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Menezes GMS, Aquino EML, Fonseca SC, Domingues RMSM. Abortion and health in Brazil: challenges to research within a context of illegality. CAD SAUDE PUBLICA 2020; 36Suppl 1:e00197918. [PMID: 32049126 DOI: 10.1590/0102-311x00197918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 03/13/2019] [Indexed: 11/22/2022] Open
Abstract
Abortion research faces great challenges, even more so in contexts in which it is illegal. Women tend to omit the voluntary termination of pregnancy or to declare having miscarried, which results in an underestimation of abortions. Research on this subject is indispensable because it enables us to estimate the incidence of abortion and its complications, and to identify unmet demands and more vulnerable groups so as to subsidize health actions and policies. In this article, we seek to describe the main challenges faced by researchers through a review of original studies on abortion and our reflections based on empirical studies we have conducted. We discuss the difficulties in obtaining information, strategies and techniques used to increase accuracy and reliability and their limits and advantages, and strategies for estimating the occurrence of abortion and its complications, using direct (interviews and data from medical charts) and indirect (secondary data on mortality and morbidity) methods. When investigating abortion complications, we address studies on mortality and morbidity, emphasizing the specificities of abortion among obstetric causes. We discuss the main indicators used by researchers and methodological aspects of their construction. We make recommendations for overcoming methodological problems and conducting new studies. In the conclusion, we reiterate the relevance of research on abortion and the need for approaches that contemplate its complexity.
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Goes EF, Menezes GMS, Almeida MDCC, Araújo TVBD, Alves SV, Alves MTSSBE, Aquino EML. Racial vulnerability and individual barriers for Brazilian women seeking first care following abortion. CAD SAUDE PUBLICA 2020; 36Suppl 1:e00189618. [PMID: 32049120 DOI: 10.1590/0102-311x00189618] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 06/17/2019] [Indexed: 11/22/2022] Open
Abstract
Social inequalities in Brazil are reflected in women's search for abortion care, when they face individual, social, and structural barriers and are exposed to situations of vulnerability. Black women are the most heavily exposed to these barriers, from the search for the service to the care itself. The study aimed to analyze factors related to individual barriers in the search for first post-abortion care according to race/color. The study was conducted in Salvador (Bahia State), Recife, (Pernambuco State) and São Luís (Maranhão State), Brazil, with 2,640 patients admitted to public hospitals. Logistic regression was performed to analyze differences according to race/color (white, brown, and black), with "no individual barriers in the search for first care" as the reference category in the dependent variable. Of the women interviewed, 35.7% were black, 53.3% brown, and 11% white. Black women had less schooling, fewer children, and reported more induced abortions (31.1%) and more second-trimester abortions (15.4%). Black women reported more individual barriers in the search for first care (32% vs. 28% in brown women and 20.3% in whites), such as fear of being mistreated and lack of money for transportation. Regression analysis confirmed the association between black and brown race/color and individual barriers in the search for post-abortion care, even after adjusting for all the selected variables. The results confirmed the situation of vulnerability for black women and brown women in Brazil. Racial discrimination in health services and abortion-related stigma can act simultaneously, delaying women's access to health services, a limitation that can further complicate their post-abortion condition.
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Fonseca SC, Domingues RMSM, Leal MDC, Aquino EML, Menezes GMS. Legal abortion in Brazil: systematic review of the scientific production, 2008-2018. CAD SAUDE PUBLICA 2020; 36Suppl 1:e00189718. [PMID: 32049121 DOI: 10.1590/0102-311x00189718] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 08/28/2019] [Indexed: 11/22/2022] Open
Abstract
Previous reviews on the subject of abortion in Brazil have estimated one million procedures per year but did not address legal abortion. This systematic review sought to update knowledge regarding legal abortion in terms of service and women's profile, student and doctor knowledge, situations of anencephaly and severe malformations. We searched MEDLINE and LILACS for articles published in all languages between 2008 and 2018. Article quality was assessed using the Joanna Briggs Institute instruments. Search, selection, quality assessment and data extraction were carried out independently by two researchers. We selected 20 articles, 11 on the knowledge and opinion of medical professionals (4 articles) and students (7 articles) revealing a less-than-ideal level of knowledge and a high degree of objection of conscience. Six studies on women who use legal abortion services found that they are young, single and that the main demand was for pregnancy resulting from rape. When women were younger and single and when the aggressor was someone close to them, there were delays in seeking care. Three studies on severe malformation found around 40% of court authorizations. In cases for which no authorization was given, the evolution of pregnancies was complicated and deliveries were done through cesarean sections. Only one article addressed legal abortion services, showing that 37 of the 68 that had been registered were active, lack of services in seven states and concentration in capitals. Knowledge regarding legal abortion is still scarce, the demand for the procedure is repressed and medical training is deficient with regard to this subject.
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Reis APD, Góes EF, Pilecco FB, Almeida MDCCD, Diele-Viegas LM, Menezes GMDS, Aquino EML. Desigualdades de gênero e raça na pandemia de Covid-19: implicações para o controle no Brasil. SAÚDE EM DEBATE 2020. [DOI: 10.1590/0103-11042020e423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
RESUMO Esta revisão narrativa sintetizou evidências científicas sobre desigualdades de gênero e raça na pandemia de Covid-19, enfocando o trabalho produtivo/reprodutivo das mulheres, a violência de gênero e o acesso aos Serviços de Saúde Sexual e Reprodutiva (SSR). Os resultados confirmam que as desigualdades sociais devem ser consideradas para o efetivo controle da pandemia e para a preservação de direitos. Para além dos efeitos diretos do SARS-CoV-2, discute-se que barreiras de acesso a serviços de SSR podem ocasionar o aumento de gravidezes não pretendidas, abortos inseguros e mortalidade materna. O distanciamento social tem obrigado muitas mulheres a permanecer confinadas com seus agressores e dificultado o acesso a serviços de denúncia, incorrendo no aumento da violência de gênero e em desfechos graves à saúde. Como principais responsáveis pelo cuidado, as mulheres estão mais expostas a adoecer nas esferas profissional e doméstica. A conciliação trabalho-família tornou-se mais difícil para elas durante a pandemia. A literatura naturaliza as diferenças de gênero, raça e classe, com ênfase em fatores de risco. Uma agenda de pesquisa com abordagem interseccional é necessária para embasar a formulação de políticas que incorporem os direitos humanos e atendam às necessidades dos grupos mais vulneráveis à Covid-19.
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Domingues RMSM, Fonseca SC, Leal MDC, Aquino EML, Menezes GMS. Aborto inseguro no Brasil: revisão sistemática da produção científica, 2008-2018. CAD SAUDE PUBLICA 2020; 36Suppl 1:e00190418. [DOI: 10.1590/0102-311x00190418] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 08/28/2019] [Indexed: 11/21/2022] Open
Abstract
O objetivo deste estudo é atualizar o conhecimento sobre o aborto inseguro no país. Foi realizada uma revisão sistemática com busca e seleção de estudos via MEDLINE e LILACS, sem restrição de idiomas, no período 2008 a 2018, com avaliação da qualidade dos artigos por meio dos instrumentos elaborados pelo Instituto Joanna Briggs. Foram avaliados 50 artigos. A prevalência de aborto induzido no Brasil foi estimada por método direto em 15% no ano de 2010 e 13% no ano de 2016. Prevalências mais elevadas foram observadas em populações socialmente mais vulneráveis. A razão de aborto induzido por 1.000 mulheres em idade fértil reduziu no período 1995-2013, sendo de 16 por 1.000 em 2013. Metade das mulheres referiu a utilização de medicamentos para a interrupção da gestação e o número de internações por complicações do aborto, principalmente complicações graves, reduziu no período 1992-2009. A morbimortalidade materna por aborto apresentou frequência reduzida, mas alcançou valores elevados em contextos específicos. Há um provável sub-registro de óbitos maternos por aborto. Transtornos mentais comuns na gestação e depressão pós-parto foram mais frequentes em mulheres que tentaram induzir um aborto sem sucesso. Os resultados encontrados indicam que o aborto é usado com frequência no Brasil, principalmente nas regiões menos desenvolvidas e por mulheres socialmente mais vulneráveis. O acesso a métodos mais seguros provavelmente contribuiu para a redução de internações por complicações e para a redução da morbimortalidade por aborto. Entretanto, metade das mulheres ainda recorre a outros métodos e o número de internações por complicações do aborto é ainda elevado.
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Girianelli VR, Tomazelli JG, Nogueira MC, Corrêa CSL, Souza EOD, Gabrielli L, Aquino EML, Guerra MR, Stavola BLD, Dos-Santos-Silva I, Silva GAE. Interobserver reliability in the classification of pairs of records formed by probabilistic linkage of SISMAMA databases. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2019; 22:e190045. [PMID: 31482984 DOI: 10.1590/1980-549720190045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 07/12/2018] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The study assessed interobserver reliability in the classification of record pairs formed during probabilistic linkage of health-related databases, a key step in the methodology validation to be used in a larger on-going study on inequalities in the access to breast and cervical cancer control activities in Brazil (DAAC-SIS). METHODOLOGY The RecLink software was used to link two databases of the Breast Cancer Control Information System (SISMAMA) in the state of Minas Gerais, Brazil: a reference database, which included 301 screening mammograms with probable benign diagnosis (BI-RADS 3 category) recorded in October 2010, and a database comprising 158,517 mammograms registered in 2011. Subsequently, the 215 pairs of records that were not assigned the maximum RecLink score were independently classified as being true or false by ten independent evaluators from four participating centers. RESULTS The Kappa coefficient ranged from 0.87 to 1.00. Six evaluators were in perfect agreement with one or more evaluators from the other centers. The global Kappa was 0.96 (95% confidence interval - 95%CI 0.94 - 0.99). DISCUSSION Assessment of interobserver reliability is key to ensuring the quality of the record linkage, and it should be routine practice in studies of this nature. The disclosure of such results contributes to transparency in the conduct of such studies and in the reporting of their findings. CONCLUSION Interobserver reliability in this study was excellent, indicating satisfactory team consistency in the classification of record pairs.
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Dos-Santos-Silva I, De Stavola BL, Renna NL, Nogueira MC, Aquino EML, Bustamante-Teixeira MT, Azevedo E Silva G. Ethnoracial and social trends in breast cancer staging at diagnosis in Brazil, 2001-14: a case only analysis. Lancet Glob Health 2019; 7:e784-e797. [PMID: 31097280 PMCID: PMC6527520 DOI: 10.1016/s2214-109x(19)30151-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 01/15/2019] [Accepted: 02/28/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Policies for early detection of breast cancer, including clinical breast examinations and mammographic screening, were introduced in Brazil in 2004, but their effect on disease stage at diagnosis is unclear. We aimed to assess whether these policies have led to a decrease in the prevalence of late-stage breast cancer at diagnosis. METHODS In this case only analysis, using an anonymised nationwide hospital based-cancer registry network, we identified women aged 18-89 years who had been diagnosed with an invasive breast cancer in Brazil during 2001-14. We extracted individual patient-level data on patient demographics, tumour variables, and health-care provider variables for the centre where the patient was diagnosed. Our objectives were to estimate the prevalence of late-stage breast cancer (TNM stage III or IV) at diagnosis overall, across age groups, and by ethnoracial and social strata (ie, self-reported ethnoracial group, as white, black, brown, Asian, or Indigenous, and educational level, marital status, and region of residence) across the study period, and compare these estimates with international data from high-income countries (Norway and the USA). We used logistic regression to estimate odds ratios (ORs) for late-stage versus early-stage (TNM stage I or II) breast cancer at diagnosis in relation to relevant exposures, either minimally adjusted (for age, year of diagnosis, and region of residence) or fully adjusted (for all patient, tumour, and health-care provider variables). FINDINGS We identified 247 719 women who were diagnosed with invasive breast cancer between Jan 1, 2001, and Dec 31, 2014, with a mean age at diagnosis of 55·4 years (SD 13·3), of whom 36·2% (n=89 550) identified as white, 29·8% (n=73 826) as black or brown, and 0·7% (n=1639) as Asian or Indigenous. Prevalence of late-stage breast cancer at diagnosis remained high throughout 2001-14, at approximately 40%, was inversely associated with educational level (p value for linear trend <0·0001), and was higher for women who identified as black (minimally adjusted OR 1·61, 95% CI 1·53-1·70; fully adjusted OR 1·45, 95% CI 1·38-1·54) and brown (minimally adjusted OR 1·26, 95% CI 1·22-1·30; fully adjusted OR 1·18, 1·14-1·23) than those who identified as white. The predicted prevalence of late-stage cancer at diagnosis was highest for women who were black or brown with little or no formal education (48·8%, 95% CI 48·2-49·5) and lowest for women who were white with university education (29·4%, 28·2-30·6), but both these prevalences were higher than that of all women diagnosed with breast cancer in Norway before the introduction of mammography screening (ie, 16·3%, 95% CI 15·4%-17·2% in 1970-74). Similar ethnoracial and social patterns emerged in analyses restricted to the age group targeted by screening (50-69 years). INTERPRETATION The persistently high prevalence of late-stage breast cancer at diagnosis across all ethnoracial and social strata in Brazil, although more substantially among the most disadvantaged populations, implies that early detection policies might have had little effect on breast cancer mortality so far, and highlights the need to focus primarily on timely diagnosis of symptomatic breast cancer rather than on screening for asymptomatic disease. FUNDING Newton Fund, Research Councils UK, and Conselho Nacional das Fundações Estaduais de Amparo à Pesquisa.
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Chor D, Pereira A, Pacheco AG, Santos RV, Fonseca MJM, Schmidt MI, Duncan BB, Barreto SM, Aquino EML, Mill JG, Molina MD, Giatti L, Almeida MD, Bensenor I, Lotufo PA. Context-dependence of race self-classification: Results from a highly mixed and unequal middle-income country. PLoS One 2019; 14:e0216653. [PMID: 31095585 PMCID: PMC6522012 DOI: 10.1371/journal.pone.0216653] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 04/25/2019] [Indexed: 02/07/2023] Open
Abstract
Ethnic-racial classification criteria are widely recognized to vary according to historical, cultural and political contexts. In Brazil, the strong influence of individual socio-economic factors on race/colour self-classification is well known. With the expansion of genomic technologies, the use of genomic ancestry has been suggested as a substitute for classification procedures such as self-declaring race, as if they represented the same concept. We investigated the association between genomic ancestry, the racial composition of census tracts and individual socioeconomic factors and self-declared race/colour in a cohort of 15,105 Brazilians. Results show that the probability of self-declaring as black or brown increases according to the proportion of African ancestry and varies widely among cities. In Porto Alegre, where most of the population is white, with every 10% increase in the proportion of African ancestry, the odds of self-declaring as black increased 14 times (95%CI 6.08-32.81). In Salvador, where most of the population is black or brown, that increase was of 3.98 times (95%CI 2.96-5.35). The racial composition of the area of residence was also associated with the probability of self-declaring as black or brown. Every 10% increase in the proportion of black and brown inhabitants in the residential census tract increased the odds of self-declaring as black by 1.33 times (95%CI 1.24-1.42). Ancestry alone does not explain self-declared race/colour. An emphasis on multiple situational contexts (both individual and collective) provides a more comprehensive framework for the study of the predictors of self-declared race/colour, a highly relevant construct in many different scenarios, such as public policy, sociology and medicine.
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Patrão AL, Almeida MDC, Matos SMA, Goes EF, Nogueira C, Aquino EML. Association Between Perceived Discrimination and Alcohol and Tobacco Consumption in ELSA-Brasil Cohort: Focusing on Gender Differences. Subst Use Misuse 2019; 54:1214-1225. [PMID: 30799670 DOI: 10.1080/10826084.2019.1573838] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Discrimination is detrimental to physical and mental health, particularly insofar as health-risk behaviors are concerned. Particular attention has been paid to excess alcohol consumption and smoking in view of the ready availability of these substances in Western societies. OBJECTIVES To determine whether an association exists between perceived discrimination and excess alcohol intake and smoking in women and men enrolled in the ELSA-Brasil cohort study. METHODS The sample included in the ELSA-Brasil cohort consisted of 15,105 civil servants. Data from waves 1 and 2 of the study were used. A multidimensional questionnaire was used to collect sociodemographic characteristics and evaluate perceived discrimination, alcohol consumption, and smoking. RESULTS An association was found between excess alcohol intake and perceived discrimination only in the men, with this association remaining significant in the youngest age group, in university-educated individuals, and in the group classified as middle-class. An association was found between smoking and lifetime perceived discrimination in women, particularly in those ≥60 years of age, brown-skinned women, those who had completed elementary school, and those classified as upper social class. This same association was found in the men, mainly those of 50-59 years of age, white-skinned males, those who had completed high school, those with a university education, and those classified as upper social class. Conclusions/Importance: Investing in public health policies aimed at combating the different forms of discrimination would appear essential. Not only does discrimination contribute to social injustice, but it also encourages health-risk behaviors such as excess alcohol intake and smoking.
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Pinto KA, Griep RH, Rotenberg L, Almeida MDCC, Barreto RS, Aquino EML. Correction: Gender, time use and overweight and obesity in adults: Results of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). PLoS One 2018; 13:e0198380. [PMID: 30089108 PMCID: PMC6082505 DOI: 10.1371/journal.pone.0198380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
[This corrects the article DOI: 10.1371/journal.pone.0194190.].
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Araújo TVBD, Aquino EML, Menezes GMS, Alves MTSSDBE, Almeida MDCC, Alves SV, Coimbra L, Campbell OMR. Delays in access to care for abortion-related complications: the experience of women in Northeast Brazil. CAD SAUDE PUBLICA 2018; 34:e00168116. [PMID: 29952404 DOI: 10.1590/0102-311x00168116] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 12/04/2017] [Indexed: 11/22/2022] Open
Abstract
Around 18 million unsafe abortions occur in low and middle-income countries and are associated with numerous adverse consequences to women's health. The time taken by women with complications to reach facilities where they can receive appropriate post-abortion care can influence the risk of death and the extent of further complications. All women aged 18+ admitted for abortion complications to public-sector hospitals in three capital cities in the Northeastern Brazil between August-December 2010 were interviewed; medical records were extracted (N = 2,804). Nearly all women (94%) went straight to a health facility, mainly to a hospital (76.6%); the rest had various care-seeking paths, with a quarter visiting 3+ hospitals. Women waited 10 hours on average before deciding to seek care. 29% reported difficulties in starting to seek care, including facing challenges in organizing childcare, a companion or transport (17%) and fear/stigma (11%); a few did not initially recognize they needed care (0.4%). The median time taken to arrive at the ultimate facility was 36 hours. Over a quarter of women reported experiencing difficulties being admitted to a hospital, including long waits (15%), only being attended after pregnant women (8.9%) and waiting for a bed (7.4%). Almost all women (90%) arrived in good condition, but those with longer delays were more likely to have (mild or severe) complications. In Brazil, where access to induced abortion is restricted, women face numerous difficulties receiving post-abortion care, which contribute to delay and influence the severity of post-abortion complications.
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Patrão AL, Almeida MDCC, Alvim S, Chor D, Aquino EML. Health behavior-related indicator of lifestyle: application in the ELSA-Brasil study. Glob Health Promot 2018; 26:62-69. [PMID: 29749297 DOI: 10.1177/1757975918763148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Various behaviors are considered health enhancing. Nevertheless, according to the current scientific literature, four health behaviors are considered particularly risky in view of their association with a group of chronic diseases: 1) smoking; 2) excessive alcohol consumption; 3) poor diet; and 4) lack of physical activity. Theoretically, it should be possible to make improvements to one's health by maximizing the number of healthy behaviors and minimizing the unhealthy ones. However, in reality, the different behaviors interconnect to create more complex lifestyles. Therefore, the objective of this paper is to present the construction of a lifestyle indicator based on health behaviors selected in the ELSA-Brazil study. This indicator revealed two lifestyles: less healthy and healthier lifestyles. The model proved adequate and was confirmed using latent class analysis (LCA). Agreement was 83.2 between the indicator and the LCA results, with a kappa coefficient of 0.65. Women were more likely to have a healthier lifestyle than men, reinforcing the scientific consistency of the indicator, since this finding is in agreement with data from the scientific literature. The indicator created to define lifestyle was found to have scientific consistency and validity; therefore, its use can be recommended for future population-based studies concerning the promotion of health and healthy lifestyles.
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Pinto KA, Griep RH, Rotenberg L, Almeida MDCC, Barreto RS, Aquino EML. Gender, time use and overweight and obesity in adults: Results of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). PLoS One 2018. [PMID: 29534115 PMCID: PMC5849321 DOI: 10.1371/journal.pone.0194190] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Perceived time constraints have been highlighted in sociological studies as representing a core issue in determining quality of life. The objective of this study was to test the hypothesis that gender inequalities regarding insufficiency of time play a role in the development of overweight and obesity in adults. The study used baseline data (2008–2010) from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), which monitors a cohort of 15,105 civil servants of 35 to 74 years of age. Insufficient time for personal care and leisure due to professional and domestic duties, as detailed in a structured questionnaire, comprised the main exposure variable. The outcome variable was overweight/obesity measured according to body mass index. Prevalence ratios were calculated using multinomial logistic regression. A greater proportion of women compared to men reported insufficient time for personal care and leisure (34.5% versus 23.8%, respectively). The prevalence of overweight was greater in men, while obesity was more common in women. Insufficient time for personal care and leisure was associated with overweight (PR = 1.29; 95% CI: 1.04–1.61) and obesity (PR = 1.65; 95% CI: 1.28–2.12) only in women working over 40 hours/week. No significant association was found for males. These results suggest that the length of the working week influences factors underlying weight gain, possibly issues linked to behavior and/or stress mechanisms. The fact that such an association was restricted to women suggests that the results originate from gender inequalities involving relationships between time and health. The findings of this study provide data on which to base public policies aimed at encouraging the redistribution of domestic responsibilities in the direction of gender equity, as well as macrosocial policies such as providing public schools for workers’ children.
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Pitanga FJG, Matos SMA, Almeida MDC, Barreto SM, Aquino EML. Leisure-Time Physical Activity, but not Commuting Physical Activity, is Associated with Cardiovascular Risk among ELSA-Brasil Participants. Arq Bras Cardiol 2018; 110:36-43. [PMID: 29412240 PMCID: PMC5831300 DOI: 10.5935/abc.20170178] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 07/04/2017] [Indexed: 12/04/2022] Open
Abstract
Background Despite reports in the literature that both leisure-time physical activity
(LTPA) and commuting physical activity (CPA) can promote health benefits,
the literature lacks studies comparing the associations of these domains of
physical activity with cardiovascular risk scores. Objective To investigate the association between LTPA and CPA with different
cardiovascular risk scores in the cohort of the Longitudinal Study of Adult
Health ELSA-Brasil. Methods Cross-sectional study with data from 13,721 participants of both genders,
aged 35-74 years, free of cardiovascular disease, from ELSA Brazil. Physical
activity was measured using the International Physical Activity
Questionnaire (IPAQ). Five cardiovascular risk scores were used: Framingham
score - coronary heart disease (cholesterol); Framingham score - coronary
heart disease (LDL-C); Framingham score - cardiovascular disease
(cholesterol); Framingham score - cardiovascular disease (body mass index,
BMI); and pooled cohort equations for atherosclerotic cardiovascular disease
(ASCVD). Associations adjusted for confounding variables between physical
activity and different cardiovascular risk scores were analyzed by logistic
regression. Confidence interval of 95% (95%CI) was considered. Results LTPA is inversely associated with almost all cardiovascular risk scores
analyzed, while CPA shows no statistically significant association with any
of them. Dose-response effect in association between LTPA and cardiovascular
risk scores was also found, especially in men. Conclusions LTPA was shown to be associated with the cardiovascular risk scores analyzed,
but CPA not. The amount of physical activity (duration and intensity) was
more significantly associated, especially in men, with cardiovascular risk
scores in ELSA-Brasil.
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Fonseca MDJMD, Juvanhol LL, Rotenberg L, Nobre AA, Griep RH, Alves MGDM, Cardoso LDO, Giatti L, Nunes MA, Aquino EML, Chor D. Using Gamma and Quantile Regressions to Explore the Association between Job Strain and Adiposity in the ELSA-Brasil Study: Does Gender Matter? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14111404. [PMID: 29149021 PMCID: PMC5708043 DOI: 10.3390/ijerph14111404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 11/09/2017] [Accepted: 11/11/2017] [Indexed: 11/16/2022]
Abstract
This paper explores the association between job strain and adiposity, using two statistical analysis approaches and considering the role of gender. The research evaluated 11,960 active baseline participants (2008-2010) in the ELSA-Brasil study. Job strain was evaluated through a demand-control questionnaire, while body mass index (BMI) and waist circumference (WC) were evaluated in continuous form. The associations were estimated using gamma regression models with an identity link function. Quantile regression models were also estimated from the final set of co-variables established by gamma regression. The relationship that was found varied by analytical approach and gender. Among the women, no association was observed between job strain and adiposity in the fitted gamma models. In the quantile models, a pattern of increasing effects of high strain was observed at higher BMI and WC distribution quantiles. Among the men, high strain was associated with adiposity in the gamma regression models. However, when quantile regression was used, that association was found not to be homogeneous across outcome distributions. In addition, in the quantile models an association was observed between active jobs and BMI. Our results point to an association between job strain and adiposity, which follows a heterogeneous pattern. Modelling strategies can produce different results and should, accordingly, be used to complement one another.
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de Matos SMA, Pitanga FJG, Almeida MDCC, Queiroz CO, dos Santos CA, de Almeida RT, da Silva ITM, Griep RH, Amorim LDAF, Patrão AL, Aquino EML. What Factors Explain Bicycling and Walking for Commuting by ELSA-Brasil Participants? Am J Health Promot 2017; 32:646-656. [DOI: 10.1177/0890117117738400] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Purpose: To analyze the factors associated with commuting by bicycling and walking in adult participants from ELSA-Brasil (Longitudinal Study of Adult Health). Design: Cross-sectional. Setting: Six teaching/research institutions throughout Brazil. Participants: A total of 15 105 civil servants. Measures: Commuting by bicycling and walking was analyzed using the long-form International Physical Activity Questionnaire. Analysis: A hierarchical model containing possible factors associated with commuting by bicycling and walking was constructed. Crude and adjusted odds ratios were calculated using multinomial logistic regression. Results: Considering the 2 forms of commuting, 66% of the participants were being considered inactive or insufficiently active. In women, being “heavier,” feeling unsafe practicing physical activity, and being a former smoker were factors negatively associated with commuting by bicycling and walking. In men, active commuting was less common among those who were overweight or had abdominal obesity, those with a negative perception of safety, and those reporting that there was nowhere suitable in the neighborhood to practice physical activity. Conclusion: Obesity and negative perceptions in the neighborhood are associated with inactive or insufficiently active commuting. The relevance of this finding for public health is reinforce developing policies aimed at promoting health in Brazil and in other countries with similar characteristics.
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Patrão AL, Almeida MDC, Matos SMA, Chor D, Aquino EML. Gender and psychosocial factors associated with healthy lifestyle in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) cohort: a cross-sectional study. BMJ Open 2017; 7:e015705. [PMID: 28851775 PMCID: PMC5724152 DOI: 10.1136/bmjopen-2016-015705] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES It has been estimated that over 50% of the premature deaths occurring in Western countries can be attributed to causes rooted in lifestyle. In turn, leading a healthy lifestyle has also been associated with a wide range of psychosocial factors. Today, it is known that these differ among men and women. The present article aimed to identify, from a gender-based perspective, the psychosocial factors associated with healthy lifestyles in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) cohort, the largest study concerning adult health conducted in Latin America to date. DESIGN This cross-sectional study was conducted using ELSA-Brasil baseline data, collected between 2008 and 2010. SETTING Six Brazilian public higher education and research institutions. PARTICIPANTS The ELSA-Brasil cohort consists of approximately 15 000 employees (8218 women and 6887 men), both currently working and retired. MAIN OUTCOME MEASURES The lifestyle indicator was constructed by summing the scores attributed to four different behaviours. RESULTS The women of the ELSA-Brasil cohort have healthier lifestyles than men. In women, strong associations were found between a healthy lifestyle and age 60 years or older, Asian race and university level of education or higher. In men, being 60 years or older, of Asian or Caucasian race, having a high-school equivalent level of education or higher, being retired, having a housekeeper, having a good or very good self-perception of health and being satisfied with body image were the psychosocial factors associated with leading a healthy lifestyle. CONCLUSIONS The factors that influenced healthy lifestyles were found to differ among men and women, a fact that must be addressed when developing programmes designed to promote health.
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Burgard S, de Pina Castiglione D, Lin KY, Nobre AA, Aquino EML, Pereira AC, Martins Bensenor IJ, Barreto SM, Chor D. Differential reporting of discriminatory experiences in Brazil and the United States. CAD SAUDE PUBLICA 2017; 33Suppl 1:e00110516. [PMID: 28492709 PMCID: PMC10497239 DOI: 10.1590/0102-311x00110516] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 11/07/2016] [Indexed: 11/22/2022] Open
Abstract
There has been little cross-national comparison of perceived discrimination, and few studies have considered how intersectional identities shape perception of discriminatory treatment in different societies. Using data from the ELSA-Brasil, a study of Brazilian civil servants, and the Americans' Changing Lives Study, a nationally-representative sample of U.S. adults, we compare reports of lifetime discrimination among race-by-gender groups in each society. We also consider whether educational attainment explains any group differences, or if differences across groups vary by level of education. Results reveal higher lifetime discrimination experiences among Black respondents in both countries, especially Black men, than among Whites, and lower reports among White women than White men. Brown men and women also reported higher levels than White men in Brazil. For all race-by-gender groups in both countries, except Brazilian White men, reports of discrimination were higher among the more educated, though adjusting for educational differences across groups did not explain group differences. In Brazil, we found the greatest racial disparities among the college educated, while U.S. Black men were more likely to report discrimination than White men at all levels of education. Results reveal broad similarities across countries, despite important differences in their histories, and an intersectional approach contributed to identification of these similarities and some differences in discrimination experiences. These findings have implications for social and public health surveillance and intervention to address the harmful consequences of discrimination.
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Pinto KA, Menezes GMDS, Griep RH, Lima KTRDS, Almeida MDC, Aquino EML. Work-family conflict and time use: psychometric assessment of an instrument in ELSA-Brazil. Rev Saude Publica 2016; 50:S0034-89102016000100704. [PMID: 27384968 PMCID: PMC4926953 DOI: 10.1590/s1518-8787.2016050005892] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 09/04/2015] [Indexed: 11/28/2022] Open
Abstract
In this study, we evaluated the psychometric properties of the items to measure the work-family conflict and the time use for personal care and leisure, included in the baseline questionnaire of the Longitudinal Study of Adult Health (ELSA-Brazil). We evaluated temporal stability (7-14 days) using kappa statistic and the validity of the construct by the correlation of Kendall’s tau with other variables. Test-retest stability was discreet to moderate and the correlations were compatible with the underlying theory. Future studies in the context of ELSA-Brazil and in other populations will complement the assessment of its relevance.
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Pitanga FJG, Matos SMA, Almeida MDC, Molina MDCB, Aquino EML. Factors associated with leisure time physical activity among ELSA-Brasil participants: Ecological model. Prev Med 2016; 90:17-25. [PMID: 27343402 DOI: 10.1016/j.ypmed.2016.06.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 06/20/2016] [Accepted: 06/21/2016] [Indexed: 11/28/2022]
Abstract
The main objective of the study was identify the prevalence and factors associated with leisure time physical activity (LTPA) in adult participants of the Longitudinal Study of Adult Health (ELSA-Brasil). The LTPA was measured using the International Physical Activity Questionnaire (IPAQ), long version. A hierarchical ecological model was built with the possible factors associated with LTPA distributed across blocks. We estimated crude and adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) using logistic regression. In men, being more educated, having a high family income, living in environments with conditions and opportunities for PA, being retired and being overweight were positively associated, while current smoking, obesity and abdominal obesity were associated negatively with the LTPA. Among women, being over 60years old, being more educated, having a high family income, living in an environment with conditions and opportunities for PA practice and being retired were positively associated, while being overweight, obese and having abdominal obesity were associated negatively with the LTPA. The proposed ecological model explains the LTPA through the social, physical and personal environment and highlights gender differences in physical activity.
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Chor D, Cardoso LO, Nobre AA, Griep RH, Fonseca MDJM, Giatti L, Bensenor I, del Carmen Bisi Molina M, Aquino EML, Diez-Roux A, de Pina Castiglione D, Santos SM. Association between perceived neighbourhood characteristics, physical activity and diet quality: results of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). BMC Public Health 2016; 16:751. [PMID: 27506819 PMCID: PMC4977638 DOI: 10.1186/s12889-016-3447-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 08/05/2016] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The study explores associations between perceived neighbourhood characteristics, physical activity and diet quality, which in Latin America and Brazil have been scarcely studied and with inconsistent results. METHODS We conducted a cross-sectional analysis of 14,749 individuals who participated in the Brazilian Longitudinal Study of Adult Health (Estudo Longitudinal de Saúde do Adulto, ELSA-Brasil) baseline. The study included current and retired civil servants, aged between 35 and 74 years, from universities and research institutes in six Brazilian states. The International Physical Activity Questionnaire (IPAQ) long form was used to characterize physical activity during leisure time and commuting; additional questions assessed how often fruit and vegetables were consumed, as a proxy for diet quality. Neighbourhood characteristics were evaluated by the "Walking Environment" and "Availability of Healthy Foods" scales originally used in the Multi-Ethnic Study of Atherosclerosis (MESA). Associations were examined using multinomial logistic regression. RESULTS Perceiving a more walkable neighbourhood was positively associated with engaging in leisure time physical activity and doing so for longer weekly. Compared with those who saw their neighbourhood as less walkable, those who perceived it as more walkable had 1.69 (95 % CI 1.57-1.83) and 1.39 (1.28-1.52) greater odds of engaging in leisure time physical activity for more than 150 min/week or up to 150 min/week (vs. none), respectively. Perceiving a more walkable neighbourhood was also positively associated with transport-related physical activity. The same pattern was observed for diet: compared with participants who perceived healthy foods as less available in their neighbourhood, those who saw them as more available had odds 1.48 greater (1.31-1.66) of eating fruits, and 1.47 greater (1.30-1.66) of eating vegetables, more than once per day. CONCLUSIONS Perceived walkability and neighbourhood availability of healthy food were independently associated with the practice of physical activity and diet quality, respectively, underlining the importance of neighbourhood-level public policies to changing and maintaining health-related habits.
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Campbell OMR, Aquino EML, Vwalika B, Gabrysch S. Signal functions for measuring the ability of health facilities to provide abortion services: an illustrative analysis using a health facility census in Zambia. BMC Pregnancy Childbirth 2016; 16:105. [PMID: 27180000 PMCID: PMC4868015 DOI: 10.1186/s12884-016-0872-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 04/14/2016] [Indexed: 11/26/2022] Open
Abstract
Background Annually, around 44 million abortions are induced worldwide. Safe termination of pregnancy (TOP) services can reduce maternal mortality, but induced abortion is illegal or severely restricted in many countries. All abortions, particularly unsafe induced abortions, may require post-abortion care (PAC) services to treat complications and prevent future unwanted pregnancy. We used a signal-function approach to look at abortion care services and illustrated its utility with secondary data from Zambia. Methods We refined signal functions for basic and comprehensive TOP and PAC services, including family planning (FP), and assessed functions currently being collected via multi-country facility surveys. We then used the 2005 Zambian Health Facility Census to estimate the proportion of 1369 health facilities that could provide TOP and PAC services under three scenarios. We linked facility and population data, and calculated the proportion of the Zambian population within reach of such services. Results Relevant signal functions are already collected in five facility assessment tools. In Zambia, 30 % of facilities could potentially offer basic TOP services, 3.7 % comprehensive TOP services, 2.6 % basic PAC services, and 0.3 % comprehensive PAC services (four facilities). Capability was highest in hospitals, except for FP functions. Nearly two-thirds of Zambians lived within 15 km of a facility theoretically capable of providing basic TOP, and one-third within 15 km of comprehensive TOP services. However, requiring three doctors for non-emergency TOP, as per Zambian law, reduced potential access to TOP services to 30 % of the population. One-quarter lived within 15 km of basic PAC and 13 % of comprehensive PAC services. In a scenario not requiring FP functions, one-half and one-third of the population were within reach of basic and comprehensive PAC respectively. There were huge urban-rural disparities in access to abortion care services. Comprehensive PAC services were virtually unavailable to the rural population. Conclusions Secondary data from facility assessments can highlight gaps in abortion service provision and coverage, but it is necessary to consider TOP and PAC separately. This approach, especially when combined with population data using geographic coordinates, can also be used to model the impact of various policy scenarios on access, such as requiring three medical doctors for non-emergency TOP. Data collection instruments could be improved with minor modifications and used for multi-country comparisons.
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Aquino EML, Almeida MDCC, Menezes GMS, de Figueiredo RC, Bensenor IM, Mengue SS, da Fonseca MDJM, Gabrielli L. Postmenopausal hormone therapy in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil): who still uses it? Pharmacoepidemiol Drug Saf 2016; 25:609-17. [DOI: 10.1002/pds.3992] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 01/26/2016] [Accepted: 02/08/2016] [Indexed: 11/11/2022]
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Azevedo E Silva G, Bustamante-Teixeira MT, Aquino EML, Tomazelli JG, Dos-Santos-Silva I. [Access to early breast cancer diagnosis in the Brazilian Unified National Health System: an analysis of data from the Health Information System]. CAD SAUDE PUBLICA 2015; 30:1537-50. [PMID: 25166949 DOI: 10.1590/0102-311x00156513] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 01/09/2014] [Indexed: 11/21/2022] Open
Abstract
The recent reduction in breast cancer mortality in high-income countries resulted from improvements in early detection and treatment. Breast cancer is the most common cancer in Brazilian women. Since 2004, the government has recommended annual clinical breast examination for women aged ≥ 40 years and biannual mammograms for those aged 50-69. This article investigates the degree of implementation of these guidelines using data from the Brazilian Unified National Health System for 2010 according to major geographic region and age group. The findings showed low national mammogram coverage in the target population (32% in the 50-59-year group; 25% from 60 to 69 years). The percentage of women with abnormal radiological findings who underwent biopsy was also low (27% for 50-59 years; 63% for 60-69 years). The number of breast cancer surgeries exceeded the number of cases detected by mammography but was well below the estimated number of incident breast cancer cases in 2010. There are striking regional inequalities in access to early detection and surgery, being the lowest access in the North Region and the highest in the South Region.
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Gabrielli L, Aquino EML. A simplified questionnaire for self-assessment of hirsutism in population-based studies. Eur J Endocrinol 2015; 172:451-9. [PMID: 25583904 DOI: 10.1530/eje-14-0591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The measurement of excess body hair is not straightforward. As the modified Ferriman-Gallwey (mFG) score is unsuitable for self-assessment and requires specialist training, a short, self-administered questionnaire to identify hirsutism was constructed and validated for large-scale application, particularly targeting population-based studies. DESIGN A validation study was conducted to assess a new hirsutism questionnaire. METHODS A total of 90 women aged 35-72 years who were enrolled in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) were evaluated. A self-administered instrument containing four questions was designed to evaluate five body areas: upper lip, chin, chest, lower abdomen, and thighs with respect to the current distribution of body hair and that before 35 years of age. A score of 0-4 was attributed to each region based on drawings provided in the instrument. Test-retest reliability was evaluated by reformulating the initial questions. An independent medical examination was conducted to apply the gold standard, the mFG score. RESULTS The area under the receiver operating characteristic curve was 0.93 (95% CI: 0.87-0.99). A cut-off score of 5 showed the best balance between sensitivity (85%) and specificity (90%), with 88.9% accuracy. Spearman's correlation between current and past body hair score was calculated at 0.82 (P=0.000), and showed a test-retest reliability of 0.49, with a trend toward similar answers regarding changes in the quantity of body hair over time, irrespective of how the questions were asked (P=0.000). CONCLUSION The accuracy and internal consistency of this self-administered questionnaire for the identification of hirsutism were good. Therefore, this questionnaire represents a useful tool for self-assessment of hirsutism in population-based studies.
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