancy was evaluated during the first interview and postpartum depression symptoms were assessed using the Edinburgh Postnatal Depression Screening Scale. The crude and adjusted odds ratios for the studied association were estimated using logistic regression analysis.RESULTS The frequency for unintended pregnancy was 60.2%; 25.9% presented postpartum depression symptoms. Those who had unintended pregnancies had a higher likelihood of presenting this symptoms, even after adjusting for confounding variables (OR = 1.48; 95%CI 1.09;2.01). When the Self Reporting Questionnaire (SRQ-20) variable was included, the association decreased, however, remained statistically significant (OR = 1.42; 95%CI 1.03;1.97).CONCLUSIONS Unintended pregnancy showed association with subsequent postpartum depressive symptoms. This suggests that high values in Edinburgh Postnatal Depression Screening Scale may result from unintended pregnancy.

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.

Factors associated with dietary supplement use by people who exercise at gyms

OBJECTIVE To assess the factors associated with the use of dietary supplements by people who exercise at gyms.METHODS A cross-sectional study with a sample defined by convenience, considering the number of gyms registered in the Conselho Regional de Educação Física (Regional Council of Physical Education) of Sao Luis, MA, Northeastern Brazil, from July 2011 to July 2012. The final sample comprised 723 individuals who exercise at gyms. The dependent variable was supplement use, and the explanatory variables were length of time and motivation of the physical exercises, duration, goal and self-perception of training, weekly frequency of gym attendance, sex, age, educational attainment, self-perception of body weight, smoking and self-perception of diet. The association between variables was analysed by hierarchical Poisson regression based on a theoretical model.RESULTS Supplement use was reported by 64.7% of the participants. Most of the sample was male (52.6%). The most frequent age group was 20 to 39 years (74.4%). Most participants (46.1%) had been exercising for over a year. The following variables were associated with supplement use: self-perceiving body weight as below ideal (p < 0.001), smoking (p < 0.001), exercising for 7 to 12 months (p = 0.028) or more than one year (p < 0.001), spending more than two hours at the gym (p = 0.051), and perceiving training as moderate (p = 0.024) or intense (p = 0.001).CONCLUSIONS The use of supplements lacks proper professional guidance, being motivated by individuals unsatisfied with their low body weight and who perceive their workout as intense, which raises the need for monitoring this population.

Gender and other factors associated with the use of hearing protection devices at work

OBJECTIVE To analyze whether sociodemographic, occupational, and health-related data are associated with the use of hearing protection devices at work, according to gender. METHODS A cross-sectional study was conducted in 2006, using a random sample of 2,429 workers, aged between 18 and 65 years old, from residential sub-areas in Salvador, BA, Northeastern Brazil. Questionnaires were used to obtain sociodemographic, occupational, and health-related data. Workers who reported that they worked in places where they needed to shout in order to be heard were considered to be exposed to noise. Exposed workers were asked whether they used hearing protection devices, and if so, how frequently. Analyses were conducted according to gender, with estimates made about prevalence of the use of hearing protection devices, prevalence ratios, and their respective 95% confidence intervals. RESULTS Twelve percent (12.3%) of study subjects reported that they were exposed to noise while working. Prevalence of the use of hearing protection devices was 59.3% for men and 21.4% for women. Men from higher socioeconomic levels (PR = 1.47; 95%CI 1.14;1.90) and who had previous audiometric tests (PR = 1.47; 95%CI 1.15;1.88) were more likely to use hearing protection devices. For women, greater perceived safety was associated with the use of protection devices (PR = 2.92; 95%CI 1.34;6.34). This perception was specifically related to the presence of supervisors committed to safety (PR = 2.09; 95%CI 1.04;4.21), the existence of clear rules to prevent workplace injuries (PR = 2.81; 95%CI 1.41;5.59), and whether they were informed about workplace safety (PR = 2.42; 95%CI 1.23;4.76). CONCLUSIONS There is a gender bias regarding the use of hearing protection devices that is less favorable to women. The use of such devices among women is positively influenced by their perception of a safe workplace, suggesting that gender should be considered as a factor in hearing conservation programs.

Specialized care for people with AIDS in the state of Ceara, Brazil

OBJECTIVE To analyze if the distribution of specialized care services for HIV/AIDS is associated with AIDS rates. METHODS Ecological study, for which the distribution of 10 specialized care services in the Ceara state, Northeastern Brazil, was obtained, and the mean rates of the disease were estimated per mesoregion. We evaluated 7,896 individuals who had been diagnosed with AIDS, were aged 13 years or older, lived in Ceara, and had been informed of their condition between 2001 and 2011. Maps were constructed to verify the relationship between the distribution of AIDS cases and institutionalized support networks in the 2001-2006 and 2007-2011 periods. BoxMap and LisaMap were used for data analysis. The Voronoi diagram was applied for the distribution of the studied services. RESULTS Specialized care services concentrated in AIDS clusters in the metropolitan area. The Noroeste Cearense and west of the Sertoes Cearenses had high AIDS rates, but a low number of specialized care services over time. Two of these services were implemented where clusters of the disease exist in the second period. The application of the Voronoi diagram showed that the specialized care services located outside the metropolitan area covered a large territory. We identified one polygon that had no services. CONCLUSIONS The scenario of AIDS cases spread away from major urban areas demands the creation of social support services in areas other than the capital and the metropolitan area of the state; this can reduce access barriers to these institutions. It is necessary to create specialized care services for HIV/AIDS in the Noroeste Cearense and north of Jaguaribe.

The effect of Schistosoma mansoni infection on child morbidity in the State in Bahia, Brazil: II — Analysis at the individual level

The present investigation was carried out on a sample of 840 children (5 to 16 years old) from ten small towns of the State of Bahia in northeastern Brazil. The objetive was to study, by using a cross sectional methodology, the evolution of schistosomiasis morbidity (hepatic and splenic enlargement) in children, and the role of the intensity of S. mansoni infection in this process. The children were analised in three age groups (5 to 8, to 12 and 13 to 16 years old) and classified as uninfected, mildly infected, moderately infected and heavily infected according to the number of eggs in the stool. In children aged 5 to 8 years, increasing egg counts were not associated with increasing frequencies of hepatic or splenic enlargement. In the 9 to 12 years old group and association was observed with the prevalence of hepatic enlargement, but not with the prevalence of spleen enlargement. In the oldest group, 13 to 16 years old, an association was observed with the prevalence of enlargement of both organs. It was evident that in this population schistosomiasis morbidity develops in the early period of life as a gradual process starting with liver enlargement and followed by spleen enlargement some years later. It was found that the intensity of infection has a fundamental role in this process, although there is a latent period of some years before clinical splenomegaly appears in moderate-heavily infected children. The Authors suggest that the prevalence of splenomegaly in the 13 to 16 years old group is a good measure of the community level of schistosomiasis morbidity and could be used to measure the impact of control programs.

Deep structure of the Santos basin-São Paulo plateau system, SE Brazil

The structure and nature of the crust underlying the Santos Basin-São Paulo Plateau System (SSPS), in the SE Brazilian margin, are discussed based on five wide-angle seismic profiles acquired during the Santos Basin (SanBa) experiment in 2011. Velocity models allow us to precisely divide the SSPS in six domains from unthinned continental crust (Domain CC) to normal oceanic crust (Domain OC). A seventh domain (Domain D), a triangular shape region in the SE of the SSPS, is discussed by Klingelhoefer et al. (2014). Beneath the continental shelf, a similar to 100km wide necking zone (Domain N) is imaged where the continental crust thins abruptly from similar to 40km to less than 15km. Toward the ocean, most of the SSPS (Domains A and C) shows velocity ranges, velocity gradients, and a Moho interface characteristic of the thinned continental crust. The central domain (Domain B) has, however, a very heterogeneous structure. While its southwestern part still exhibits extremely thinned (7km) continental crust, its northeastern part depicts a 2-4km thick upper layer (6.0-6.5km/s) overlying an anomalous velocity layer (7.0-7.8km/s) and no evidence of a Moho interface. This structure is interpreted as atypical oceanic crust, exhumed lower crust, or upper continental crust intruded by mafic material, overlying either altered mantle in the first two cases or intruded lower continental crust in the last case. The deep structure and v-shaped segmentation of the SSPS confirm that an initial episode of rifting occurred there obliquely to the general opening direction of the South Atlantic Central Segment.

Les plus anciens mammifères terrestres du Miocène marin de Lisbonne - le gisement du Km 10

For the first time, small mammals were found at the earliest marine level in the northeastern part of the lower Tagus basin, to the NE of Lisbon. At this new locality, at the 10 kilometer of the Lisbon-Oporto A1-IP1 highway,conglomerates yielded, along with marine fossils, more or less abraded teeth and bones from insectivores,lagomorphs, rodents and small artiodactyls (sec Tableau 1). Age may he ascribed to the lower Miocene, MN 2b Neogene mammal unit (about 22 My), but an early MN 3 age cannot be entirely excluded. That corresponds to latest Aquitanian (or less probably earliest Burdigalian) (sec Tableau 2). This is the first hitherto found locality with small mammals of this age as far as Portugal is concerned, as well as the oldest locality so far known in the Tagus basin. Km 10 is somewhat older than the localities of Universidade Católica and Avenida do Uruguay in Lisbon (ANTUNES & MEIN, 1986). Hence we can rather accurately date the age of the first marine transgression in the northeastern part of the lower Tagus basin. This shows that in this region there are no marine equivalents of the "Venus ribeiroi beds" (Aquitanian,Division 1 of the Lisbon Miocene series). Correlation between this unit and the uppermost levels of the essentially paleogene "Complexo de Benfica" may be possible. Fossils at km 10 point out to shallow, coastal, highenergy marine environments. Sedimentological features are compatible with this model. Dry land and swamps with brackish (or ev en fresh) waters were present nearby. From those areas came remains of mammals, crocodylians, as well as oysters and charophytes that were later transported to the sea. Sea was warmer than the extant Atlantic at the same latitudes, even if conditions were not strictly tropical then. These conditions surely influenced climate in the nearby regions. Ecological data concerning mammalian faunas distinctly point out to nearby forest-rich environments, much more so than for Universidade Católica and Avenida do Uruguay localities, from where drier, even steppe environment forms largely prevail.

Projecto Bragança: uma criação em teatro e comunidade: trabalho de projecto

Trabalho de Projecto submetido à Escola Superior de Teatro e Cinema para cumprimento dos requisitos necessários à obtenção do grau de Mestre em Teatro - especialização em Teatro e Comunidade.

The detrital origin of the Moncorvo ordovician ironstones

The Moncorvo Ordovician ironstones in northeastern Portugal consist of iron ore sedimentary horizons frequently interbanded with psamites and quartzites. Ore reserves may probably exceed 1 000 million tonnes and this makes Moncorvo the largest iron ore deposit in the European Union. Compact poorly banded massive layers may exceed 90 meters in thickness which is quite an extraordinary feature for a Phanerozoic deposit. If the thickness of Precambrian deposits may reach a few hundred meters, the thickness of Phanerozoic deposits never exceed a maximum of 15 meters generally forming a number of comparatively thin layers confined to a particular member of a sedimentary sequence. A detailed microscopic analysis of the ores revealed that initially a compact magnetite/quartzite layer, detrital in character (the magnetite occasionally showing chromite cores), was deposited by entrapment in near shore lagoons where rivers debouched, rather than in the open sea. This stage was followed by oscilating and transgressive shore lines which gave rise to breaks in sedimentation in combined river delta and shallow water marine environment where detrital material and fine iron oxide and clay suspensions were deposited in fluctuating environments. These events gave rise to layers of both magnetite (martite) and specularite intergrown with quartz, silicates and phosphates. Textural and mineralogical studies show that the deposits consist of ferruginous clastic sediments and are not chemically deposited cherts. Field, geological and palaeontological evidence also supports a detrital origin, the facies being typical of zones rich in oxygen and close to the feeding continent. The uncommon huge development of Moncorvo was due to the fact that the deposits occur in restricted basins on a continental platform were clastic sediments were predominantly deposited. Not only morphologically but also chemically the deposits are more similar to Precambrian iron formations than to Phanerozoic ironstones.

Palynologic data from Aquitaine (SW France) Middle Miocene Sables Fauves Formation. Climatic evolution

Climatic reconstructions based on palynological data from Aquitaine outcrops emphasize an important degradation phase during the Lower Serravallian. Climatic and environmental changes can be related to sea-level variations (Bur 5 / Lan 1, Lan 2 / Ser 1 and Ser 2 cycles). Transgressive phases feature warmer conditions and more open environments whereas regressive phases are marked by a cooler climate and an extent of the forest cover. From Langhian to Middle Serravallian, a general cooling is highlighted, with disappearance of most megathermic taxa and a transition from warm and dry climate to warm-temperate and much more humid conditions. Conclusions are consistent with studies on bordering areas and place the major degradation phase around 14 My. The palynologic data allow filling a gap in the climatic evolution of Southern France, as a connection between Lower and Upper Miocene, both well recorded. These results document, on Western Europe scale, latitudinal climatic gradient across Northern hemisphere while featuring a transition between Mediterranean area and northeastern Atlantic frontage.

Prevalence and pathogenicity of Entamoeba histolytica in three different regions of Pernambuco, Northeast Brazil

Parasitological examinations were carried out on 663 individuals of three different cities of Pernambuco State, Northeastern Brazil: Recife, Palmares and Bodocó. The population from a drought area of Pernambuco State, Bodocó, was investigated for amoebiasis and compared with Recife, metropolitan city (about 1.3 million of inhabitants) and another inland community, Palmares, located inside of the sugar-cane plantation region of the State. No evidence of invasive strains of E. histolytica were found in these inhabitants, provided that the isolated zymodemes I, III, IV, VIII, IX, X, XVII and XVIII are recognized as nonpathogenic strains of E. histolytica. Furthermore, the prevalence of intestinal helminths and other protozoan infections showed that these individuals are infected by other agents responsible for diarrhoeal diseases.