Characteristics of basic health units and detection of tuberculosis cases

INTRODUCTION

Tuberculosis (TB) is an infectious and contagious disease caused by Mycobacterium tuberculosis. TB emerged in the 21st century as an unsolved public health problem. This study aimed to analyze the relationship between the characteristics of basic health units (BHUs) and the number of TB cases detected in Maranhão, Brazil.

METHODS

An ecological, analytical study was conducted using the municipalities in the state of Maranhão as the unit of analysis. Data regarding the number of detected TB cases was obtained from the Sistema de Informação de Agravos de Notificação database, and the characteristics of the BHUs were obtained from the first cycle of data collection for the Program to Improve Access and Quality of Basic Care. The BHU structure was classified as adequate (80%-100%), partially adequate (60%-79%), poorly adequate (40%-59%), or inadequate (<40%) according to the presence of specified items. The number of BHUs per municipality in each adequacy category was estimated. Inflated Poisson regression analysis was performed to estimate the incidence density ratios (IDRs) and the 95% confidence intervals (95% CIs).

RESULTS

Municipalities with a higher level of BHU adequacy had a higher number of detected TB cases (IDR = 1.61, 95% CI: 1.01-2.60).

CONCLUSIONS

Better structured health services in primary care may be associated with better detection and/or notification of TB cases.

Is there a fair distribution of the structure of dental services in the capitals of the Brazilian Federative Units?

Background

Brazilian Primary Care Facilities (PCF) provide primary care and must offer dental services for diagnosis, prevention, and treatment of diseases. According to a logic of promoting equity, PCF should be better structured in less developed places and with higher need for oral health services.

Objective

To analyze the structure of dental caries services in the capitals of the Brazilian Federative Units and identify whether socioeconomic factors and caries (need) are predictors of the oral health services structure.

Methods

This is an ecological study with variables retrieved from different secondary databases, clustered for the level of the federative capitals. Descriptive thematic maps were prepared, and structural equations were analyzed to identify oral health service structure’s predictors (Alpha = 5%). Four models with different outcomes related to dental caries treatment were tested: 1) % of PCF with a fully equipped office; 2) % of PCF with sufficient instruments, and 3) % of PCF with sufficient supplies; 4) % of PCF with total structure.

Results

21.6% of the PCF of the Brazilian capitals had a fully equipped office; 46.9% had sufficient instruments, and 30.0% had sufficient supplies for caries prevention and treatment. The four models evidenced proper fit indexes. A correlation between socioeconomic factors and the structure of oral health services was only noted in model 3. The worse the socioeconomic conditions, the lower the availability of dental supplies (standard factor loading: 0.92, P = 0.012). Estimates of total, direct and indirect effects showed that dental caries experience observed in the Brazilian population by SB-Brasil in 2010 did not affect the outcomes investigated.

Conclusion

Material resources are not equitably distributed according to the socioeconomic conditions and oral health needs of the population of the Brazilian capitals, thus contributing to persistent oral health inequities in the country.

Acesso e utilização dos serviços de saúde bucal por idosos de Pelotas, Rio Grande do Sul, Brasil

Resumo: O objetivo foi medir a falta de acesso e a utilização dos serviços de saúde bucal por idosos de Pelotas, Rio Grande do Sul, Brasil. Estudo transversal de base populacional foi realizado no ano de 2014, na zona urbana do município, incluindo indivíduos com 60 anos e mais. Variáveis sociodemográficas e de necessidade autorreferidas foram associadas aos desfechos. Utilizou-se regressão de Poisson para as análises bruta e ajustada. Foram entrevistados 1.451 idosos mediante um questionário estruturado. Falta de acesso no último ano alcançou uma prevalência de 1,8% (IC95%: 0,7-3,0). Idosos que nunca consultaram somaram 3,1% (IC95%: 2,2-4,0) e a utilização de serviços de saúde bucal no último ano registrou prevalência de 38,3% (IC95%: 36,0-41,0). A utilização no último ano apresentou associação positiva com as seguintes variáveis: faixa etária mais jovem (RP = 1,16), ter companheiro (RP = 1,28), alta escolaridade (RP = 1,31), problema na boca ou nos dentes (RP = 1,93), necessidade de prótese dentária (RP = 1,36) e ser edêntulo (RP = 3,11). A falta de acesso no último ano foi baixa. A utilização de serviços de saúde bucal foi mais alta do que a observada em outros estudos. Os achados parecem refletir a expansão desses serviços, particularmente na rede pública, sendo úteis para as ações de planejamento das políticas de saúde.

Geolocation of hospitalizations registered on the Brazilian National Health System's Hospital Information System: a solution based on the R Statistical Software

OBJECTIVE

to describe a solution enabling geolocation of hospital admissions (AIH), processed on the Brazilian National Health System's Hospital Information System.

METHODS

in order to spatialize AIHs an R language script was written, based on the microdatasus and CepR packages; the script was applied to identify all AIHs in Goiás state in the year 2015; after downloading and pre-processing the data, the procedure for AIH spatialization was detailed.

RESULTS

of the 361,213 AIHs processed, we were able to retrieve 24,220 different ZIP codes (CEPs); from this set of ZIP codes, 23,910 (98.7%) were geolocated; these geolocated ZIP codes enabled spatialization of 97.7% of AIHs processed for the state of Goiás.

CONCLUSION

it is possible to spatialize AIHs with a high success rate; the method detailed in this paper opens a new range of possibilities for the design of evaluation studies, formulation of policies and planning of health care actions.

Functional disability indicators and associated factors in the elderly: a population-based study in Bagé, Rio Grande do Sul, Brazil

OBJECTIVE

to estimate the prevalence of functional disability in basic and instrumental daily activities and associated factors in elderly who live in the urban area of Bagé-RS, Brazil.

METHODS

this is a population-based cross-sectional study, conducted in 2008; functional disability was defined by basic and instrumental daily activities, using Katz index and Lawton and Brody scale; Poisson regression was used for crude and adjusted analyses.

RESULTS

1,593 elderly individuals were investigated; the prevalence of disability for basic activities was of 10.6% (95%CI: 9.1;12.1) and of 34.2% (95%CI: 31.9;36.6) for instrumental activities; both disabilities were statistically associated to the increment of age, low education level, alcohol consumption, history of cerebrovascular diseases, cognitive impairment, hospitalization and home care.

CONCLUSION

a high proportion of elderly presented functional disability; the outcomes were associated to the following variables: demographic, socioeconomic, behavioral, health status and use of health services.

Time trend of lack of access to health services in Brazil, 1998-2013

OBJECTIVE

to analyze the time trend on the demand and lack of access to public health services in Brazil.

METHODS

this is a panel of cross-sectional studies with data of the National Household Sample Survey (1998, 2003, 2008) and the National Health Survey (2013); the prevalence of demand and lack of access within the fifteen days prior to the survey was estimated; Poisson regression was used for trend analysis.

RESULTS

the demand for health services increased from 13.0% (95%CI 12.3;13.7), in 1998, to 15.0% (95%CI 14.5;15.4), in 2013; the lack of access remained stable, being of 3.7% (95%CI 3.2;4.2) in 1998 and 4.5% (95%CI 4.0;5.0) in 2013.

CONCLUSIONS

the increase in demand for health services and the stability in the lack of access indicate improvements in the Brazilian public health system performance; additional efforts are required to ensure universal access to public health services in Brazil.

Assessment of a Brazilian public policy intervention to address schistosomiasis in Pernambuco state: the SANAR program, 2011-2014

BACKGROUND

Brazil is an endemic country for schistosomiasis in the Latin American and Caribbean countries. Pernambuco is a higher-endemic Brazilian state among the 19 states reporting the disease in the country; schistosomiasis affects 102 (55%) of its 185 municipalities. Our objective was to evaluate the effectiveness of the treatment cycles of the SANAR Program (Plan to Reduce and Eliminate Neglected Diseases) in Pernambuco State in Northeast Brazil.

METHODS

A cross-sectional population-based study was conducted in 2014 via a household survey in 117 hyperendemic locations in the state of Pernambuco. We compared the schistosomiasis prevalence rates in hyperendemic locations, aggregated by geographical region, before and after the intervention. The dependent variable was a positive stool test result by the Kato-Katz method, and the main exposure variable was the number of treatment cycles (one/two). The covariables were the regions of the state and socioenvironmental, socioeconomic, demographic and behavioral characteristics.

RESULTS

In all, 12,969 individuals were interviewed, 8932 of whom had stool tests. Of these, 4969 (55.6%) underwent two cycles of collective treatment. Changes in the environmental conditions since 2011 were minimal. Comparison before (2011) and after (2014) treatment showed an average schistosomiasis prevalence of 18.6%, decreasing to 4.1% and 2.0% in locations with one and two treatment cycles, respectively. In 2014, the highest schistosomiasis prevalence was found in the forest area (2.8%), while the lowest was found in the northern region (1.2%) of the state. The adjusted analysis showed a lower occurrence of schistosomiasis in individuals living in areas with two treatment cycles than in individuals from areas with just one cycle (PR 0.65, 95% CI: 0.47-0.89).

CONCLUSIONS

The political decision made in Pernambuco to implement the SANAR Program in 2011 greatly impacted the burden of schistosomiasis. This program was effective in reducing the occurrence of schistosomiasis in hyperendemic areas in Pernambuco, with a stronger response in areas with two cycles of collective treatment.

Multimorbidity: The Brazilian Longitudinal Study of Aging (ELSI-Brazil)

OBJECTIVE

To evaluate the occurrence and factors associated with multimorbidity among Brazilians aged 50 years and over.

METHODS

This is a cross-sectional study in a nation-based cohort of the non-institutionalized population in Brazil. Data were collected between 2015 and 2016. Multimorbidity was assessed from a list of 19 morbidities, which were categorized into ≥ 2 and ≥ 3 diseases. The analysis included the calculation of frequencies and the most frequent 10 pairs and triplets of combinations of diseases. The crude and adjusted analyses evaluated the demographic, socioeconomic, behavioral, and contextual variables (area of residence, geopolitical region, and coverage of the Family Health Strategy) using Poisson regression.

RESULTS

From the total of 9,412 individuals, 67.8% (95%CI 65.6–69.9) and 47.1% (95%CI 44.8–49.4) showed ≥ 2 and ≥ 3 diseases, respectively. In the adjusted analysis, women, older persons, and those who did not consume alcohol had increased multimorbidity. There were no associations with race, area of residence, geopolitical region, and coverage of the Family Health Strategy. The 10 pairs (frequencies observed between 11.6% and 23.2%) and the 10 triplets (frequencies observed between 4.9% and 9.5%) of the most frequent diseases mostly included back problems (15 times) and systemic arterial hypertension (11 times). All combinations were statistically higher than expected by chance.

CONCLUSIONS

The occurrence of multimorbidity was high even among younger individuals (50 to 59 years). Approximately two in three (≥ 2 diseases) and one in two (≥ 3 diseases) individuals aged 50 years and over presented multimorbidity, which represents 26 and 18 million persons in Brazil, respectively. We observed high frequencies of combinations of morbidities.

[Dialogues on the work process in oral health in Brazil: an analysis based on the PMAQ-AB survey]

The study aimed to: (1) describe the work process in Brazil's oral health teams, based on the essential attributes of primary health care, according to geographic region, type of team, and the municipality's socioeconomic characteristics and (2) verify whether the data in the work process of the oral health teams in the Brazilian National Program to Improve Access and Quality in primary health (PMAQ-AB) were capable of measuring such attributes. This was a nationwide ecological study with data from cycle I of PMAQ-AB. The study included descriptive, exploratory factor, and confirmatory factor analyses (α = 5%). Constructs were analyzed in light of the essential attributes of primary health care (first contact, coordination of care, comprehensiveness, and continuity). The first three constructs and a fourth factor were formed, called dental prosthesis actions. However, the continuity attribute was not formed. The models' goodness-of-fit measures were satisfactory. Factor loads were greater than 0.5, except for the two variables in factor 3. The actions most frequently performed by the oral health teams (> 60%) were in first contact, and the least frequent were those in comprehensiveness, highlighting referrals to specialties (7.6%). There were differences in the work process in oral health teams between regions of the country, type of team, and certification strata (p < 0.05). In conclusion, data on the work process in oral health teams from cycle primary health care in the services' work routine. Further research is recommended on continuity of care. In addition, the oral health teams participating in cycle I of PMAQ-AB should make further progress in actions related to comprehensiveness and coordination of care.

Qualidade da Atenção Primária à Saúde no Brasil: avanços, desafios e perspectivas

RESUMO O ensaio reúne avanços, problemas e propostas sobre a qualidade da Atenção Básica no Brasil, com ênfase na integralidade do cuidado, expressa na completude das ações de saúde. Estudos sobre acesso e qualidade da Estratégia Saúde da Família (ESF) evidenciam avanços na ampliação das coberturas da ESF e do acesso da população, na melhoria da estrutura dos serviços, na provisão de médicos e na cobertura de ações de saúde. Persistem problemas de estrutura, com destaque para a disponibilidade de insumos essenciais e de tecnologias de informação e comunicação. A organização e a gestão dos serviços e a prática profissional das equipes padecem de um problema sistêmico de incompletude da oferta de ações e de cuidados de saúde, apesar dos padrões de referência, diretrizes, metas e protocolos. Propõe-se a universalização do modelo de atenção da ESF no Brasil com garantias de aportes na estrutura dos serviços de equipes completas com médicos, enfermeiros, dentistas, técnicos de enfermagem e Agentes Comunitários de Saúde com dedicação integral. Programas de educação permanente, institucionalização de práticas de monitoramento e avaliação em equipes locais e a realização de 'mutirões de qualidade' estimulam a melhoria sistêmica da qualidade da ESF no Brasil, contribuindo para a redução das desigualdades em saúde.

Prevalence of urinary incontinence among the elderly and relationship with physical and mental health indicators

Abstract Objective: to verify the prevalence of urinary incontinence and its relationship with physical and mental health indicators in the elderly population of Bagé, Rio Grande do Sul, Brazil. Method: a cross-sectional population-based study was conducted in 2008 with 1,593 elderly persons. Poisson regression was used for crude and adjusted analysis between the outcomes and the independent variables. Results: the prevalence of urinary incontinence was 20.7%, being 26.9% among women and 10.3% among men. The associated factors were female gender, age 70 to 74 and 75 years or over, yellow/brown/indigenous ethnicity/skin color and no schooling. The prevalence of functional disability, depression, cognitive deficit and very poor/poor self-perception of health was significantly higher in women with urinary incontinence. Among incontinent men, the same was observed with regard to functional disability and cognitive deficit. Conclusion: the occurrence of urinary incontinence in the elderly is frequent, especially in women, with a significant relationship with physical and mental health conditions in the elderly population. These results support the development of care strategies to prevent incontinence and minimize its health impacts.

National Registry of Health Facilities: data reliability evidence

This study compared the reliability of a data group registered in the secondary databases of the National Registry of Health Facilities. A survey was conducted in 2,777 with hospitals to achieve this objective. Visited hospitals provided information on equipment, geographic location, operating status and number of beds. Regarding matching data between visited hospitals and the National Registry, it can be noted that the operating status was updated in 89% of cases, the number of beds in 44%, 82% had the correct amount of equipment and 63% had accurate geographic coordinates. These findings point to a good reliability of information from the National Registry of Health Facilities, regarding the compared categories, excepting for data on the number of registered beds and for some equipment. As a further development of this work, we stress the need to discuss strategies and incentives to improve the reliability of data that still have inconsistencies, in order to improve the instruments used to formulate public policies.

Health education and promotion actions among teams of the National Primary Care Access and Quality Improvement Program, Rio Grande do Sul state, Brazil

OBJETIVO

to investigate the provision of health education and promotion actions in primary care, and their association with demographic characteristics and Family Health Strategy (FHS) coverage in Rio Grande do Sul state, Brazil.

METHODS

this is a cross-sectional study conducted with 816 teams that adhered to the 2012 Primary Care Access and Quality Improvement Program.

RESULTS

the most frequent actions were directed towards people with diabetes (91.2%), hypertension (90.8%) as well as antenatal and postnatal care (84.6%). The least frequent were directed to wards crack, alcohol and other drug users (32.4%), anxiolytic/benzodiazepine users (20.3%), people with tuberculosis (31.4%) and leprosy (21.0%). The greatest provision of health promotion and education actions occurred in smaller municipalities and with greater Family Health coverage.

CONCLUSION

actions aimed at the reproductive period and chronic morbidities were the focus of primary care. FHS implementation strengthens health promotion.

[Structure of primary healthcare units for treating persons with diabetes: Cycles I and II of the Brazilian National Program to Improve Access and Quality]

The objective was to describe the necessary structure for treating diabetes patients in the primary healthcare system, as evaluated in Cycles I and II of the Brazilian National Program for the Improvement of Access and Quality (PMAQ) in 2012 and 2014, according to the municipalities' characteristics. A descriptive study was used to assess primary care units whose teams participated in Cycles I and II of the PMAQ in 2012 and 2014. The study used variables from Module I of the external evaluation of the PMAQ that addresses the primary care units' structure. Materials (150kg scale, sphygmomanometer, adult stethoscope, tape measure, blood glucose monitor, monofilament packs, ophthalmoscope, and capillary blood glucose strips); medicines (NPH and regular insulin, glyburide, and metformin); and physical space (clinical consultation room, pharmacy, reception/waiting room, and meeting room). All the medicines and the reception/waiting room increased by more than 10p.p. from 2012 to 2014. The prevalence rates for adequate structure of materials, medicines, and physical space in the primary care units were higher in 2014. Adequate structure increased as follows: for materials, from 3.9% to 7.8%, for medicines, from 31.3% to 49.9%, for physical space, from 15.3% to 23.3%. Municipalities with more than 300,000 inhabitants, higher Human Development Index (HDI), and lower coverage of the Family Health Strategy (FHS) showed higher prevalence rates for adequate primary care units. Units that adhered to Cycles I and II of the PMAQ showed improvement in their structures. However, there was a low prevalence of primary care units with adequate structures, besides differences in the services' structure according to population size, HDI, and FHS coverage.

Physicians' reflections on the personal learning process and the significance of distance learning in family health

The scope of the article is to present the reflections of professionals from the Mais Médicos Program (More Doctors Program) on the significance of the specialization course in Family Health in terms of professional practice and learning the most important concepts. This is an empirically based qualitative study on the statements recorded in the "Critical reflection on their personal learning process" of the final work of the specialization course at the Federal University of Pelotas. For textual analysis, 101 reports were randomly selected from a total of 1,011 reports completed in seven states of the North, Northeast and South of Brazil from June to December 2015. The initial barriers were overcome with tutor support and team integration, with emphasis on teaching tools for the improvement of clinical practice and strategic organization of work and greater understanding of the public health system. Fostering the learning of the Portuguese language and the exchange of experience in the forums were considered valuable positive aspects. Despite the difficulty in Internet access in some municipalities it reaffirmed the central role of ongoing education and the viability of the problem-solving methodology, even from a distance.

Quality of infant care in primary health services in Southern and Northeastern Brazil

OBJECTIVE

To assess the quality of the health care provided to children aged under one year old performed by primary health services in the South and Northeast regions of Brazil.

METHODS

This is a cross-sectional, population-based study carried out in 2010 with 7,915 children aged from one to four years, whose homes are located in the areas of health service coverage. We described the prevalence of procedures and guidelines, such as weight and height measurement, vaccination, newborn blood spot screening, evaluation of umbilical cord, instruction on breastfeeding and introduction of new food, and their respective 95% confidence intervals. The differences were analyzed using the chi-square test of heterogeneity and linear trend. We considered the main outcome of high-quality infant care if the child had received all recommended procedures and guidelines in the first year of life. For this analysis, we used the Poisson regression considering hierarchical model.

RESULTS

There was low prevalence for the instruction on breastfeeding in the first week of life (58.8%, 95%CI 57.5-60.0) and on the introduction of new food in the fourth month care. The prevalence of high-quality in childcare was 42.0% (95%CI 40.5-43.5). The adjusted analysis according to hierarchical model indicated greater probability of this outcome in the Northeast region (PR = 1.17, 95%CI 1.09-1.26), in smaller municipalities (PR = 1.17, 95%CI 1.03-1.33), and in municipalities with 50,000 and 99,000 inhabitants (PR = 1.20, 95%CI 1.09-1.34).

CONCLUSIONS

The Northeast region has higher-quality infant care services, which can be explained by the consolidation of the Family Health Strategy in that region.

Oral primary care: an analysis of its impact on the incidence and mortality rates of oral cancer

Background

Oral cancer is a potentially fatal disease, especially when diagnosed in advanced stages. In Brazil, the primary health care (PHC) system is responsible for promoting oral health in order to prevent oral diseases. However, there is insufficient evidence to assess whether actions of the PHC system have some effect on the morbidity and mortality from oral cancer. The purpose of this study was to analyze the effect of PHC structure and work processes on the incidence and mortality rates of oral cancer after adjusting for contextual variables.

Methods

An ecological, longitudinal and analytical study was carried out. Data were obtained from different secondary data sources, including three surveys that were nationally representative of Brazilian PHC and carried out over the course of 10 years (2002–2012). Data were aggregated at the state level at different times. Oral cancer incidence and mortality rates, standardized by age and gender, served as the dependent variables. Covariables (sociodemographic, structure of basic health units, and work process in oral health) were entered in the regression models using a hierarchical approach based on a theoretical model. Analysis of mixed effects with random intercept model was also conducted (alpha = 5%).

Results

The oral cancer incidence rate was positively association with the proportion of of adults over 60 years (β = 0.59; p = 0.010) and adult smokers (β = 0.29; p = 0.010). The oral cancer related mortality rate was positively associated with the proportion of of adults over 60 years (β = 0.24; p < 0.001) and the performance of preventative and diagnostic actions for oral cancer (β = 0.02; p = 0.002). Mortality was inversely associated with the coverage of primary care teams (β = −0.01; p < 0.006) and PHC financing (β = −0.52⁻⁹; p = 0.014).

Conclusions

In Brazil, the PHC structure and work processes have been shown to help reduce the mortality rate of oral cancer, but not the incidence rate of the disease. We recommend expanding investments in PHC in order to prevent oral cancer related deaths.

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3700-z) contains supplementary material, which is available to authorized users.

Addressing geographic access barriers to emergency care services: a national ecologic study of hospitals in Brazil

Background

Unequal distribution of emergency care services is a critical barrier to be overcome to assure access to emergency and surgical care. Considering this context it was objective of the present work analyze geographic access barriers to emergency care services in Brazil. A secondary aim of the study is to define possible roles to be assumed by small hospitals in the Brazilian healthcare network to overcome geographic access challenges.

Methods

The present work can be classified as a cross-sectional ecological study. To carry out the present study, data of all 5843 Brazilian hospitals were categorized among high complexity centers and small hospitals. The geographical access barriers were identified through the use of two-step floating catchment area method. Once concluded the previous step an evaluation using the Getis-Ord-Gi method was performed to identify spatial clusters of municipalities with limited access to high complexity centers but well covered by well-equipped small hospitals.

Results

The analysis of accessibility index of high complexity centers highlighted large portions of the country with nearly zero hospital beds by inhabitant. In contrast, it was possible observe a group of 1595 municipalities with high accessibility to small hospitals, simultaneously with a low coverage of high complexity centers. Among the 1595 municipalities with good accessibility to small hospitals, 74% (1183) were covered by small hospitals with at least 60% of minimum emergency service requirements. The spatial clusters analysis aggregated 589 municipalities with high values related to minimum emergency service requirements. Small hospitals in these 589 cities could promote the equity in access to emergency services benefiting more than eight million people.

Conclusions

There is a spatial disequilibrium within the country with prominent gaps in the health care network for emergency services. Taking this challenge into consideration, small hospitals could be a possible solution and foster equity in access to emergency and surgical care. However more investments in are necessary to improve small hospitals capabilities to fill this gap.

Structure and work process in primary care and hospitalizations for sensitive conditions

OBJECTIVE

The objective of this study is to investigate whether the characteristics of the structure of primary health units and the work process of primary care teams are associated with the number of hospitalizations for primary care sensitive conditions.

METHODS

In this ecological study, we have analyzed data of Brazilian municipalities related to sociodemographic characteristics, coverage of care programs, structure of primary health units, and work process of primary care teams. We have obtained the data from the first cycle of the Brazilian Program for Improving Access and Quality of the Primary Care, of the Department of Information Technology of the Brazilian Unified Health System, the Brazilian Institute of Geography and Statistics, and the United Nations Development Programme. The associations have been estimated using negative binomial regression coefficients (β) and respective 95% confidence intervals, with a hierarchical approach in three levels (alpha = 5%).

RESULTS

In the adjusted analysis for the outcome in 2013, in the distal level, the coverage of the Bolsa Família Program (β = -0.001) and private insurance (β = -0.01) had a negative association, and the human development index (β = 1.13), the proportion of older adults (β = 0.05) and children under the age of five (β = 0.05), and the coverage of the Community Health Agent Strategy (β = 0.002) showed positive association with hospitalizations for primary care sensitive conditions. In the intermediate level, minimum hours (β = -0.14) and availability of vaccines (β = -0.16) showed a negative association, and availability of medications showed a positive association (β = 0.16). In the proximal level, only the variable of matrix support (β = 0.10) showed a positive association. The variables in the adjusted analysis of the number of hospitalizations for primary care sensitive conditions in 2014 presented the same association as in 2013.

CONCLUSIONS

The characteristics of the structure of primary health units and the work process of the primary care teams impact the number of hospitalizations for primary care sensitive conditions in Brazilian municipalities.

Quality of cervical cancer screening in Brazil: external assessment of the PMAQ

OBJECTIVE

To examine whether demographic and socioeconomic variables and the variables of the organization of services are associated with the quality of cervical cancer screening.

METHODS

This is a survey carried out in the health services of the five Brazilian regions in 2012. The sample consisted of users of basic health units participating in the Program for Improving Access and Quality of the Primary Care. The independent variables analyzed were: socioeconomic characteristics (municipal context), demographic characteristics (user profile), and two domains related to the organization of basic services (work structure and process). The low quality of the screening was assessed from the lack of access, late examination, and lack of guidance. Crude and adjusted analyses by Poisson regression assessed the association between outcomes and independent variables.

RESULTS

The values of lack of access, late examination, and lack of guidance were 6.7%, 11.2%, and 19.2%, respectively. Problems of quality were lower according to the increase in Municipal Human Development Index and per capita household income, increasing with population size and municipal coverage of the Family Health Strategy. The Midwest region of the country presented the highest occurrences of low quality outcomes. Indigenous and yellow women had the highest prevalence of outcomes. Women with partner, who received the Bolsa Família Program, and who had paid work had less chances of having lack of access, late examination, and lack of guidance. The appropriate work process in health services decreased the likelihood of low quality in all indicators.

CONCLUSIONS

Investments in the work process of health teams, social cash transfer programs, and social conditions of the population are essential to improve the quality of the program of cervical cancer screening in Brazil.

Waist-to-height ratio as an anthropometric marker of overweight in elderly Brazilians

This study's objective was to identify the cut-off point for waist-to-height ratio (WHtR) with the best sensitivity, specificity, and accuracy for the elderly Brazilian population, using body mass index (BMI) as the anthropometric reference. A representative sample of the Brazilian population consisted of 5,428 elderly individuals participating in an epidemiological survey. The variables were weight, height, and waist circumference (WC). WHtR was assessed with BMI as the gold standard, using two proposals for classification of the elderly population's nutritional status. The ideal cut-off point for WHtR simultaneously showing the highest sensitivity and specificity was determined using the receiver operating characteristic (ROC) curve. Sensitivity from 94.9% to 98.4%, specificity from 43% to 55.4%, and values for area under the ROC curve from 0.878 to 0.883 were identified with a cut-off point of 0.55. We recommend use of WHtR in clinical practice due to its simplicity and good power to detect overweight in the elderly.

Socioeconomic determinants of access to health services among older adults: a systematic review

OBJECTIVE

The objective of this study was to analyze the association between the socioeconomic characteristics and the access to or use of health services among older adults.

METHODS

This is a systematic review of the literature. The search has been carried out in the databases PubMed, LILACS and Web of Science, without restriction of dates and languages; however we have included only articles published in Portuguese, English, and Spanish. The inclusion criteria were: observational design, socioeconomic factors as variables of interest in the analysis of the access to or use of health services among older adults, representative sample of the target population, adjustment for confounding factors, and no selection bias.

RESULTS

We have found 5,096 articles after deleting duplicates and 36 of them have been selected for review after the process of reading and evaluating the inclusion criteria. Higher income and education have been associated with the use and access to medical appointments in developing countries and some developed countries. The same association has been observed in dental appointments in all countries. Most studies have shown no association between socioeconomic characteristics and the use of inpatient and emergency services. We have identified greater use of home visits in lower-income individuals, with the exception of the United States.

CONCLUSIONS

We have observed an unequal access to or use of health services in most countries, varying according to the type of service used. The expansion of the health care coverage is necessary to reduce this unequal access generated by social inequities.

Hospitalization in older adults: association with multimorbidity, primary health care and private health plan

OBJECTIVE

Evaluate the association of multimorbidity, primary health care model and possession of a private health plan with hospitalization.

METHODS

A population-based cross-sectional study with 1,593 elderly individuals (60 years old or older) living in the urban area of the city of Bagé, State of Rio Grande do Sul, Brazil. The outcome was hospitalization in the year preceding the interview. The multimorbidity was evaluated through two cut-off points (≥ 2 and ≥ 3). The primary health care model was defined by residence in areas covered by traditional care or by Family Health Strategy. The older adults mentioned the possession of a private health plan. We performed a gross and adjusted analysis by Poisson regression using a hierarchical model. The adjustment included demographic, socioeconomic, functional capacity disability and health services variables.

RESULTS

The occurrence of overall and non-surgical hospitalization was 17.7% (95%CI 15.8–19.6) and 10.6% (95%CI 9.1–12.1), respectively. Older adults with multimorbidity were admitted to hospitals more often when to older adults without multimorbidity, regardless of the exhibition’ form of operation. Having a private health plan increased the hospitalization by 1.71 (95%CI 1.09–2.69) times among residents in the areas of the Family Health Strategy when compared to elderly residents in traditional areas without a private health plan.

CONCLUSIONS

The multimorbidity increased the occurrence of hospitalizations, especially non-surgical ones. Hospitalization was more frequent in older adults with private health plan and those living in Family Health Strategy areas, regardless of the presence of multiple diseases.

[Quality of prenatal services in primary healthcare in Brazil: indicators and social inequalities]

The aim of this study was to describe quality indicators for prenatal care in Brazil as part of the Program for the Improvement of Access and Quality (PMAQ-AB). The study analyzed number of prenatal visits, vaccination status, prescription of ferrous sulfate, physical examination, orientation, and laboratory tests, based on which a summary quality indicator was constructed. Data were collected in 2012-2013 during interviews conducted by External Evaluators of the PMAQ-AB, with 6,125 users who had done their last prenatal follow-up in Family Health units. During prenatal follow-up, 89% reported six or more visits, more than 95% received a tetanus booster and prescription of ferrous sulfate, 24% reported having received all the procedures in the physical examination, 60% received all the orientation, and 69% had all the recommended laboratory tests. Only 15% of interviewees had received adequate prenatal care, including all the recommended measures, and there was a significantly higher proportion of "complete" care in pregnant women that were older, with higher income, in the Southeast region of Brazil, in municipalities with more than 300,000 inhabitants, and in those with (HDI) in the upper quartile. There are persist social and individual inequalities that can be targeted by measures to upgrade the teams' work processes.