Materno-infantilism, feminism and maternal health policy in Brazil

In the last days of 2011, President of Brazil Dilma Rousseff issued a provisional measure (or draft law) entitled "National Surveillance and Monitoring Registration System for the Prevention of Maternal Mortality" (MP 557), as part of a new maternal health programme. It was supposed to address the pressing issue of maternal morbidity and mortality in Brazil, but instead it caused an explosive controversy because it used terms such as nascituro (unborn child) and proposed the compulsory registration of every pregnancy. After intense protests by feminist and human rights groups that this law was unconstitutional, violated women's right to privacy and threatened our already limited reproductive rights, the measure was revised in January 2012, omitting "the unborn child" but not the mandatory registration of pregnancy. Unfortunately, neither version of the draft law addresses the two main problems with maternal health in Brazil: the over-medicalisation of childbirth and its adverse effects, and the need for safe, legal abortion. The content of this measure itself reflects the conflictive nature of public policies on reproductive health in Brazil and how they are shaped by close links between different levels of government and political parties, and religious and professional sectors. (C) 2012 Reproductive Health Matters

Strategies and results of the oral cancer prevention campaign among the elderly in Sao Paulo, Brazil, 2001 to 2009

Objective. To describe the strategies and results obtained by the early diagnosis and prevention of an oral cancer campaign targeting the population aged 60 years or older developed since 2001 in the state of Sao Paulo. Methods. The main strategies used to develop the campaign were described based on the review of documents issued by the Health Ministry, National Cancer Institute, Sao Paulo State Health Department, Oncocentro Foundation of Sao Paulo, Sao Paulo City Health Department, School of Public Health at the University of Sao Paulo (USP), and Santa Marcelina Health Care Center. The impact of the campaign on the incidence of new cases of oral cancer in the target population was evaluated. Results. In 2001, 90 886 elderly were examined vs. 629 613 in 2009. The following strategies were identified: training of professionals, development of printed materials to guide municipal governments in developing the campaign and using standardized codes and criteria, guidelines for data consolidation, establishment of patient referral flows, practical training with a specialist at the basic health care unit after the follow-up examination of individuals presenting changes in soft tissues, and increase in the number of oral diagnosis services. Between 2005 and 2009, there was a significant reduction in the rate of confirmed cases of oral cancer per 100 000 individuals examined, from 20.89 to 11.12 (P = 0.00003). Conclusions. The campaign was beneficial to the oral health of the elderly and could be extended to include other age groups and regions of the country. It may also provide a basis for the development of oral cancer prevention actions in other countries, as long as local characteristics are taken into account.

Effectiveness of a multifactorial falls prevention program in community-dwelling older people when compared to usual care: study protocol for a randomised controlled trial (Prevquedas Brazil)

Background Falling in older age is a major public health concern due to its costly and disabling consequences. However very few randomised controlled trials (RCTs) have been conducted in developing countries, in which population ageing is expected to be particularly substantial in coming years. This article describes the design of an RCT to evaluate the effectiveness of a multifactorial falls prevention program in reducing the rate of falls in community-dwelling older people. Methods/design Multicentre parallel-group RCT involving 612 community-dwelling men and women aged 60 years and over, who have fallen at least once in the previous year. Participants will be recruited in multiple settings in Sao Paulo, Brazil and will be randomly allocated to a control group or an intervention group. The usual care control group will undergo a fall risk factor assessment and be referred to their clinicians with the risk assessment report so that individual modifiable risk factors can be managed without any specific guidance. The intervention group will receive a 12-week Multifactorial Falls Prevention Program consisting of: an individualised medical management of modifiable risk factors, a group-based, supervised balance training exercise program plus an unsupervised home-based exercise program, an educational/behavioral intervention. Both groups will receive a leaflet containing general information about fall prevention strategies. Primary outcome measures will be the rate of falls and the proportion of fallers recorded by monthly falls diaries and telephone calls over a 12 month period. Secondary outcomes measures will include risk of falling, fall-related self-efficacy score, measures of balance, mobility and strength, fall-related health services use and independence with daily tasks. Data will be analysed using the intention-to-treat principle.The incidence of falls in the intervention and control groups will be calculated and compared using negative binomial regression analysis. Discussion This study is the first trial to be conducted in Brazil to evaluate the effectiveness of an intervention to prevent falls. If proven to reduce falls this study has the potential to benefit older adults and assist health care practitioners and policy makers to implement and promote effective falls prevention interventions. Trial registration ClinicalTrials.gov (NCT01698580)

N-3 fatty acids and cardiovascular prevention

In this study we elucidate the role of polyunsaturated fatty acids (PUFAs) in the prevention of cardiovascular diseases, focusing the attention on their role in the modulation of acyl composition of cell lipids and of gene expression. Regarding this latter mechanism, the effectiveness of PUFAs as activators of two transcriptional factors, SREBPs and PPARs, have been considered. Two different model system have been used: primary cultures of neonatal rat cardiomyocytes and an human hepatoma cell line (HepG2). Cells have been supplemented with different PUFAs at physiological concentration, and special attention has been devoted to the main n-3 PUFAs, EPA and DHA. PUFAs influence on global gene expression in cardiomyocytes has been evaluated using microarray technique. Furthermore, since it is not fully elucidated which transcription factors are involved in this modulation in the heart, expression and activation of the three different PPAR isoforms have been investigated. Hepatocytes have been used as experimental model system in the evaluation of PUFAs effect on SREBP activity. SREBPs are considered the main regulator of cholesterol and triglyceride synthesis, which occur mainly in the liver. In both experimental models the modification of cell lipid fatty acid composition subsequent to PUFAs supplementation has been evaluated, and related to the effects observed at molecular level. The global vision given by the obtained results may be important for addressing new researches and be useful to educators and policy makers in setting recommendations for reaching optimal health through good nutrition.

Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation

Increasing awareness of the importance of cardiovascular prevention is not yet matched by the resources and actions within health care systems. Recent publication of the European Commission's European Heart Health Charter in 2008 prompts a review of the role of cardiac rehabilitation (CR) to cardiovascular health outcomes. Secondary prevention through exercise-based CR is the intervention with the best scientific evidence to contribute to decrease morbidity and mortality in coronary artery disease, in particular after myocardial infarction but also incorporating cardiac interventions and chronic stable heart failure. The present position paper aims to provide the practical recommendations on the core components and goals of CR intervention in different cardiovascular conditions, to assist in the design and development of the programmes, and to support healthcare providers, insurers, policy makers and consumers in the recognition of the comprehensive nature of CR. Those charged with responsibility for secondary prevention of cardiovascular disease, whether at European, national or individual centre level, need to consider where and how structured programmes of CR can be delivered to all patients eligible. Thus a novel, disease-oriented document has been generated, where all components of CR for cardiovascular conditions have been revised, presenting both well-established and controversial aspects. A general table applicable to all cardiovascular conditions and specific tables for each clinical disease have been created and commented.

A Comparative Study of Central and Eastern European Social Policy Concernig Mental Disability

The main goal of this project was to identity whether an imported system of social policy can be suitable for a host country, and if not why not. Romanian social policy concerning the mentally disabled represents a paradoxical situation in that while social policy is designed to ensure both an institutional structure and a juridical environment, in practice it is far from successful. The central question which Ms. Ciumageanu asked therefore was whether this failure was due to systemic factors, or whether the problem lay in reworking an imported social policy system to meet local needs. She took a comparative approach, also considering both the Scandinavian model of social policy, particularly the Danish model which has been adopted in Romania, and the Hungarian system, which has inherited a similar universal welfare system and perpetuated it to some extent. In order to verify her hypothesis, she also studied the transformation of the welfare system in Great Britain, which meant a shift from state responsibility towards community care. In all these she concentrated on two major aspects: the structural design within the different countries and, at a micro level, the societal response. Following her analyses of the various in the other countries concerned, Ms. Ciumageanu concluded that the major differences lie first in the difference between the stages of policy design. Here Denmark is the most advanced and Romania the most backwards. Denmark has a fairly elaborate infrastructure, Britain a system with may gaps to bridge, and Hungary and Romania are struggling with severe difficulties owing both to the inherited structure and the limits imposed by an inadequate GDP. While in Denmark and Britain, mental patients are integrated into an elaborate system of care, designed and administered by the state (in Denmark) or communities (in Britain), in Hungary and Romania, the state designs and fails to implement the policy and community support is minimal, partly due to the lack of a fully developed civil society. At the micro level the differences are similar. While in Denmark and Britain there is a consensus about the roles of the state and of civil societies (although at different levels in the two countries, with the state being more supportive in Denmark), in Romania and to a considerable extent in Hungary, civil society tends to expect too much from the state, which in its turn is withdrawing faster from its social roles than from its economic ones, generating a gap between the welfare state and the market economy and disadvantaging the expected transition from a welfare state to a welfare society and, implicitly, the societal response towards those mentally disabled persons in it. On an intermediate level, the factors influencing social policy as a whole were much the same for Hungary and Romania. Economic factors include the accumulated economic resources of both state and citizens, and the inherited pattern of redistribution, as well as the infrastructure; institutional resources include the role of the state and the efficiency of the state bureaucracy, the strength and efficiency of the state apparatus, political stability and the complexity of political democratisation, the introduction of market institutions, the strength of civil society and civic sector institutions. From the standpoint of the societal response, some factors were common to all countries, particularly the historical context, the collective and institutional memories and established patterns of behaviour. In the specific case of Romania, general structural and environmental factors - industrialisation and forced urbanisation - have had a definite influence on family structure, values and behavioural patterns. The analysis of Romanian social policy revealed several causes for failure to date. The first was the instability of the policy and the failure to consider the structural network involved in developing it, rather than just the results obtained. The second was the failure to take into account the relationship between the individual and the group in all its aspects, followed by the lack of active assistance for prevention, re-socialisation or professional integration of persons with mental disabilities. Finally, the state fails to recognise its inability to support an expensive psychiatric enterprise and does not provide any incentive to the private sector. This creates tremendous social costs for both the state and the individual. NGOs working in the field in Romania have been somewhat more successful but are still limited by their lack of funding and personnel and the idea of a combined system is as yet utopian in the circumstances in the country.

A high-resolution soil erosion risk map of Switzerland as strategic policy support system

Soil erosion models and soil erosion risk maps are often used as indicators to assess potential soil erosion in order to assist policy decisions. This paper shows the scientific basis of the soil erosion risk map of Switzerland and its application in policy and practice. Linking a USLE/RUSLE-based model approach (AVErosion) founded on multiple flow algorithms and the unit contributing area concept with an extremely precise and high-resolution digital terrain model (2 m × 2 m grid) using GIS allows for a realistic assessment of the potential soil erosion risk, on single plots, i.e. uniform and comprehensive for the agricultural area of Switzerland (862,579 ha in the valley area and the lower mountain regions). The national or small-scale soil erosion prognosis has thus reached a level heretofore possible only in smaller catchment areas or single plots. Validation was carried out using soil loss data from soil erosion damage mappings in the field from long-term monitoring in different test areas. 45% of the evaluated agricultural area of Switzerland was classified as low potential erosion risk, 12% as moderate potential erosion risk, and 43% as high potential erosion risk. However, many of the areas classified as high potential erosion risk are located at the transition from valley to mountain zone, where many areas are used as permanent grassland, which drastically lowers their current erosion risk. The present soil erosion risk map serves on the one hand to identify and prioritise the high-erosion risk areas, and on the other hand to promote awareness amongst farmers and authorities. It was published on the internet and will be made available to the authorities in digital form. It is intended as a tool for simplifying and standardising enforcement of the legal framework for soil erosion prevention in Switzerland. The work therefore provides a successful example of cooperation between science, policy and practice.

Cigarette smoking and Ecuadorian adolescents: A cross-sectional survey and policy review

This study investigates the relationship between cigarette smoking and adolescents in Ecuador, South America. Using the Social Learning Theory as a basis, the cross-sectional survey focuses attention on such social influences as the smoking habits of family members and peers as well as, the role of cigarette advertisements. Actual use prevalence, access to cigarettes and knowledge and attitudes about smoking are also obtained.^ The survey was conducted in both urban and rural areas, with 50 schools in 40 different communities participating. Two thousand four hundred and fifty-seven adolescents aged 9 to 15 years completed a self-administered questionnaire. This part of the study was conducted in collaboration with the international health organization Amigos de las Americas (AMIGOS). Staff assigned to the AMIGOS Ecuador projects worked with local health and education officials to implement the cross-sectional survey in the field.^ The key informant survey and subsequent policy review were designed to illuminate the social, cultural and institutional environment for anti-smoking activities and interventions in Ecuador. Key individuals involved with this issue on both national and local levels were interviewed. A review of past legislative efforts and present anti-smoking laws was also conducted.^ The current smoking prevalence among the study population was 8.6 percent. Findings from the cross-sectional survey revealed significant positive associations between the smoking habits of siblings and peers and the smoking behavior of the adolescents surveyed. Significant age and gender differences were also found in association with several different variables.^ The policy review found an unfavorable environment for anti-smoking efforts. Several factors contribute to this including, most importantly, lack of funding and lack of public support. The present anti-smoking law is often vague and lacks important provisions, such as a prohibition on selling tobacco products to minors.^ Together, the two surveys provide comprehensive information for the purpose of designing smoking prevention interventions. Using the results from the two surveys, recommendations for intervention are proposed. ^

Structural and Institutional Determinants of Influence Reputation: A Comparison of Collaborative and Adversarial Policy Networks in Decision Making and Implementation

The central assumption in the literature on collaborative networks and policy networks is that political outcomes are affected by a variety of state and nonstate actors. Some of these actors are more powerful than others and can therefore have a considerable effect on decision making. In this article, we seek to provide a structural and institutional explanation for these power differentials in policy networks and support the explanation with empirical evidence. We use a dyadic measure of influence reputation as a proxy for power, and posit that influence reputation over the political outcome is related to vertical integration into the political system by means of formal decision-making authority, and to horizontal integration by means of being well embedded into the policy network. Hence, we argue that actors are perceived as influential because of two complementary factors: (a) their institutional roles and (b) their structural positions in the policy network. Based on temporal and cross-sectional exponential random graph models, we compare five cases about climate, telecommunications, flood prevention, and toxic chemicals politics in Switzerland and Germany. The five networks cover national and local networks at different stages of the policy cycle. The results confirm that institutional and structural drivers seem to have a crucial impact on how an actor is perceived in decision making and implementation and, therefore, their ability to significantly shape outputs and service delivery.

Crack and powder cocaine federal legislation: A sentencing disparity and potential for policy improvement

Since its introduction into the United States in the 1980s, crack cocaine has been a harsh epidemic that has taken its toll on a countless number of people. This highly addictive, cheap and readily available drug of abuse has permeated many demographic sectors, mostly in low income, lesser educated, and urban communities. This epidemic of crack cocaine use in inner city areas across the Unites States has been described as an expression of economic marginality and “social suffering” coupled with the local and international forces of drug market economies (Agar 2003). As crack cocaine is a derivative of cocaine, it utilizes the psychoactive component of the drug, but delivers it in a much stronger, quicker, and more addictive fashion. This, coupled with its ready availability and cheap price has allowed for users to not only become very addicted very quickly, but to be subject to the stringent and sometimes unequal or inconsistent punishments for possession and distribution of crack-cocaine. ^ There are many public health and social ramifications from the abuse of crack-cocaine, and these epidemics appear to target low income and minority groups. Public health issues relating to the physical, mental, and economic strain will be addressed, as well as the direct and indirect effects of the punishments that come as a result of the disparity in penalties for cocaine and crack-cocaine possession and distribution. ^ Three new policies have recently been introduced into the United Stated Congress that actively address the disparity in sentencing for drug and criminal activities. They are, (1) Powder-Crack Cocaine Penalty Equalization Act of 2009, (HR 18, 111th Cong. 2009), (2) The Drug Sentencing Reform and Cocaine Kingpin Trafficking Act of 2009, (HR 265, 111th Cong. 2009) and (3) The Justice Integrity Act of 2009, (111th Cong. 2009). ^ Although they have only been initiated, if passed, they have potential to not only eliminate the crack-cocaine disparity, but to enact laws that help those affected by this epidemic. The final and overarching goal of this paper is to analyze and ultimately choose the ideal policy that would not only eliminate the cocaine and crack disparity regardless of current or future state statutes, but will provide the best method of rehabilitation, prevention, and justice. ^

Strategies for obesity prevention in child care settings: A literature review

Background. Children in the age group of 2-5 years spend substantial amount of time during the day in some kind of childcare setting. These settings are an excellent environmental infrastructure to enhance their nutrition and physical activity behavior and to promote healthy eating and physical activity habits. Due to the steep rise in overweight and obesity among children in the past three decades, it becomes essential to intervene early. There exists a need for literature on a comprehensive and sustainable approach to obesity prevention for younger children in these settings. ^ Methods. Systematic literature search was undertaken using databases like Medline Ovid, Pubmed, Medline Ebsco, and Cochrane Library. Articles published in English as well as English language abstracts of foreign articles were included. The inclusion criteria were as follows: (1) Studies conducted in any part of the world exploring relevant themes and a child care or preschool setting would be included. (2) The interventions promoted physical activity, nutrition/healthy eating/improved diet, reduced television viewing, reduced BMI, changed knowledge and behavior of children and or staff or affected policy/standards/regulations. (3) The population was children in the age group of at least 2 years to 5 years. (4) Articles published in English and English language abstracts for foreign articles would be included. ^ Results. 16 articles were included in the review that consisted of primary interventions in the form of randomized control trials or pre-post interventions were conducted in a preschool or child care or day care setting only. The outcomes pertaining to healthy weight in children were increased vegetable intake, reduced BMI and increased knowledge among others. ^ Conclusion. There is a dearth of data on strong intervention trials in the child care setting. Preschool research studies in the young children that have been conducted are not strong enough. There is a need for more randomized control trials and a well planned evaluation in the preschool age children. There is a need to develop outcome measures that can accurately assess the changes in diet and physical activity in this age group. Child care nutrition and physical activity standards need to be made stringent. ^

A Su Salud Injury Prevention expansion: Analysis of injury prevention perceptions in a Hispanic community

Unintentional injury is the leading cause of death for American ages one to 44 and is ranked in the top ten causes of death for all age groups (CDC, 2006a). A Su Salud Injury Prevention was developed to address injury prevention awareness and education. The program is a mass media education campaign that uses role models, mass media, and community outreach to prevent injury. In 2009, University Health System (UHS) expanded the program. Baseline data were collected from 426 residents in targeted neighborhoods northwest of downtown San Antonio to support the expansion. The purpose of this study was to explore injury perceptions, knowledge, and behaviors of adults living in the expansion area, and define the predominant factors associated with these perceptions. A secondary aim was to assess community awareness and willingness to participate in the program.^ Survey results showed motor vehicle crashes (MVC), falls, drinking and driving, and guns and assaults were considered the most serious injures for adults. The most serious child injuries were MVC, abuse and neglect, falls, and head injuries. Residents were knowledgeable of state seatbelt policy, and over 90% responded as compliant for seatbelt and child car seat use. Most were knowledgeable about drinking and driving state policy and negative outcomes. However, 70% of those reporting driving under the influence of alcohol within the last year engaged in repeat high risk behavior. Men and residents under the age of 55 were more likely to engage in repeat drinking and driving (OR= 3.6, 7.0 respectively). Residents consider injury prevention an important issue, and have interest in a local injury prevention program. Younger women are the most likely to participate in a local program as potential role models and volunteers.^ Results from the study are summarized into an injury prevention and demographic profile of the community that will be used to develop tailored injury prevention messages to create a more effective program, and support program coordinators in effective community engagement. Results will also be used as a comparative basis for future evaluation of a behavioral injury prevention program focused on a predominantly Mexican-American community.^