Factors associated with lack of prenatal care in a large municipality

OBJECTIVE To analyze the factors associated with a lack of prenatal care in a large municipality in southern Brazil. METHODS In this case-control age-matched study, 716 women were evaluated; of these, 179 did not receive prenatal care and 537 received prenatal care (controls). These women were identified using the Sistema Nacional de Informação sobre Nascidos Vivos (Live Birth Information System) of Pelotas, RS, Southern Brazil, between 2009 and 2010. Multivariate analysis was performed using conditional logistic regression to estimate the odds ratios (OR). RESULTS In the final model, the variables associated with a lack of prenatal care were the level of education, particularly when it was lesser than four years [OR 4.46; 95% confidence interval (CI) 1.92;10.36], being single (OR 3.61; 95%CI 1.85;7.04), and multiparity (OR 2.89; 95%CI 1.72;4.85). The prevalence of a lack of prenatal care among administrative regions varied between 0.7% and 3.9%. CONCLUSIONS The risk factors identified must be considered when planning actions for the inclusion of women in prenatal care by both the central management and healthcare teams. These indicated the municipal areas with greater deficits in prenatal care. The reorganization of the actions to identify women with risk factors in the community can be considered to be a starting point of this process. In addition, the integration of the activities of local programs that target the mother and child is essential to constantly identify pregnant women without prenatal care.

Lack of access and continuity of adult health care: a national population-based survey

OBJECTIVE To describe the lack of access and continuity of health care in adults.METHODS A cross-sectional population-based study was performed on a sample of 12,402 adults aged 20 to 59 years in urban areas of 100 municipalities of 23 states in the five Brazilian geopolitical regions. Barriers to the access and continuity of health care and were investigated based on receiving, needing and seeking health care (hospitalization and accident/emergency care in the last 12 months; care provided by a doctor, by other health professional or home care in the last three months). Based on the results obtained by the description of the sample, a projection is provided for adults living in Brazilian urban areas.RESULTS The highest prevalence of lack of access to health services and to provision of care by health professionals was for hospitalization (3.0%), whilst the lowest prevalence was for care provided by a doctor (1.1%). The lack of access to care provided by other health professionals was 2.0%; to accident and emergency services, 2.1%; and to home care, 2.9%. As for prevalences, the greatest absolute lack of access occurred in emergency care (more than 360,000 adults). The main reasons were structural and organizational problems, such as unavailability of hospital beds, of health professionals, of appointments for the type of care needed and charges made for care.CONCLUSIONS The universal right to health care in Brazil has not yet been achieved. These projections can help health care management in scaling the efforts needed to overcome this problem, such as expanding the infrastructure of health services and the workforce.

Population health diagnosis with an ecohealth approach

OBJECTIVE To analyze the characteristics of health diagnosis according to the ecohealth approach in rural and urban communities in Mexico.METHODS Health diagnosis were conducted in La Nopalera, from December 2007 to October 2008, and in Atlihuayan, from December 2010 to October 2011. The research was based on three principles of the ecohealth approach: transdisciplinarity, community participation, gender and equity. To collect information, a joint methodology and several techniques were used to stimulate the participation of inhabitants. The diagnostic exercise was carried out in five phases that went from collecting information to prioritization of problems.RESULTS The constitution of the transdisciplinary team, as well as the participation of the population and the principle of gender/equity were differentials between the communities. In the rural community, the active participation of inhabitants and authorities was achieved and the principles of transdisciplinarity and gender/equity were incorporated.CONCLUSIONS With all the difficulties that entails the boost in participation, the incorporation of gender/equity and transdisciplinarity in health diagnosis allowed a holistic public health approach closer to the needs of the population.

Free-trade agreements: challenges for global health

In this study new free-trade agreements are discussed, which are based on the breaking down of tariff and technical barriers and normally exclude most of the poorest countries in the world. Considering the current context of economic globalization and its health impacts, seven controversial points of these treaties and their possible implications for global public health are presented, mainly regarding health equity and other health determinants. Finally, this research proposes a greater social and health professionals participation in the formulation and discussion of these treaties, and a deeper insertion of Brazil in this important international agenda.

Economic crisis and counter-reform of universal health care systems: Spanish case

The economic crisis that has been affecting Europe in the 21st century has modified social protection systems in the countries that adopted, in the 20th century, universal health care system models, such as Spain. This communication presents some recent transformations, which were caused by changes in Spanish law. Those changes relate to the access to health care services, mainly in regards to the provision of care to foreigners, to financial contribution from users for health care services, and to pharmaceutical assistance. In crisis situations, reforms are observed to follow a trend which restricts rights and deepens social inequalities.

Health care costs of domestic violence against women – evidence from Portugal

Our main objective is to estimate the additional health care costs to the Portuguese National Health Service (NHS) due to domestic violence against women. We collected information through a survey addressed to health care centres’ female users. Both victims and non-victims of violence were inquired. We estimate costs according to five different groups – consultation costs, health care treatment and therapeutic costs, costs of complementary and diagnostic exams, drugs costs and transport costs. The estimations have been split into two perspectives – the NHS perspective (public perspective) and private perspective of inquired women (out of pocket payments). The timeframe of our calculations is one year, referring to all costs generated by domestic violence situations in the last twelve months. Essentially costs were estimated through the product of total number of episodes by the average estimated price per episode. Additionally, for the private costs, we also considered the costs originated by income losses, the opportunity cost of time spent on health care treatments and the work inability caused by sickness. The results suggest that the victims of domestic violence’s additional demand for health care is valued €140 per annum, that is about 22% higher than health care costs of non-victims. These results match those of similar studies for the United States, taking account of per capita differences in health care spending. A large proportion (90%) of the additional costs associated with domestic violence is supported by the NHS, where consultations and drugs are the most important contributors of such costs. Health consequences of domestic violence result from losses in quality of life and worst health status of victims and correspond to additional permanent economic costs of domestic violence episodes.

Epidemiological aspects of acute viral hepatitis in São Paulo, Brazil

As few reports on the prevalence of each type of viral hepatitis have been published in our country, we studied 154 patients with acute viral hepatitis consecutively seen at the Liver Unit from November 1980 to November 1984. The frequency of hepatitis A, B and non-A, non-B was 52.6%, 27.3% and 20.1% respectively. Greater frequency in young people, previous contact with infected patients and ingestion of suspected foods were the predominant epidemiological features in the hepatitis A group. Hepatitis B was characterized by the parenteral, non-transfusional exposure, previous contact and a high occurence in health-care workers. A history of blood transfusion was a significant finding in the hepatitis non-A, non-B group. Finally, the routes of transmission were unknown in 30-40% of the three groups of patients.

Avaliação da Usabilidade de um Projeto de eHealth, enquadrado na visão europeia de Health Technology Assessment (HTA)

Trabalho de projeto apresentado à Escola Superior de Comunicação Social como parte dos requisitos para obtenção de grau de mestre em Audiovisual e Multimédia.

Stress in university students and cardiovascular response to academic stressors

Introduction: University students are frequently exposed to events that can cause stress and anxiety, producing elevated cardiovascular responses. Repeated exposure to academic stress has implications to students’ success and well-being and may contribute to the development of long-term health problems. Objective: To identify stress levels and coping strategies in university students and assess the impact of stress experience in heart rate variability (HRV). Methods: 17 university students, 19-23 years, completed the University Students Stress Inventory, the Depression Anxiety Stress Scales and the Ways of Coping Questionnaire. Two 24h-Holter recordings were performed, on academic activity days, including one of them an exam situation. Results: Students tend to present moderate stress levels, and prefer problem-focused coping strategies in order to manage stress. Exam situations are perceived as significant stressors. Although we found no significant differences in HRV (SDNN), between days with and without an exam, we registered a lower SDNN score and a variation in heart rate (HR) related to exam situation (maximum HR peak at 10 minutes before the exam, and total HR recovery 20 minutes after the exam), reflecting sympathetic activation due to stress. Conclusions: These results suggest that academic events, especially those related to exam situations, are the cause of stress in university students, with implications at cardiovascular level, underlying the importance of interventions that help these students improve their coping skills and optimize stress management, in order to improve academic achievement and promote well-being and quality of life.

The contribution of cellblock – histogel – in bronchial washing samples

Introduction: The cellblock is a technique that enables the pathologist to study the morphological detail of residual samples and can be used when it is necessary to perform additional diagnostic techniques. Objective: Demonstrate the processing of bronchial washings in liquid based cytology to cellblock using HistoGel in residual samples, evaluating the morphology and preservation of cytological material. Methods: There were used 40 residual samples from bronchial washings in liquid based cytology, after determination of the clinical diagnosis, being made subsequently 40 cellblocks using HistoGel. For each cellblock there was made one histological section for analysis of cell morphology, which was subsequently stained with the routine histological staining. After microscope observation, the morphology was evaluated by 3 experts in the field of pathology, based on the parameters: Cellularity, Preservation and Background. Results: The average final score of 3 evaluators, on a scale of 0 to 100, in assessing the morphology of the 40 samples was 55.6. From the 40 histological sections, 5 of them were considered not viable for evaluation. Conclusions: The results obtained indicate median quality maintenance of morphology. However, it is noted that in only 5 cases it was not possible to determine an evaluation, knowing from the outset that these are residual samples with a very scant cellularity. Thus, it is possible to say that the processing of bronchial washings to cellblock using HistoGel contributes to a concentration of the cytological material, allowing its evaluation and subsequent diagnosis. Additional diagnostic techniques are shown equally viable in these cellblocks.

Education for health: alcohol and young aged school teenagers

Introduction: Alcohol consumption starts at an early age in Portuguese people. Health problems and risk behavior associated with excessive consumption can be prevented or highly reduced through effective school programs. Health professionals, such as biomedical scientists, (BSc), are important in promoting healthy lifestyles through the transmission of knowledge. Objective: Explore the role of the BSc in promoting health via intervention and clarification actions, (ICA), with 9th grade students from Agrupamento de Escolas da Portela e Moscavide (AEPM) and Visconde Juromenha (AEVJ); Verify the relationship between participating in the ICA and the level of knowledge acquired from it. Methods: Behaviors and beliefs concerning alcohol consumption and knowledge about the repercussions of it in the human body, mainly regarding the liver, were assessed by questionnaire. The questionnaire was completed before and after the ICA, by the control group (CG) and the study group (SG), respectively. The answers concerning knowledge were given points, later converted to a score from 0 to 100%. Data was analyzed applying descriptive statistics and the t-student test using SPSS 20.0. Results: After statistical analysis, it was found an average score of 48.8% for SG and 46.2% for CG. The difference between groups was statistically significant only in AEPM where ICA included a practical methodology (microscopic and macroscopic observation of pork livers), contrary to AEVJ. Conclusions: BSc intervention through ICA’s improves teenagers’ knowledge. Theoretical knowledge associated with practical approaches improves the retention of information and the development of a conscious behavior about the consumption of alcohol.

Chronic disease prevention and health promotion. Public policies and social network analysis of the hospitals services and oyhers health and social organizations to support joint action for children with diabetes

Comunicação apresentada na 18th Conference International of Health Promotion Hospitals & Health Services "Tackling causes and consequences of inequalities in health: contributions of health services and the HPH network", em Manchester de 14-16 de april de 2010

Defining health law or the edgewood syndrome

ABSTRACT - The authors’ main purpose is to present ideas on defining Health Law by highlighting the particularities of the field of Health Law as well as of the teaching of this legal branch, hoping to contribute to the maturity and academic recognition of Health Law, not only as a very rich legal field but also as a powerful social instrument in the fulfillment of fundamental human rights. The authors defend that Health Law has several characteristics that distinguish it from traditional branches of law such as its complexity and multidisciplinary nature. The study of Health Law normally covers issues such as access to care, health systems organization, patients’ rights, health professionals’ rights and duties, strict liability, healthcare contracts between institutions and professionals, medical data protection and confidentiality, informed consent and professional secrecy, crossing different legal fields including administrative, antitrust, constitutional, contract, corporate, criminal, environmental, food and drug, intellectual property, insurance, international and supranational, labor/employment, property, taxation, and tort law. This is one of the reasons why teaching Health Law presents a challenge to the teacher, which will have to find the programs, content and methods appropriate to the profile of recipients which are normally non jurists and the needs of a multidisciplinary curricula. By describing academic definitions of Health Law as analogous to Edgewood, a fiction house which has a different architectural style in each of its walls, the authors try to describe which elements should compose a more comprehensive definition. In this article Biolaw, Bioethics and Human Rights are defined as complements to a definition of Health Law: Biolaw because it is the legal field that treats the social consequences that arise from technological advances in health and life sciences; Bioethics which evolutions normally influence the shape of the legal framework of Health; and, finally Human Rights theory and declarations are outlined as having always been historically linked to medicine and health, being the umbrella that must cover all the issues raised in the area of Health Law. To complete this brief incursion on the definition on Health Law the authors end by giving note of the complex relations between this field of Law and Public Health. Dealing more specifically on laws adopted by governments to provide important health services and regulate industries and individual conduct that affect the health of the populations, this aspect of Health Law requires special attention to avoid an imbalance between public powers and individual freedoms. The authors conclude that public trust in any health system is essentially sustained by developing health structures which are consistent with essential fundamental rights, such as the universal right to access health care, and that the study of Health Law can contribute with important insights into both health structures and fundamental rights in order to foster a health system that respects the Rule of Law.-------------------------- RESUMO – O objectivo principal dos autores é apresentar ideias sobre a definição de Direito da Saúde, destacando as particularidades desta área do direito, bem como do ensino deste ramo jurídico, na esperança de contribuir para a maturidade e para o reconhecimento académico do mesmo, não só como um campo juridicamente muito rico, mas, também, como um poderoso instrumento social no cumprimento dos direitos humanos fundamentais. Os autores defendem que o Direito da Saúde tem diversas características que o distinguem dos ramos tradicionais do direito, como a sua complexidade e natureza multidisciplinar. O estudo do Direito da Saúde abrangendo normalmente questões como o acesso aos cuidados, a organização dos sistemas de saúde, os direitos e deveres dos doentes e dos profissionais de saúde, a responsabilidade civil, os contratos entre instituições de saúde e profissionais, a protecção e a confidencialidade de dados clínicos, o consentimento informado e o sigilo profissional, implica uma abordagem transversal de diferentes áreas legais, incluindo os Direitos contratual, administrativo, antitrust, constitucional, empresarial, penal, ambiental, alimentar, farmacêutico, da propriedade intelectual, dos seguros, internacional e supranacional, trabalho, fiscal e penal. Esta é uma das razões pelas quais o ensino do Direito da Saúde representa um desafio para o professor, que terá de encontrar os programas, conteúdos e métodos adequados ao perfil dos destinatários, que são normalmente não juristas e às necessidades de um currículo multidisciplinar. Ao descrever as várias definições académicas de Direito da Saúde como análogas a Edgewood, uma casa de ficção que apresenta um estilo arquitectónico diferente em cada uma de suas paredes, os autores tentam encontrar os elementos que deveriam compor uma definição mais abrangente. No artigo, Biodireito, Bioética e Direitos Humanos são descritos como complementos de uma definição de Direito da Saúde: o Biodireito, dado que é o campo jurídico que trata as consequências sociais que surgem dos avanços tecnológicos na área da saúde e das ciências da vida; a Bioética cujas evoluções influenciam normalmente o quadro jurídico da Saúde; e, por fim, a teoria dos Direitos Humanos e as suas declarações as quais têm estado sempre historicamente ligadas à medicina e à saúde, devendo funcionar como pano de fundo de todas as questões levantadas na área do Direito da Saúde. Para finalizar a sua breve incursão sobre a definição de Direito da Saúde, os autores dão ainda nota das complexas relações entre este último e a Saúde Pública, onde se tratam mais especificamente as leis aprovadas pelos governos para regular os serviços de saúde, as indústrias e as condutas individuais que afectam a saúde das populações, aspecto do Direito da Saúde que requer uma atenção especial para evitar um desequilíbrio entre os poderes públicos e as liberdades individuais. Os autores concluem afirmando que a confiança do público em qualquer sistema de saúde é, essencialmente, sustentada pelo desenvolvimento de estruturas de saúde que sejam consistentes com o direito constitucional da saúde, tais como o direito universal ao acesso a cuidados de saúde, e que o estudo do Direito da Saúde pode contribuir com elementos

Dispositivos médicos para diagnóstico in vitro : impacto operacional, clínico e económico da sua utilização em instituições de saúde

RESUMO - Introdução: Os dispositivos médicos para diagnóstico in vitro (DMDIV) são testes de diagnóstico rápido que podem ser realizados em diversos contextos, seja na enfermaria, no departamento de urgência, no bloco operatório, no consultório médico, centros de enfermagem, farmácias, lares de terceira idade ou até na própria residência, uma vez que a sua utilização não requer formação especializada em técnicas de laboratório. Os DMDIV têm inúmeras finalidades: triagem de utentes, diagnóstico de situações agudas, monitorização de fármacos ou acompanhamento de doenças crónicas. Objectivos: conhecer as potenciais implicações operacionais, clínicas e económicas da implementação generalizada de DMDIV em instituições de saúde da região de Lisboa e Vale do Tejo, bem como conhecer o nível de utilização e opinião sobre DMDIV de médicos e enfermeiros da região de saúde de Lisboa e Vale do Tejo. Metodologia: foi realizado um estudo observacional, analítico e transversal. Como instrumento de recolha de dados, foi aplicado um questionário a uma amostra de conveniência constituída por médicos e enfermeiros a exercer funções em instituições hospitalares públicas e privadas e em instituições de cuidados de saúde primários da região de saúde de Lisboa e Vale do Tejo. Conclusão: a utilização de DMDIV permite diminuir o tempo de resposta do resultado analítico, o que se traduz numa maior rapidez do diagnóstico e numa intervenção clínica mais célere, com impacto ao nível da redução do número de admissões desnecessárias, do tempo de internamento e do número de consultas médicas, com a consequente redução do consumo de recursos hospitalares. Na região de saúde de Lisboa e Vale do Tejo, um número significativo de instituições de saúde disponibiliza este tipo de equipamentos portáteis que, de uma forma geral, têm uma boa aceitação por parte dos profissionais de saúde.

Web-assisted tobacco intervention in Portuguese : intentions to make behavioural changes and behavioural changes

ABSTRACT - The problem of how to support “intentions to make behavioural changes” (IBC) and “behaviour changes” (BC) in smoking cessation when there is a scarcity of resources is a pressing issue in public health terms. The present research focuses on the use of information and communications technologies and their role in smoking cessation. It is developed in Portugal after the ratification of WHO Framework Convention on Tobacco Control (on 8 November 2005). The prevalence of smokers over fifteen years of age within the population stood at 20.9% (30.9% for men and 11.8% for women). While the strategy of helping people to quit smoking has been emphasised at National Health Service (NHS) level, the uptake of cessation assistance has exceeded the capacity of the service. This induced the search of new theoretical and practical venues to offer alternative options to people willing to stop smoking. Among these, the National Health Plan (NHP) of Portugal (2004-2010), identifies the use of information technologies in smoking cessation. eHealth and the importance of health literacy as a means of empowering people to make behavioural changes is recurrently considered an option worth investigating. The overall objective of this research is to understand, in the Portuguese context, the use of the Internet to help people to stop smoking. Research questions consider factors that may contribute to “intentions to make behavioural changes” (IBC) and “behavioural changes” (BC) while using a Web-Assisted Tobacco Intervention Probe (WATIP). Also consideration is given to the trade-off on the use of the Web as a tool for smoking cessation: can it reach a vast number of people for a small cost (efficiency) demonstrating to work in the domain of smoking cessation (efficacy)”? In addition to the introduction, there is a second chapter in which the use of tobacco is discussed as a public health menace. The health gains achieved by stopping smoking and the means of quitting are also examined, as is the use of the Internet in smoking cessation. Then, several research issues are introduced. These include background theory and the theoretical framework for the Sense of Coherence. The research model is also discussed. A presentation of the methods, materials and of the Web-Assisted Tobacco Intervention Probe (WATIP) follows. In chapter four the results of the use of the Web-Assisted Tobacco Intervention Probe (WATIP) are presented. This study is divided into two sections. The first describes results related to quality control in relation to the Web-Assisted Tobacco Intervention Probe (WATIP) and gives an overview of its users. Of these, 3,150 answered initial eligibility questions. In the end, 1,463 met all eligibility requirements, completed intake, decided on a day to quit smoking (Dday) and declared their “intentions to make behavioural changes” (IBC) while a second targeted group of 650 did not decide on a Dday. With two quit attempts made before joining the platform, most of the participants had experienced past failures while wanting to stop. The smoking rate averaged 21 cigarettes per day. With a mean age of 35, of the participants 55% were males. Among several other considerations, gender and the Sense of Coherence (SOC) influenced the success of participants in their IBC and endeavour to set quit dates. The results of comparing males and females showed that, for current smokers, establishing a Dday was related to gender differences, not favouring males (OR=0.76, p<0.005). Belonging to higher Socio-economic strata (SES) was associated with the intention to consider IBC (when compared to lower SES condition) (OR=1.57, p<0.001) and higher number of school years (OR=0.70, p<0.005) favoured the decision to smoking cessation. Those who demonstrated higher confidence in their likelihood of success in stopping in the shortest time had a higher rate of setting a Dday (OR=0.51, p<0.001). There were differences between groups in IBC reflecting the high and low levels of the SOC score (OR=1.43, p=0.006), as those who considered setting a Dday had higher levels of SOC. After adjusting for all variables, stages of readiness to change and SOC were kept in the model. This is the first Arm of this research where the focus is a discussion of the system’s implications for the participants’ “intentions to make behavioural changes” (IBC). Moreover, a second section of this study (second Arm) offers input collected from 77 in-depth interviews with the Web-Assisted Tobacco Intervention Probe (WATIP) users. Here, “Behaviour Change” (BC) and the usability of the platform are explored a year after IBC was declared. A percentage of 32.9% of self-reported, 12-month quitters in continuous abstinence from smoking from Dday to the 12-month follow- up point of the use of the Web-Assisted Tobacco Intervention Probe (WATIP) has been assessed. Comparing the Sense of Coherence (SOC) scores of participants by their respective means, according to the two groups, there was a significant difference in these scores of non smokers (BC) (M=144,66, SD=22,52) and Sense of Coherence (SOC) of smokers (noBC) (M=131,51, SD=21,43) p=0.014. This WATIP strategy and its contents benefit from the strengthening of the smoker’s sense of coherence (SOC), so that the person’s progress towards a life without tobacco may be experienced as comprehensible, manageable and meaningful. In this sample the sense of coherence (SOC) effect is moderate although it is associated with the day to quit smoking (Dday). Some of the limitations of this research have to do with self-selection bias, sample size (power) and self-reporting (no biochemical validation). The enrolment of participants was therefore not representative of the smoking population. It is not possible to verify the Web-Assisted Tobacco Intervention Probe (WATIP) evaluation of external validity; consequently, the results obtained cannot be applied generalized. No participation bias is provided. Another limitation of this study is the associated limitations of interviews. Interviewees’ perception that fabricating answers could benefit them more than telling the simple truth in response to questions is a risk that is not evaluated (with no external validation like measuring participants’ carbon monoxide levels). What emerges in this analysis is the relevance of the process that leads to the establishment of the quit day (Dday) to stop using tobacco. In addition, technological issues, when tailoring is the focus, are key elements for scrutiny. The high number of dropouts of users of the web platform mandates future research that should concentrate on the matters of the user-centred design of portals. The focus on gains in health through patient-centred care needs more research, so that technology usability be considered within the context of best practices in smoking cessation.