Inequalities in healthy life expectancy by Brazilian geographic regions: findings from the National Health Survey, 2013

[Regional differences and trends in healthy life expectancy in Germany]

BACKGROUND

Against the background of increasing life expectancy, the question arises in which state of health the additional years of life are spent. The aim of this study is to assess for the first time regional differences in healthy life expectancy for Germany.

METHODS

The concept of healthy life expectancy allows for the combination of regional differences in health status and mortality in a single measure. This article uses the concept of partial healthy life expectancy. We use official data on deaths and population numbers to calculate abridged life tables. Data from the Socio-Economic Panel (SOEP) are used to determine the age- and sex-specific prevalences of health status. Regional differences are analyzed from 2002 to 2019 by dividing Germany into four regions (North, South, East, West).

RESULTS

The regional differences in healthy life expectancy in Germany are greater than differences in life expectancy, and trends in healthy life expectancy partly differ from the corresponding trends in mortality. These differences over time also vary according to age: while healthy life expectancy has tended to stagnate and, in some cases, decline among the population aged between 20 and 64, the number and proportion of years in good health has increased among older adults up to the age of 79.

CONCLUSION

There are striking regional differences and trends in the distribution of expected years in good health in Germany. The timely identification of regionally divergent developments could facilitate the implementation of targeted health-promoting measures.

Comparison of 1-year survival between patients initiating chronic hemodialysis under public and private health insurance: register-based data analysis from Brazil

PURPOSE

Brazil has one of the world's highest numbers of patients on hemodialysis (HD). Most dialysis centers are private and perform HD for patients with private and public health insurance. We compared 1-year survival between patients initiating chronic HD with public and private health insurance.

METHODS

This is an HD register-based retrospective cohort. Adult patients starting HD from January 2011 to December 2021 were included. Survival analysis was stratified according to the period entered in the HD register. Multivariate Cox regression focused on 1-year survival differences between private and public patients.

RESULTS

In the final sample (n = 5114), 68.5% of participants had public and 31.3% to private health insurance, with overall 1-year survival of 92.8% and 89.9%, respectively (p = 0.002). Crude analysis showed a slightly higher survival rate among patients with public health insurance than those with private health insurance (91 vs. 87%, p = 0.030) in the first period (2019-21). However, the adjusted hazard ratio (HR) did not remain significantly higher for patients with private health insurance compared to those with public health insurance (HR = 1.07; 95% CI 0.80-1.41; p = 0.651), even after propensity score matching of the groups by several baseline features.

CONCLUSION

Brazilian chronic HD patients funded by either private health plans or the public system have a similar 1-year mortality risk after controlling for several sociodemographic and clinical parameters.

Impact of the COVID-19 pandemic on excess maternal deaths in Brazil: A two-year assessment

BACKGROUND

Accurate estimates of the COVID-19 pandemic's indirect impacts are crucial, especially in low- and middle-income countries. This study aims to update estimates of excess maternal deaths in Brazil during the first two years of the COVID-19 pandemic.

METHODS

This was an exploratory mixed ecological study using the counterfactual approach. The observed maternal deaths were gathered from the Mortality Information System (SIM) for the period between March 2015 and February 2022. Expected deaths from March 2020 to February 2022 were estimated using quasipoisson generalized additive models, considering quadrimester, age group, and their interaction as predictor variables. Analyses were performed in R version 4.1.2, RStudio, version 2023.03.1+446 and carried out with support from the "mgcv" and "plot_model" libraries.

RESULTS

A total of 5,040 maternal deaths were reported, with varying excess mortality across regions and age groups, resulting in 69% excess maternal mortality throughout Brazil during the first two years of the pandemic. The Southeast region had 50% excess mortality throughout the first two years and 76% excess in the second year. The North region had 69% excess mortality, increasing in the second year, particularly among women aged 20-34. The Northeast region showed 80% excess mortality, with a significant increase in the second year, especially among women aged 35-49. The Central-West region had 75% excess mortality, higher in the second year and statistically significant among women aged 35-49. The South region showed 117% excess mortality, reaching 203% in the second year among women aged 20-34, but no excess mortality in the 10-19 age category.

CONCLUSIONS

Over two years, Brazil saw a significant impact on maternal excess deaths, regardless of region and pandemic year. The highest peak occurred between March and June 2021, emphasizing the importance of timely and effective epidemic responses to prevent avoidable deaths and prepare for new crises.

Excess suicides in Brazil during the first 2 years of the COVID-19 pandemic: Gender, regional and age group inequalities

BACKGROUND

While the COVID-19 pandemic's total impact on global mortality is uncertain, an estimated 15 million excess deaths occurred during the first two pandemic years, suggesting that a broad impact, since several causes of death showed a substantial rise.

AIMS

To estimate excess suicides in Brazil and evaluate differences within and between subgroups during the first 2 years of the COVID-19 pandemic.

METHOD

Based on suicide data from the mortality information system of the Brazilian Ministry of Health, the expected number of suicides was estimated by age group, gender, 4-month periods and regions through quasi-Poisson generalized additive models. Analyses were performed in R software and RStudio.

RESULTS

Between March 2020 and February 2022, 29,295 suicides were reported in Brazil, close to what would be expected (30,116; 95% Confidence Interval (95% CI): [28,009, 32,224]), albeit in males and females aged 30 to 59 years and 60 years and over, there were excess suicides in at least one of the six 4-month periods evaluated, especially in the second pandemic year. In the Southeast region, a 28% increase was observed in women 60 years and older during the second year. In the North region, suicide increased 23% and 32% among women aged 30 to 59 years during the first and second pandemic years, respectively. The Northeast region had a 16% excess in suicides among men aged 30 to 59 years and 61% among women 60 years old and older during the second pandemic year, reaching 83% in July to October 2021.

CONCLUSIONS

During the first 2 pandemic years, the pattern of suicides was not homogeneous in Brazil. There were substantial excess suicides in women aged 30 to 59 years from the North and Northeast, while among the elderly and men there was a consistent pattern in several four-month periods throughout Brazil.

Twenty-first-century demographic and social inequalities of heat-related deaths in Brazilian urban areas

Population exposure to heat waves (HWs) is increasing worldwide due to climate change, significantly affecting society, including public health. Despite its significant vulnerabilities and limited adaptation resources to rising temperatures, South America, particularly Brazil, lacks research on the health impacts of temperature extremes, especially on the role played by socioeconomic factors in the risk of heat-related illness. Here, we present a comprehensive analysis of the effects of HWs on mortality rates in the 14 most populous urban areas, comprising approximately 35% of the country's population. Excess mortality during HWs was estimated through the observed-to-expected ratio (O/E) for total deaths during the events identified. Moreover, the interplay of intersectionality and vulnerability to heat considering demographics and socioeconomic heterogeneities, using gender, age, race, and educational level as proxies, as well as the leading causes of heat-related excess death, were assessed. A significant increase in the frequency was observed from the 1970s (0-3 HWs year-1) to the 2010s (3-11 HWs year-1), with higher tendencies in the northern, northeastern, and central-western regions. Over the 2000-2018 period, 48,075 (40,448-55,279) excessive deaths were attributed to the growing number of HWs (>20 times the number of landslides-related deaths for the same period). Nevertheless, our event-based surveillance analysis did not detect the HW-mortality nexus, reinforcing that extreme heat events are a neglected disaster in Brazil. Among the leading causes of death, diseases of the circulatory and respiratory systems and neoplasms were the most frequent. Critical regional differences were observed, which can be linked to the sharp North-South inequalities in terms of socioeconomic and health indicators, such as life expectancy. Higher heat-related excess mortality was observed for low-educational level people, blacks and browns, older adults, and females. Such findings highlight that the strengthening of primary health care combined with reducing socioeconomic, racial, and gender inequalities represents a crucial step to reducing heat-related deaths.

Evidence of waste management impacting severe diarrhea prevalence more than WASH: An exhaustive analysis with Brazilian municipal-level data

Adequate housing protects from diarrhea, which is a substantial health concern in low- and middle-income countries. The purpose of this study was to quantify the relationship between severe diarrhea and housing features at the municipal level to help in public health planning. Regression analyses were performed on annual (2000-2012) datasets on Brazilian municipalities (5570) in six household feature categories (e.g., waste management) and four severe diarrhea outcomes (e.g., diarrhea deaths of under-5 children). Household data were not available elsewhere of this magnitude and granularity, highlighting the scientific value-add of this study. Municipalities were clustered prior to regression analysis because of data heterogeneity. The compositional household feature data were also subjected to principal component analysis to diminish feature variable multicollinearity. The highest explanatory power was found for diarrhea deaths of under-5 children (R2 = 10-22 %), while those in the over-5 population were the least best explained (R2 = 0.3-7 %). Household features predicted diarrhea outcomes more accurately in the "advanced" housing municipality cluster (R2 = 16-22 %) than in the "mid-level" (R2 = 7-20 %) and "basic" (R2 = 6-12 %) ones (over-5 diarrhea deaths excluded). Under-5 children's diarrhea death prevalence was three times higher in the "basic" cluster than in the "advanced" cluster. Importantly, the impact of waste management was overall the largest of all household features, even larger than those of WASH, i.e., water supply, sanitation, and household drinking water treatment. This is surprising in the context of existing literature because WASH is generally regarded as the most important household factor affecting gastrointestinal health. In conclusion, public health interventions could benefit from customizing interventions for diarrhea outcomes, municipality types, and household features. Waste management's identified stronger association with diarrhea compared to WASH may have important implications beyond the water field and Brazil.

Is parenthood associated with self-rated health among women in Brazil?

BACKGROUND

Previous studies conducted in Europe and North America addressing the relationship between self-rated health and parenthood offer inconsistent results, with effects ranging from nonsignificant to significant and in opposite directions. The aim of the present study was to explore the relationship between parenthood and self-rated health (SRH) among women in Brazil (a country with strong inequalities) considering the time interval from the last delivery in the analyses, as proposed in previous studies set in Sweden.

METHODS

The study used data from cross-sectional National Health Surveys in Brazil conducted from 2013 to 2014 and 2019 to 2020 with selected groups of 20,046 and 25,100 women for whom complete data were available on the variables of interest. The primary outcome was self-rated health measured on a five-point scale. Partial proportional odds models were employed.

RESULTS

Compared to women that were not a parent, primiparous women whose delivery was within less than one year had a lower likelihood of worse SRH (OR (95% CI): 0.58-0.84 in 2013, and 0.64-0.94 in 2019), whereas multiparous women whose last delivery was more than one year earlier had greater likelihood of worse SRH (OR (95% CI): 1.08-1.27 in 2013, and 1.21-1.39 in 2019).

CONCLUSIONS

An association was found between parenthood and SRH among Brazilian women. Considering the epidemiological relevance of SRH, different aspects of parenthood concerning parity and time since the last delivery should be considered in further analyses.

Prevalence of dynapenia and overlap with disability, depression, and executive dysfunction

OBJECTIVE

This study aims to investigate handgrip strength and dynapenia prevalence among older adults stratified by Brazilian macroregions. Additionally, we aim to evaluate the overlap between dynapenia and Instrumental Activities of Daily Living (IADL) disability, depression, and executive dysfunction on a national basis and by each Brazilian macroregion.

METHODS

This cross-sectional analysis was based on data from the Brazilian Longitudinal Study of Aging (ELSI-Brazil). A multistage cluster sample design was used, with a representative population-based study of non-institutionalized community-dwelling Brazilians aged ≥ 50 years from 70 municipalities across all five macroregions of the country. The outcome variable was dynapenia. Covariables were IADL disability, depression, and executive dysfunction. The Brazilian macroregions were used for stratification. In addition, the following additional variables were included: age group, gender, education level, macroregions (North, Northeast, Southeast, South, and Midwest), self-reported health, multimorbidity, and falls.

RESULTS

A total of 8,849 (94%) of the sample provided complete information for the handgrip strength assessment and were included in this analysis. Dynapenia prevalence was higher in North and Northeast regions (28.5% and 35.1%, respectively). We identified statistically significant differences between different macroregions for dynapenia, IADL disability, and verbal fluency, with worse values in the North and Northeast regions. In the North and Northeast macroregions, nearly half of the subjects that presented executive dysfunction and IADL disability also had dynapenia. There was a more significant overlap in the prevalence of all four conditions in the North and Northeast regions (4.8% and 5.5%, respectively), whereas the overlap was smaller in the South (2.3%). There was also a smaller overlap in the prevalence of dynapenia and depression in the South (5.8%) compared with other macroregions.

CONCLUSIONS

Macroregions in Brazil exhibit marked differences in the prevalence of dynapenia and in its overlap with IADL disability, depression, and executive dysfunction.

Does patient and public involvement impact public health decision-making? A 10 year retrospective analysis of public consultation in Brazil

BACKGROUND

 The aim of this work is to characterize the processes associated with patient and public involvement (PPI) in the form of public consultations (PC) during the first 10 years of operation of the National Committee for Health Technology Incorporation in the Unified Health System (Conitec) of Brazil, and to identify factors associated with changes in Conitec's recommendations following these PC.

METHODS

 This cross-sectional study analysed all processes related to the adoption of technologies that took place in Brazil between 2012 and 2021 based on technical reports and self-reported information collected from PC participants. A multiple logistic regression model identified factors associated with changes in Conitec's recommendations following PC.

RESULTS

 A total of 479 technical reports were published, of which 83% (n = 400) were submitted to PC. Demands were made mainly by applicants from the government (n = 262; 55%), regarding the adoption of medicines (n = 366; 76%), in which context neoplasms and infectious diseases were the most frequent indications (n = 66; 14% for each). A total of 264 (55%) processes resulted in a final recommendation in favour of introducing the technology. Over the period of 10 years, 196 483 contributions were received in response to PC. The largest volume of contributions was made by patients and their families or representatives (n = 99 082; 50%), females (122 895; 67%), white individuals (129 165; 71%) and individuals between the ages of 25 and 59 years (145 364; 80%). Alteration of the preliminary recommendation occurred in 13% (n = 53) of the PC, with a higher proportion of recommendations being altered from 2017 onwards. Increased participation by patients had a significant impact on the alteration of the preliminary recommendation (odds ratio 3.87, 95% CI 1.33-13.35, p = 0.02).

CONCLUSIONS

Increased engagement of patients and their families and caregivers in PC was associated with changing the preliminary recommendation of Conitec about the adoption of technologies into the public health system in Brazil.

Risk for Severe Illness and Death among Pediatric Patients with Down Syndrome Hospitalized for COVID-19, Brazil

Down syndrome is the most common human chromosomal disorder. Whether Down syndrome is a risk factor for severe COVID-19 outcomes in pediatric patients remains unclear, especially in low-to-middle income countries. We gathered data on patients <18 years of age with SARS-CoV-2 infection from a national registry in Brazil to assess the risk for severe outcomes among patients with Down syndrome. We included data from 14,684 hospitalized patients, 261 of whom had Down syndrome. After adjustments for sociodemographic and medical factors, patients with Down syndrome had 1.8 times higher odds of dying from COVID-19 (odds ratio 1.82, 95% CI 1.22-2.68) and 27% longer recovery times (hazard ratio 0.73, 95% CI 0.61-0.86) than patients without Down syndrome. We found Down syndrome was associated with increased risk for severe illness and death among COVID-19 patients. Guidelines for managing COVID-19 among pediatric patients with Down syndrome could improve outcomes for this population.

Impact of socioeconomic factors and health determinants on preterm birth in Brazil: a register-based study

BACKGROUND

More than 15 million children are born preterm annually. While preterm survival rates have increased in high-income countries. Low- and middle-income countries, like Brazil, continue to battle high neonatal mortality rates due to a lack of adequate postnatal care. Globally, neonatal mortality is higher for preterm infants compared to those born at term. Our study aims to map and analyze the spatial, socioeconomic, and health coverage determinants related to preterm birth in Brazil in order to understand how spatial variations in demographics and access to primary care may affect preterm birth occurrences.  METHODS: Using publicly available national-level data from the Brazilian health system for 2008-2017, we conducted an ecological study to visualize the spatial distributions of preterm birth along with socioeconomic status, the structure of health services, and primary care work process, each consisting of multiple variables reduced via principal component analysis. Regression models were created to determine predictive effects of numeric and spatial variation of these scores on preterm birth rates.

RESULTS

In Brazil, preterm birth rates increased from 2008-2017, with small and rural municipalities frequently exhibiting higher rates than urban areas. Scores in socioeconomic status and work process were significant predictors of preterm birth rates, without taking into account spatial adjustment, with more positive scores in socioeconomic status predicting higher preterm birth rates (coefficient 0.001145) and higher scores in work process predicting lower preterm birth rates (coefficient -0.002416). Geographically weighted regression showed socioeconomic status to be a more significant predictor in the North, with the work process indicators being most significant in the Northeast.

CONCLUSIONS

Results support that primary care work process indicators are more significant in estimating preterm birth rates than physical structures available for care. These results emphasize the importance of ensuring the presence of the minimum human resources needed, especially in the most deprived areas of Brazil. The association between social determinants of health and preterm birth rates raises questions regarding the importance of policies dedicated to foster equity in the accessibility of healthcare services, and improve income as protective proxies for preterm birth.

Excess suicides in Brazil: Inequalities according to age groups and regions during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has already claimed more than six million direct deaths. Low-and middle-income countries, such Brazil, were severely hit, not only due to direct effects on mortality, but also for its indirect effects on other causes of deaths.

AIMS

The objective of this study was to estimate the excess suicides in Brazil and evaluate patterns within and between its regions during the COVID-19 pandemic in 2020.

METHOD

The observed suicides are gathered from the mortality information system of the Brazilian Ministry of Health. The estimates of expected suicides, according to sex, age group, bimonthly period and region, were reached through quasi-Poisson generalized additive models, with adjustment for overdispersion. The analyses were performed in R software, version 3.6.1 and RStudio, version 1.2.1335.

RESULTS

From March 2020 to December 2020, 10,409 suicides were observed in Brazil, resulting in an overall decrease of 13%, in comparison to the expected rate for the period. There were excess suicides of 26% in men from the Northern region in the 60 years and more age group, as well as in women from the Northern region in the 30 to 59 years age group in two consecutive bimonthly periods. Excess suicides of 40% was also observed in women in the 60 years and more age group from the Northeastern region.

CONCLUSIONS

Despite the overall decrease in suicides in Brazil over the period assessed, substantial excess suicides were observed in different age groups and sexes from the Northern and Northeastern regions of the country, which are regions that are historically more prone to health and socioeconomic inequalities.

[Evaluation of cervical cancer control actions within Brazil and its regions based on data recorded in the Brazilian Unified National Health System]

This study analyzes the performance of screening and diagnosis tests for cervical cancer among women aged 25 to 64 years, as well as the delay for the initiation of treatment within Brazil and in its geographic regions, from 2013 to 2020. Information on populational procedures and estimates was obtained from the information systems of the Brazilian Unified National Health System and the Brazilian National Supplementary Health Agency. We calculated the coverage indicators of the Pap smear, the percentages of altered cytopathological and histopathological tests, and the percentage of women diagnosed with cervical cancer with over 60 days of treatment. There was great variation in the coverage of the Pap smear test among the Brazilian regions with a downward trend from 2013, which was aggravated from 2019 to 2020. The number of altered cytopathological tests was 40% lower than estimated, and the difference between the recorded number of cancer diagnoses and the estimated number of patients was below 50%. The percentage of women diagnosed with invasive cervical cancer, who started treatment after 60 days, ranged from 50% in the South to 70% in the North Region with a decrease from 2018. In 2020, there was a decrease in the number of screening and follow-up tests, reducing the proportion of women delayed in starting treatment in the North, Southeast, and South regions. The decline in screening coverage and inadequate follow-up of women with altered results indicate the need to improve early detection strategies for the disease and establish mechanisms for constant evaluation and monitoring of actions.

Time-to-treatment initiation for cutaneous melanoma reflects disparities in healthcare access in Brazil: a retrospective study

OBJECTIVES

This study aimed at identifying the sociodemographic and first treatment characteristics affecting time-to-treatment initiation (TTI) of patients with cutaneous melanoma assisted by the Brazilian Unified Health System (SUS).

STUDY DESIGN

Retrospective observational study using cutaneous melanoma cases recorded in the Brazilian Hospital-Based Cancer Registries (HBCR).

METHODS

A total of 12,783 cutaneous melanoma cases were included in the analysis. Based on the legislation, TTI in Brazil is 60 days; therefore, the cohort was dichotomized into TTI within 60 days and over. The association among variables was evaluated through the Chi-squared test. Kaplan-Meier method and log-rank hypothesis test were used to determine the probability of initiating treatment within 60 days. Cox proportional hazards regression model was used for multivariate analysis.

RESULTS

Median TTI was 28 days (95% CI, 25-29). First treatment in SUS provided more than 60 days after diagnosis (34.8%) was associated with females; low level of formal education; living or getting treatment in northern Brazil; being diagnosed in SUS and treated at different healthcare facilities, in addition to starting treatment with radiotherapy or systemic therapy. There were no significant differences in access to health care before and after the enactment of the 60-day law.

CONCLUSION

Increased TTI for cutaneous melanoma is associated with sociodemographic and first treatment characteristics in Brazil; approximately one-third of cases did not have access to first treatment within the period established by law. Receiving the diagnosis and treatment at different healthcare facilities (transitions in care) is the main independent factor associated with TTI longer than 60 days.

A biopsychosocial examination of chronic back pain, limitations on usual activities, and treatment in Brazil, 2019

Background

Chronic back pain is prevalent in Brazil, leading to enormous healthcare costs and social burdens. It also disproportionately affects low-income and less-healthy people.

Objectives

This study examines the associations of chronic back pain with biological, psychological, and social factors; how it limits usual activities; and how chronic back pain influences the use of treatment services.

Methods

Using Brazil’s National Health Survey (PNS-2019), multivariate logistic regressions were conducted to examine how biological, psychological, and social factors correlate with chronic back pain, limitations on usual activities, and pain treatment.

Results

PNS-2019 data showed that 23.4% (95% CI 22.8–24.0) of Brazilian adults aged over 20 reported back pain. A higher prevalence of chronic back pain was associated with biological factors (older age, being female, overweight or obese, current smoking, and having more chronic conditions), lower social conditions (low education, low per capita household income, non-married, and living in rural areas), and poor psychological health (more depressive symptoms). Chronic back pain is more likely to limit usual activities among those with low social conditions (lower education, lower income), poor physical and behavioral health (obese, current smokers, and those with a greater number of chronic conditions), and worse psychological health (more depressive symptoms). However, married people and those who do not consume alcohol were also more likely to report limited activities. Among those with back pain, 68% received at least one form of treatment. Those with intense limitations on their usual activities were 2.2 times as likely to report treatment. People with higher social conditions (higher income, college education, and private health insurance) were more likely to receive treatment.

Conclusion

The results show significant biological, psychological, and social disparities in the prevalence of chronic back pain in Brazil. The findings point to the need for tailored policies and prevention programs with attention to vulnerable groups. Even though Brazil has universal health care, those with better socioeconomic conditions are more likely to receive treatment.

Perceptions of Critical Care Shortages, Resource Use, and Provider Well-being During the COVID-19 Pandemic: A Survey of 1,985 Health Care Providers in Brazil

BACKGROUND

Brazil has been disproportionately affected by COVID-19, placing a high burden on ICUs.

RESEARCH QUESTION

Are perceptions of ICU resource availability associated with end-of-life decisions and burnout among health care providers (HCPs) during COVID-19 surges in Brazil?

STUDY DESIGN AND METHODS

We electronically administered a survey to multidisciplinary ICU HCPs during two 2-week periods (in June 2020 and March 2021) coinciding with COVID-19 surges. We examined responses across geographical regions and performed multivariate regressions to explore factors associated with reports of: (1) families being allowed less input in decisions about maintaining life-sustaining treatments for patients with COVID-19 and (2) emotional distress and burnout.

RESULTS

We included 1,985 respondents (57% physicians, 14% nurses, 12% respiratory therapists, 16% other HCPs). More respondents reported shortages during the second surge compared with the first (P < .05 for all comparisons), including lower availability of intensivists (66% vs 42%), ICU nurses (53% vs 36%), ICU beds (68% vs 22%), and ventilators for patients with COVID-19 (80% vs 70%); shortages were highest in the North. One-quarter of HCPs reported that families were allowed less input in decisions about maintaining life-sustaining treatments for patients with COVID-19, which was associated with lack of intensivists (adjusted relative risk [aRR], 1.37; 95% CI, 1.05-1.80) and ICU beds (aRR, 1.71; 95% CI, 1.16-2.62) during the first surge and lack of N95 masks (aRR, 1.43; 95% CI, 1.10-1.85), noninvasive positive pressure ventilation (aRR, 1.56; 95% CI, 1.18-2.07), and oxygen concentrators (aRR, 1.50; 95% CI, 1.13-2.00) during the second surge. Burnout was higher during the second surge (60% vs 71%; P < .001), associated with witnessing colleagues at one's hospital contract COVID-19 during both surges (aRR, 1.55 [95% CI, 1.25-1.93] and 1.31 [95% CI, 1.11-1.55], respectively), as well as worries about finances (aRR, 1.28; 95% CI, 1.02-1.61) and lack of ICU nurses (aRR, 1.25; 95% CI, 1.02-1.53) during the first surge.

INTERPRETATION

During the COVID-19 pandemic, ICU HCPs in Brazil experienced substantial resource shortages, health care disparities between regions, changes in end-of-life care associated with resource shortages, and high proportions of burnout.

Education-related health inequities in noncommunicable diseases: an analysis of the Brazilian National Health Survey, 2013 and 2019

This study assesses changes in the prevalence and distribution of noncommunicable diseases (NCDs) and related risk factors among Brazilian adults from the 2013 and 2019 Brazilian National Health Surveys (PNS). It is based on the hypothesis that deteriorating socioeconomic conditions over this period would lead to increased NCDs among the least advantaged populations. We estimated adjusted prevalence ratios by education category and three inequality measures - the slope index of inequality (SII), the relative index of inequality (RII), and population attributable fraction (PAF) - for obesity, hypertension, arthritis, asthma, cancer, depression, diabetes, heart disease, having any chronic condition, and multimorbidity by survey year. We also estimated the 27 Brazilian Federative Units RII and prevalence rates for diabetes and multimorbidity per year and plotted the RII against prevalence by year. Results showed that all NCDs increased over the period observed, ranging from an 8% increase in the adjusted prevalence of arthritis to a 24% increase in the adjusted prevalence of obesity. Measures of inequality showed that most conditions exhibited significant educational inequities in both 2013 and 2019. However, on average, education-based inequities did not significantly change between the two periods. Considering the deterioration of the socioeconomic conditions of most Brazilians, the erosion of social protections, and the continuing economic, political, and health crises occurring in the nation, we observed an urgent need for discussion about the best way to adopt equity-promoting health policies and programs and action to reduce socioeconomic and geographic inequalities in NCDs throughout the country.

Socio-spatial inequalities in healthy life expectancy in the elderly, Brazil, 2013 and 2019

The growth in longevity in Brazil has drawn attention to more useful population health measures to complement mortality. In this paper, we investigate socio-spatial differences in life expectancy and healthy life expectancy based on information from the Brazilian National Health Survey (PNS), 2013 and 2019. A three-stage cluster sampling with stratification of the primary sampling units and random selection in all stages was used in both PNS editions. Healthy life expectancy was estimated by Sullivan's method by sex, age, and Federated Units (UF). Severe limitations to at least one noncommunicable chronic disease (NCD) or poor self-rated health were used to define the unhealthy state. Inequality indicators and a Principal Component analysis were used to investigate socio-spatial inequalities. From 2013 to 2019, both life expectancy and healthy life expectancy increased. The analysis by UF show larger disparities in healthy life expectancy than in life expectancy, with healthy life expectancy at age 60 varying from 13.6 to 19.9 years, in 2013, and from 14.9 to 20.1, in 2019. Healthy life expectancy in the wealthiest quintile was 20% longer than for those living in the poorest quintile. Wide socio-spatial disparities were found with the worst indicators in the UF located in the North and Northeast regions, whether considering poverty concentration or health care utilization. The socio-spatial inequalities demonstrated the excess burden of poor health experienced by older adults living in the less developed UF. The development of strategies at subnational levels is essential not only to provide equal access to health care but also to reduce risk exposures and support prevention policies for adoption of health behaviors.

Impact of COVID-19 pandemic on vaccination against meningococcal C infection in Brazil

Objective

Analyzing the impact of COVID-19 pandemic on meningococcal C conjugate vaccination in Brazil.

Methods

Ecological study, based on interrupted time series, carried out with data collected through the Information System of the National Immunization Program (IS-NIP). Collected data refer to the number of meningococcal C conjugate vaccine doses administered from March 2019 to December 2020.

Results

In total, 14,832,054 meningococcal C conjugate vaccine doses were administered throughout the investigated period; 66.30% of them, from March 2019 to February 2020 and 33.70%, from March to December 2020. Statistically significant steps were observed, i.e., the COVID-19 pandemic had negative impact on the number of MenC vaccine doses administered in the North and South regions (26,98% and 41.47%, respectively) and in the eleven Brazilian States.

Conclusion

The current study has shown that the COVID-19 pandemic had negative impact on the number of MenC vaccine doses administered in the Northern and Southern Brazil, and in eleven Brazilian states. Among all challenges experienced during the COVID-19 pandemic, one finds reduced MenC vaccine coverage, which, consequently, may lead to increased meningococcal infection rates in Brazil.

An overview of the trajectory of Brazilian individuals with 22q11.2 deletion syndrome until diagnosis

Background

22q11.2 deletion syndrome (22q11.2DS) is a rare disease with an important characteristic—clinical heterogeneity. The diversity of organs, regions, and systems of the body that can be affected requires periodic updating of health professionals so that they can recognize these clinical signs as belonging to 22q11.2DS. Updated professionals are equally important for the appropriate and timely clinical management of individuals with a positive diagnosis. In this context, this article aimed to map and analyze the access to healthcare for individuals with 22q11.2DS until the moment of diagnosis.

Results

We analyzed the clinical data of 111 individuals with 22q11.2DS registered in the Brazilian Database on Craniofacial Anomalies (BDCA) from 2008 to 2020. In this study, individuals were diagnosed at a median age of 9 years (mean = 9.7 years). Before the genetic investigation, they accessed 68.75% of the internationally recommended evaluations available at BDCA. Recurrent 22q11.2DS clinical manifestations such as delayed neuropsychomotor development, lip and/or palate defects, cardiac malformation and/or hematological/immunological alteration co-occurred in at least 72.06% of individuals. Cardiac malformation was the only clinical alteration that lowered the median diagnostic age, corresponding to 6.5 years of age with a cardiac malformation versus 11 years of age without one (p = 0.0006).

Conclusions

In Brazil, 22q11.2 DS is under-recognized, and early diagnosis and management of affected individuals are still a distant reality. In this sense, 22q11.2 DS suspicion followed by the elimination of obstacles for its diagnosis confirmation is essential to increase life expectancy and improve the quality of life of these individuals in Brazil.

Dual Use of Public and Private Health Care Services in Brazil

(1) Background: Brazil has a universal public healthcare system, but individuals can still opt to buy private health insurance and/or pay out-of-pocket for healthcare. Past research suggests that Brazilians make combined use of public and private services, possibly causing double costs. This study aims to describe this dual use and assess its relationship with socioeconomic status (SES). (2) Methods: We calculated survey-weighted population estimates and descriptive statistics, and built a survey-weighted logistic regression model to explore the effect of SES on dual use of healthcare, including demographic characteristics and other variables related to healthcare need and use as additional explanatory variables using data from the 2019 Brazilian National Health Survey. (3) Results: An estimated 39,039,016 (n = 46,914; 18.6%) persons sought care in the two weeks before the survey, of which 5,576,216 were dual users (n = 6484; 14.7%). Dual use happened both in the direction of public to private (n = 4628; 67.3%), and of private to public (n = 1855; 32.7%). Higher income had a significant effect on dual use (p < 0.0001), suggesting a dose–response relationship, even after controlling for confounders. Significant effects were also found for region (p < 0.0001) and usual source of care (USC) (p < 0.0001). (4) Conclusion: A large number of Brazilians are seeking care from a source different than their regular system. Higher SES, region, and USC are associated factors, possibly leading to more health inequity. Due to its high prevalence and important implications, more research is warranted to illuminate the main causes of dual use.

Hospitalization and ambulatory costs related to breast cancer due to physical inactivity in the Brazilian state capitals

The aim of this study was to estimate the hospitalization and ambulatory costs related to breast cancer due to physical inactivity in the female population from Brazilian capitals over a three-year period (2015 to 2017). This study was carried out with data from the Brazilian health system and had as metrics incidence of breast cancer, total and standardized rate hospitalizations by breast cancer, hospitalization and ambulatory costs by breast cancer and prevalence of physical inactivity. The Population Attributable Fraction (PAF) calculation was used. The total hospitalization cost by breast cancer in women aged ≥ 20 years in Brazil from 2015 to 2017 was US$ 33,484,920.54. Of this total, US$ 182,736.76 was due to physical inactivity. Outpatient expenses related to breast cancer in the Brazilian female population from 2015 to 2017 was US$ 207,993,744.39. Of this total, US$ 1,178,841.86 was due to physical inactivity. Outpatient and hospitalization expenses were higher in the states of Southeastern, Southern and Northeastern regions. Physical inactivity has contributed to the high number of hospitalizations for breast cancer in Brazil, which resulted in economic burden for health services (inpatient and outpatient) of more than US$ 1,300,000.00 from 2015 to 2017.

The Panorama of Cleft Lip and Palate Live Birth in Brazil: Follow-up of a 10-Year Period and Inequalities in the Health System

OBJECTIVE

To provide the prevalence and an overview of cleft lip and palate (CL/P) in the period of 2008 to 2017, as well as the profile of care provided for this condition in Brazil.

DESIGN

Cross-sectional study of epidemiological character.

SETTING

Brazilian government website.

PARTICIPANTS

National Live Birth and Hospital Information System.

INTERVENTION

Organization of the end databases and performance-based statistical analysis.

MAIN OUTCOME MEASURE(S)

Analysis of the prevalence of CL/P in newborns, sociodemographic condition of the mothers, surgical procedures and hospitalizations, and specialized hospitals in Brazil within a 10-year period.

RESULTS

The average prevalence of CL/P in Brazil was ∼52 children per 100 000 live births in the covered period, corresponding to 1 per 1924 newborns. The presence of cleft was associated with preterm birth, being underweight, and the male gender. The highest prevalence was found in the South region, while the lowest was found in the Northeast region, with increasing rates in the North region of Brazil. The states with the highest prevalence were not those with a great number of hospitalizations and surgical procedures for live births with CL/P.

CONCLUSION

In the 10-year study period, the prevalence of CL/P was 0.52 newborns per 1000 live births, a result which differs among the states of Brazil. The need to reinforce the national monitoring of the prevalence and surgical procedures of cleft patients have also emphasized the need to improve public medical care for CL/P subjects.

Cross-National Perspectives on Ageing and Place: Implications for Age-Friendly Cities and Communities

BACKGROUND AND OBJECTIVES

The age-friendly cities and communities (AFCC) agenda has led to a range of policy initiatives aimed at supporting ageing-in-place for older people. Whilst there is case study evidence of how people age across urban contexts, there has been little research exploring cross-national understandings of age-friendly places amongst older people. The objective of this paper is to identify the place experiences of older people living across cities and communities in India, Brazil and the UK and to discuss implications for the AFCC agenda.

RESEARCH DESIGN AND METHODS

A total of 300 semi-structured interviews were undertaken with older people across nine cities and 27 communities in India, Brazil and the UK. The data was analysed using thematic analysis undertaken by each national team and then discussed and revised at collaborative workshops with researchers from each of the three country teams.

RESULTS

The data captures the ways in which place is constructed from the perspective of older people drawing upon social, community and cultural dimensions of ageing across diverse urban environments. We explore how older people negotiate place in the context of their everyday life and identify the relational and interconnected ways in which place attachment, belonging and identity is constructed.

DISCUSSION AND IMPLICATIONS

Age-friendly interventions need to attend to the changing physical, social and cultural dimensions of ageing and place. Integrated place-making practices are required to support older people to age in the right place across rapidly transforming urban contexts globally.

The COVID-19 epidemic in Brazil: how statistics education may contribute to unravel the reality behind the charts

The world is now facing the most severe health, social, and economic event of the last hundred years, which has made the need to acquire statistical thinking to interpret the information disseminated on a daily basis by the media clear to society. This article proposes a discussion on the role that statistics education might play in supporting the acquisition of such knowledge, contributing to the development of critical citizens, aware of their social responsibility. In this context, we present examples of curves and other charts to demonstrate how to use the several levels defined by experts in reading and interpreting the charts. At a more advanced level, these examples will allow discussion on the impacts of this epidemic on the most vulnerable population in Brazil. The charts presented reveal a great regional inequality, suggesting that mortality due to the virus is distinguished by region and micro-region when considering access to hospital beds. The examples signpost ways for educators to be able to develop projects or research based on the discussion on the reality of the pandemic, the necessary public policies, and how political coordination grounded on science and on a humanitarian vision would have mitigated the Brazilian tragedy.

Gestational weight gain adequacy for favourable obstetric and neonatal outcomes: A nationwide hospital-based cohort gestational weight gain for favourable obstetric and neonatal outcomes

BACKGROUND & AIMS

Most Brazilian women fail to gain weight within recommendations during pregnancy but current guidelines about gestational weight gain was based on North American population analysis. There are no standardized recommendations developed from Brazilian population data, which should be particularly analysed due to ethnic and sociodemographic characteristics. This study analyses the gestational weight gain of Brazilian women with favourable obstetric and neonatal outcomes according to the pre-pregnancy body mass index, considering maternal sociodemographic characteristics.

METHODS

We analysed data from the Birth in Brazil: national survey into labour and birth study, a nationwide hospital-based cohort carried out in 266 Brazilian hospitals from February/2011 to July 2012, including adult pregnant women who have no chronic diseases and who have single foetal gestation, born alive and without malformation. Favourable obstetric and neonatal outcomes considered were gestational age at birth greater than or equal to 37 and less than 42 weeks, birthweight between 2500 g and 4000 g, and birthweight suitable for gestational age. Sociodemographic characteristics were obtained from medical records and interviews. Weight and height information was obtained from the prenatal card or self-reported. The pre-pregnancy BMI was classified in low weight, normal weight, overweight, obesity I, obesity II, and obesity III. For the missing cases on pre-pregnancy weight or height, body mass index was imputed by multiple imputation prediction model. Gestational weight gain was the difference between the last weight before delivery and the pre-pregnancy weight and was presented as mean and confidence interval, mean and standard deviation, and percentiles distribution (10th to 90th) for each pre-pregnancy body mass index, thus compared to Institute of Medicine recommendations.

RESULTS

The analysis included 8184 Brazilian women. The gestational weight gain was lower in women with less favoured social conditions. The mean gestational weight gain according to pre-pregnancy body mass index was within the Institute of Medicine recommendations, except for women with overweight or obesity class I, who have the mean weight gain higher than upper limit of the Institute of Medicine range. Gestational weight gain decreased with an increase in the categories of body mass index; the mean (±standard deviation) were: 15.41 kg (±5.53), 13.54 kg (±4.97), 12.45 kg (±5.86), 9.38 kg (±6.31), 7.15 kg (±6.43), and 5.04 kg (±7.10), for low weight, normal weight, overweight, and obesity I, II and III, respectively. Women had favourable obstetric and neonatal outcomes gaining less, within or more than the recommendations with higher range of variation amongst obesity classes I, II, and III which do not have specific ranges stated in Institute of Medicine guidelines.

CONCLUSION

Brazilian women had favourable obstetric and neonatal outcomes gaining less, within or more than the Institute of Medicine recommendations. We highlight the need of population-based high-quality research to investigate the optimal GWG recommendations for this population.

Emergency Care Sensitive Conditions in Brazil: A Geographic Information System Approach to Timely Hospital Access

Background

The benefits of treatment for many conditions are time dependent. The burden of these emergency care sensitive conditions (ECSCs) is especially high in low- and middle-income countries. Our objective was to analyze geospatial trends in ECSCs and characterize regional disparities in access to emergency care in Brazil.

Methods

From publicly available datasets, we extracted data on patients assigned an ECSC-related ICD-10 code and on the country's emergency facilities from 2015-2019. Using ArcGIS, OpenStreetMap, and WorldPop, we created catchment areas corresponding to 180 minutes of driving distance from each hospital. We then used ArcGIS to characterize space-time trends in ECSC admissions and to complete an Origin-Destination analysis to determine the path from household to closest hospital.

Findings

There were 1362 municipalities flagged as "hot spots," areas with a high volume of ECSCs. Of those, 69.7% were more than 180 minutes (171 km) from the closest emergency facility. These municipalities were primarily located in the states of Minas Gerais, Bahia, Espiríto Santo, Tocantins, and Amapá. In the North region, only 69.1% of the population resided within 180 minutes of an emergency hospital.

Interpretations

Significant geographical barriers to accessing emergency care exist in certain areas of Brazil, especially in peri-urban areas and the North region. One limitation of this approach is that geolocation was not possible in some areas and thus we are likely underestimating the burden of inadequate access. Subsequent work should evaluate ECSC mortality data.

Funding

This study was funded by the Duke Global Health Institute Artificial Intelligence Pilot Project.

Contextual factors underpinning geographical inequalities in disability-free life expectancy in 100 French départements

The objectives were to estimate disability-free life expectancy (DFLE) and life expectancy with disability (DLE) by gender for the 100 French départements (administrative geographical subdivisions) and to investigate associations with socioeconomic factors, supply of healthcare and services for older persons. DFLE and DLE at age 60 are estimated using the Sullivan method and based on the GALI indicator provided by the French cross-sectional survey Vie Quotidienne et Santé 2014. In 2014, DFLE for men and women aged 60 was 14.3 years and 15.6 years, respectively. Variations across départements were considerable (5.4 years for men, 6.7 years for women). Multivariate random effects meta-regression models indicated a negative association for men between DFLE and some of the socioeconomic contextual indicators (ratio of manual workers to higher-level occupations and unemployment rate); the level of in-home nursing services (HNS) was negatively associated with DFLE and density of nurses positively associated with DLE. Among women, ratio of manual workers to higher-level occupations, unemployment rate, proportion of the population living in large urban areas, density of nurses, and level of HNS were negatively associated with DFLE; density of physiotherapy supply was associated positively with DFLE and negatively with DLE. Our results suggest that geographical inequalities in health expectancies are significantly correlated with socioeconomic status and with healthcare supply, support for older persons, and urban environments, particularly among women. These results underline the importance of monitoring these indicators and disparities at infra-national-level, and of investigating their relations with local context, particularly the supply of healthcare and services.

Daily physical activity, human development index and insomnia in a representative sample of Brazilian adolescents: a cross-sectional analysis

BACKGROUND

Although there is a growing body of research pointing towards the need to investigate how different movement behaviors, such as physical activity and sleep, influence each other, the joint relationship between these factors and insomnia has been little explored among adolescents in developing countries.

OBJECTIVES

To investigate the association between daily physical activity and insomnia in a national sample of Brazilian adolescents, according to the Human Development Index (HDI) of each Brazilian region.

DESIGN AND SETTINGS

Cross-sectional study on 102,072 Brazilian students aged 11 to 19 years, selected from all regions of the country.

METHODS

Information on insomnia and physical activity was self-reported by adolescents.

RESULTS

Our analyses revealed that girls who accumulated at least 60 minutes/day of physical activity on up to three days/week were less prone to present insomnia. This pattern of association was maintained only for those who lived in high HDI regions (odds ratio, 0.87; 95% confidence interval, 0.75-0.99). For boys, there was a positive association between the number of active days and protection against insomnia, especially for those who lived in high HDI regions.

CONCLUSION

Even amounts of physical activity that were lower than the weekly guidelines, were associated with better sleep quality for Brazilian adolescents, especially girls, and even for those who lived in regions with greater social and economic vulnerability.

Hipertensión arterial autorreferida en adultos mayores brasileños: uso de medicación y recomendaciones para el control

Objetivo Estimar la prevalencia de hipertensión arterial (HA) autorreferida y del uso de medicación en los adultos mayores brasileños (≥65 años), según las características sociodemográficas, y evaluar el uso de los servicios de salud y de las recomendaciones de los médicos y profesionales de salud para el control de la enfermedad. Método Estudio transversal con datos de la Pesquisa Nacional de Salud del 2013 (n=7.712). Resultados La prevalencia de HA fue del 54,1%, con diferencia entre los sexos. En los hombres, la prevalencia de HA fue mayor en las regiones Sur y Sudeste, y en las mujeres fue mayor en los subgrupos de 75 a 79 años y de menor escolaridad. El uso de medicación para la HA fue mencionado por el 91,7%, sin diferencia entre los sexos. Las mujeres fueron diagnosticadas con más precocidad (≤39 años) que los hombres (≥65 años). Conclusión El mantenimiento de una alimentación saludable y el consumo reducido de sal se observaron con mayor frecuencia en las mujeres. Los resultados destacan la necesidad de intervenciones para promover el autocuidado, sobre todo entre los hombres.

A Comparative Case Study: Does the Organization of Primary Health Care in Brazil and Turkey Contribute to Reducing Disparities in Access to Care?

Brazil and Turkey are among the few high-middle-income countries that explicitly chose to strengthen their primary health care (PHC) systems as the centerpiece of much broader health system reforms aiming to narrow inequities in access to care. This comparative case study reviews the organization of Brazil and Turkey's PHC systems to derive lessons that can apply to other countries that may consider reforming the organization of PHC systems as a way to address health inequities. The analysis uses the Flagship Framework to investigate how the organization of PHC delivery in Brazil and Turkey can lead to measurable improvements in access to care. It compares (1) the degree of decentralization in PHC service delivery responsibilities, (2) the use of multi-professional PHC teams, and (3) patient impanelment strategies. The comparative analysis offers three important lessons. First, changes in the organization of PHC systems can contribute to observable improvements in the level and distribution of health outcomes, but organizational strategies do not guarantee eliminating disparities in access. Second, PHC systems can operate in health systems with varying degrees of decentralization, but the level of decentralization may influence implementation. Third, relying on multi-professional PHC teams that serve geographically empaneled populations can improve equitable access to care, but course corrections may be needed to address evolving health demands.

The impact of inequalities and health expenditure on mortality due to oral and oropharyngeal cancer in Brazil

This study aims to assess the magnitude and trend of mortality rates due to oral (OC) and oropharyngeal cancer (OPC) in the 133 Intermediate Geographic Regions (IGR) of Brazil between 1996 and 2018 and to analyze its association with sociodemographic variables and provision of health services. It also aims to compare the trend of mortality from neoplasms that have been reported as associated with HPV (OPC) with the trend of neoplasms that have been reported as not associated with HPV (OC). We obtained mortality data from the Mortality Information System in Brazil and analyzed the trends using the Prais-Winsten method. Then, we assessed the relationship between mortality trends and socioeconomic, health spending, and health services provision variables. The median of the annual percent change of the country’s mortality rates was 0.63% for OC and 0.83% for OPC. Trends in mortality in the IGRs correlated significantly with the Human Development Index and government expenditure on ambulatory health care and hospitalizations. Mortality from both types of cancer decreased in those IGR in which the government spent more on health and in the more socioeconomically developed ones. This study found no epidemiological indication that HPV plays the leading etiological factor in OPC in Brazil.

Analyzing Spatial Patterns of Health Vulnerability to Drought in the Brazilian Semiarid Region

Health determinants might play an important role in shaping the impacts related to long-term disasters such as droughts. Understanding their distribution in populated dry regions may help to map vulnerabilities and set coping strategies for current and future threats to human health. The aim of the study was to identify the most vulnerable municipalities of the Brazilian semiarid region when it comes to the relationship between drought, health, and their determinants using a multidimensional index. From a place-based framework, epidemiological, socio-economic, rural, and health infrastructure data were obtained for 1135 municipalities in the Brazilian semiarid region. An exploratory factor analysis was used to reduce 32 variables to four independent factors and compute a Health Vulnerability Index. The health vulnerability was modulated by social determinants, rural characteristics, and access to water in this semiarid region. There was a clear distinction between municipalities with the highest human welfare and economic development and those municipalities with the worst living conditions and health status. Spatial patterns showed a cluster of the most vulnerable municipalities in the western, eastern, and northeastern portions of the semiarid region. The spatial visualization of the associated vulnerabilities supports decision making on health promotion policies that should focus on reducing social inequality. In addition, policymakers are presented with a simple tool to identify populations or areas with the worst socioeconomic and health conditions, which can facilitate the targeting of actions and resources on a more equitable basis. Further, the results contribute to the understanding of social determinants that may be related to medium- and long-term health outcomes in the region.

Actions for early detection of breast cancer in two municipalities in the Western Amazon

OBJECTIVE

to assess the implementation of actions for early detection of breast cancer in Primary Care and to verify the adequacy of these actions with the Ministry of Health recommendations.

METHOD

a cross-sectional study conducted from September 2017 to March 2018 with 736 women registered in Basic Health Units in two municipalities in Acre. For data collection, a validated questionnaire was used. In statistical analysis, the chi-square test or Fisher's exact test was applied.

RESULTS

the frequency of mammography was 42%. Of the women at standard risk for breast cancer, only 5,8% underwent mammography properly.

CONCLUSION

there was a low compliance of early detection actions to the Ministry of Health recommendations; thus, the need to adopt measures to increase professionals' adherence to government proposals is highlighted, as well as continuous actions assessments.

Improving treatment outcomes for leprosy in Pernambuco, Brazil: a qualitative study exploring the experiences and perceptions of retreatment patients and their carers

BACKGROUND

Brazil has a high leprosy burden and poor treatment outcomes (TOs), manifesting in high relapse rates. Pernambuco, an impoverished Brazilian state suffering notable geographical health inequalities, has 'hyperendemic' leprosy. Although current literature identifies barriers and facilitators influencing leprosy treatment compliance, inadequate investigation exists on other factors influencing TOs, including carers' roles and psycho-dermatological impact. This qualitative study explores experiences and perceptions of leprosy patients and their carers in Pernambuco, Brazil; to identify location-specific factors influencing TOs, and consequently inform future management.

METHODS

27, semi-structured, in-depth interviews were conducted with 14 patients and 13 carers. Participants were recruited using maximum variation and snowball sampling from three clinics in Petrolina, Pernambuco. Transcripts and field notes from both participant groups were separately analysed using conventional thematic and deviant case analysis. The University of Birmingham Internal Research Ethics Committee and Instituto Lauro de Souza Lima provided ethical approval.

RESULTS

Two homologous sets of four, primary, interdependent themes influencing leprosy TOs emerged: 'personal factors'; 'external factors'; 'clinical factors'; and 'the healthcare professional (HCP)-patient-carer relationship'. Poor participant knowledge and lack of symptomatic relief caused patients to distrust treatment. However, because participants thought HCP-led interventions were vital for optimal TOs, patients were effectively persuaded to adhere to pharmaceutical treatments. High standard patient and population education facilitated treatment engagement by encouraging evidence-based medicine belief, and dispelling health myths and stigma. Healthcare, on occasions, was perceived as disorganised, particularly in resource-scarce rural areas, and for those with mental health needs. Participants additionally experienced incorrect/delayed diagnoses and poor contact tracing. Leprosy's negative socio-economic impact on employment - together with stigma, dependency and changing relationships - caused altered senses of identity, negatively impacting TOs. Better dialogue between patients, HCPs and carers facilitated individualised patient support.

CONCLUSION

This study highlights the importance of: effective evidence-based leprosy education; communication between HCPs, patients and carers; state-funded support; and healthcare resource distribution. These findings, if prioritised on governmental scales, provide the valuable insight needed to inform location-specific management strategies, and consequently improve TOs. Future research should evaluate the effectiveness of these implementations. Failure to address these findings will hinder regional elimination efforts.

A baseline evaluation of PAH body burden in sardines from the southern Brazilian shelf

The concentrations of 37 polycyclic aromatic hydrocarbons (PAHs) and their potential risk to human health were determined in fifty sardine muscle (Sardinella brasiliensis) samples collected along the southern Brazilian shelf. Parental and alkylated PAHs were identified and quantified using a pressurized liquid extraction with in-cell purification method and gas chromatography-mass spectrometry identification and quantification. The concentrations of Σ37 PAHs in muscle ranged between 6.02 and 4074 μg kg^-1 wet weight, which are comparable to levels reported for commercially important fish worldwide. The most abundant compounds were pyrene and fluoranthene, which originate from both petrogenic and pyrolytic hydrocarbon inputs. In only 4% of the samples the benzo[a] pyrene equivalent concentration was above the threshold of 6 μg kg^-1 suggested for safe fish consumption in Brazil. These findings will serve as baseline data for monitoring the quality of sardines consumed in the country and for studying fish populations.

Characterisation of the first 250,000 hospital admissions for COVID-19 in Brazil: a retrospective analysis of nationwide data

Background

Most low-income and middle-income countries (LMICs) have little or no data integrated into a national surveillance system to identify characteristics or outcomes of COVID-19 hospital admissions and the impact of the COVID-19 pandemic on their national health systems. We aimed to analyse characteristics of patients admitted to hospital with COVID-19 in Brazil, and to examine the impact of COVID-19 on health-care resources and in-hospital mortality.

Methods

We did a retrospective analysis of all patients aged 20 years or older with quantitative RT-PCR (RT-qPCR)-confirmed COVID-19 who were admitted to hospital and registered in SIVEP-Gripe, a nationwide surveillance database in Brazil, between Feb 16 and Aug 15, 2020 (epidemiological weeks 8–33). We also examined the progression of the COVID-19 pandemic across three 4-week periods within this timeframe (epidemiological weeks 8–12, 19–22, and 27–30). The primary outcome was in-hospital mortality. We compared the regional burden of hospital admissions stratified by age, intensive care unit (ICU) admission, and respiratory support. We analysed data from the whole country and its five regions: North, Northeast, Central-West, Southeast, and South.

Findings

Between Feb 16 and Aug 15, 2020, 254 288 patients with RT-qPCR-confirmed COVID-19 were admitted to hospital and registered in SIVEP-Gripe. The mean age of patients was 60 (SD 17) years, 119 657 (47%) of 254 288 were aged younger than 60 years, 143 521 (56%) of 254 243 were male, and 14 979 (16%) of 90 829 had no comorbidities. Case numbers increased across the three 4-week periods studied: by epidemiological weeks 19–22, cases were concentrated in the North, Northeast, and Southeast; by weeks 27–30, cases had spread to the Central-West and South regions. 232 036 (91%) of 254 288 patients had a defined hospital outcome when the data were exported; in-hospital mortality was 38% (87 515 of 232 036 patients) overall, 59% (47 002 of 79 687) among patients admitted to the ICU, and 80% (36 046 of 45 205) among those who were mechanically ventilated. The overall burden of ICU admissions per ICU beds was more pronounced in the North, Southeast, and Northeast, than in the Central-West and South. In the Northeast, 1545 (16%) of 9960 patients received invasive mechanical ventilation outside the ICU compared with 431 (8%) of 5388 in the South. In-hospital mortality among patients younger than 60 years was 31% (4204 of 13 468) in the Northeast versus 15% (1694 of 11 196) in the South.

Interpretation

We observed a widespread distribution of COVID-19 across all regions in Brazil, resulting in a high overall disease burden. In-hospital mortality was high, even in patients younger than 60 years, and worsened by existing regional disparities within the health system. The COVID-19 pandemic highlights the need to improve access to high-quality care for critically ill patients admitted to hospital with COVID-19, particularly in LMICs.

Funding

National Council for Scientific and Technological Development (CNPq), Coordinating Agency for Advanced Training of Graduate Personnel (CAPES), Carlos Chagas Filho Foundation for Research Support of the State of Rio de Janeiro (FAPERJ), and Instituto de Salud Carlos III.

Cancer mortality in the Capitals and in the interior of Brazil: a four-decade analysis

OBJECTIVE:

to describe the trend of mortality from general cancer and more frequent types among men and women living in the Capitals and other municipalities of the five macro-regions of Brazil between 1978 and 2017.

METHODS:

Time series study with mortality data corrected by redistribution of ill-defined causes. Proportional cancer mortality was calculated for Brazil and regions. The annual percentage change in rates for total cancer and specific types in each segment and in the selected unit of analysis was calculated by generalized linear regression with Gaussian binding.

RESULTS:

the proportion of cancer increased progressively for both sexes from 1978 to 2017. Important differences between the Capitals and the interior of the macro-regions were seen with disaggregated data. The greatest declines occurred for stomach cancer, except in the northern and interior regions of the Northeast, and for the cervix cancer, with a generalized fall, with the exception of the interior of the northern region. Lung cancer decreased among men in the Southeast and South regions and had a generalized increase among women. Breast and prostate cancers tended to decrease in the Southeast and South regions and among residents of the Capitals but showing an increase in the interior of the North and Northeast regions. Colorectal cancer had a general tendency to increase; with stability among men in the Capitals of the South region and among women of the Southeast and Midwest regions and, since 2007, a decrease among women in the South region.

CONCLUSIONS:

Cancer mortality showed great variation among residents of capitals and the interior of the country's major regions. Clear decrease in mortality was seen for the main types in the Southeast and South regions. The North and Northeast regions have patterns compatible with cancers associated with poverty, while the large increase of the cancers related to sedentary lifestyle stand out.

Why do some countries do better or worse in life expectancy relative to income? An analysis of Brazil, Ethiopia, and the United States of America

BACKGROUND

While in general a country's life expectancy increases with national income, some countries "punch above their weight", while some "punch below their weight" - achieving higher or lower life expectancy than would be predicted by their per capita income. Discovering which conditions or policies contribute to this outcome is critical to improving population health globally.

METHODS

We conducted a mixed-method study which included: analysis of life expectancy relative to income for all countries; an expert opinion study; and scoping reviews of literature and data to examine factors that may impact on life expectancy relative to income in three countries: Ethiopia, Brazil, and the United States. Punching above or below weight status was calculated using life expectancy at birth and gross domestic product per capita for 2014-2018. The scoping reviews covered the political context and history, social determinants of health, civil society, and political participation in each country.

RESULTS

Possible drivers identified for Ethiopia's extra 3 years life expectancy included community-based health strategies, improving access to safe water, female education and gender empowerment, and the rise of civil society organisations. Brazil punched above its weight by 2 years. Possible drivers identified included socio-political and economic improvements, reduced inequality, female education, health care coverage, civil society, and political participation. The United States' neoliberal economics and limited social security, market-based healthcare, limited public health regulation, weak social safety net, significant increases in income inequality and lower levels of political participation may have contributed to the country punching 2.9 years below weight.

CONCLUSIONS

The review highlighted potential structural determinants driving differential performance in population health outcomes cross-nationally. These included greater equity, a more inclusive welfare system, high political participation, strong civil society and access to employment, housing, safe water, a clean environment, and education. We recommend research comparing more countries, and also to examine the processes driving within-country inequities.

Physical inactivity as a risk factor to mortality by ischemic heart disease during economic and political crisis in Brazil

Background

To investigate the burden of mortality due to ischemic heart disease (IHD) attributable to low levels of physical activity in the Brazilian population (aged ≥ 25 years) before, during and after economic and political crises (2007–2017).

Methods

This study was focused on IHD as a cause of death. The International Statistical Classification of Diseases (10th revision) codes related to IHD have been mapped. The data used for the physical activity estimates of the present study refer to surveys with random sampling carried out in the Brazilian territory that considers all domains of physical activity. The contribution of physical activity for mortality due to IHD was estimated using a comparative risk assessment approach. In addition, we verified the association between mortality due to IHD attributable to low levels of physical activity according to the Socio-demographic Index of the Brazilian states.

Results

For males it was estimated that in 2007 and 2017 there were, respectively, 9,585 and 11,821 deaths due to IHD as a result low physical activity. For females there were 8,689 deaths in 2007 and 10,779 deaths in 2017 due to IHD attributable to low physical activity. From 2007 to 2017, there was 12.0% (for males) and 16.0% (for females) of reduction in age-adjusted mortality rate due to IHD attributable to low physical activity. This reduction was not observed in the Northern and Northeastern regions of Brazil for the male population. Brazilian states with better socioeconomic conditions showed greater reductions in age-adjusted mortality rate due to IHD attributable to low physical activity (male: ρ = −0.74; female: ρ = −0.54)

Conclusion

The fiscal austerity policies implemented and the lower investment in social programs in the period of economic and political crisis highlighted the social inequalities between Brazilian geographic regions for the burden of mortality due to IHD attributable to low levels of physical activity.

Health care seeking due to COVID-19 related symptoms and health care cancellations among older Brazilian adults: the ELSI-COVID-19 initiative

The continent of the Americas has the greatest number of people infected and deaths associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the world. Brazil occupies the 2nd position in numbers of infected cases and deaths, preceded only by the United States. Older adults and those with pre-existing chronic illnesses are more vulnerable to the consequences of the virus. The SARS-CoV-2 epidemic has serious consequences for health services. Therefore, an assessment of the pandemic's effect on the older Brazilian population is urgently needed. The study examines the prevalence of COVID-19 related symptoms, care-seeking, and cancellation of surgery or other scheduled medical care among a nationally representative sample of Brazilians aged 50 and over derived from the Brazilian Longitudinal Study of Aging (ELSI-Brazil) and a telephone follow-up survey (the ELSI-COVID-19 initiative) between late May and early June 2020. About 10.4% of older adults reported any fever, dry cough or difficulty breathing in the 30 days prior to the interview, with the highest prevalence in the North region (50%). Among individuals with symptoms, only 33.6% sought care. Individuals living in the South or Southeast regions were significantly less likely to seek care for COVID-19 related symptoms. Nearly one in six participants had to cancel scheduled surgery or other medical care; this proportion was higher among women, those with more education, and people with multiple chronic conditions. This paper is among the first to investigate the effect of COVID-19 on health care use in Brazil among older adults. Results highlight the need to adapt health care delivery (such as through telemedicine) to ensure the continuity of care as well as the urgent need for wide dissemination of information to guide the population on disease prevention measures and how to obtain healthcare when needed.

Estimating completeness of national and subnational death reporting in Brazil: application of record linkage methods

Background

In Brazil, both the Civil Registry (CR) and Ministry of Health (MoH) Mortality Information System (SIM) are sources of routine mortality data, but neither is 100% complete. Deaths from these two sources can be linked to facilitate estimation of completeness of mortality reporting and measurement of adjusted mortality indicators using generalized linear modeling (GLM).

Methods

The 2015 and 2016 CR and SIM data were linked using deterministic methods. GLM with covariates of the deceased’s sex, age, state of residence, cause of death and place of death, and municipality-level education decile and population density decile, was used to estimate total deaths and completeness nationally, subnationally and by population sub-group, and to identify the characteristics of unreported deaths. The empirical completeness method and Global Burden of Disease (GBD) 2017 estimates were comparators at the national and state level.

Results

Completeness was 98% for SIM and 95% for CR. The vast majority of deaths in Brazil were captured by either system and 94% were reported by both sources. For each source, completeness was lowest in the north. SIM completeness was consistently high across all sub-groups while CR completeness was lowest for deaths at younger ages, outside facilities, and in the lowest deciles of municipality education and population density. There was no clear municipality-level relationship in SIM and CR completeness, suggesting minimal dependence between sources. The empirical completeness method model 1 and GBD completeness estimates were each, on average, less than three percentage points different from GLM estimates at the state level. Life expectancy was lowest in the northeast and 7.5 years higher in females than males.

Conclusions

GLM using socio-economic and demographic covariates is a valuable tool to accurately estimate completeness from linked data sources. Close scrutiny of the quality of variables used to link deaths, targeted identification of unreported deaths in poorer, northern states, and closer coordination of the two systems will help Brazil achieve 100% death reporting completeness. The results also confirm the validity of the empirical completeness method.

Extensive CFTR sequencing through NGS in Brazilian individuals with cystic fibrosis: unravelling regional discrepancies in the country

BACKGROUND

The Brazilian population has a tri-hybrid composition with a high degree of ethnic admixture. We hypothesized that Brazilian individuals with CF from different Brazilian regions have a specific distribution of CFTR variants.

METHODS

Individuals with CF with data available in the Patient Registry and without an established genotype were submitted to CFTR sequencing by Next Generation Sequencing (NGS) methodology, and results were anonymously incorporated to the Registry Database. Genotyping results were expressed as 'positive', 'inconclusive' or 'negative'. Logistic regression models were performed to investigate the association between demographic/clinical variables and genotyping results. Mediation analysis was conducted to estimate direct and indirect effects of Brazilian region on a binary positive genotyping response.

RESULTS

In October 2017, data from 4,654 individuals with CF were available, and 3,104(66.7%) of them had a genotyping result. A total of 236 variants (114 new variants) were identified, with F508del identified in 46% of the alleles tested. Genotyping revealed 2,002(64.5%) individuals positive, 757(24.4%) inconclusive and 345(11.1%) negative. Distribution of genotype categories was markedly different across Brazilian Regions, with greater proportions of negative individuals in the North (45%) and Northeast (26%) regions. Newborn screening (CF-NBS) and age at diagnosis were identified as mediators of the effect of Brazilian region on a positive genotyping result.

CONCLUSIONS

This large initiative of CFTR genotyping showed significant regional discrepancies in Brazil, probably related to socio-economic conditions, lack of adequate CF-NBS and poor access to reliable sweat testing. These results may be useful to indicate Regions where CF care demands more attention.

Disability-free life expectancy and life expectancy in good self-rated health in Chile: Gender differences and compression of morbidity between 2009 and 2016

Background

Chile has one of the highest life expectancies at 60 years in South America. This study was aimed to determine healthy life expectancies among Chilean older people, according to self-rated health and disability, and to explore gender differences.

Methods

Data from the National Survey of Health (2009 and 2016) were used to estimate prevalence of less than good self-rated health and disability among people aged 60 years and above. Health expectancies were calculated with the Sullivan method.

Results

In both years, women expected to live a lower proportion of their life expectancy in good self-rated health (54.5% [95% CI 50.0–58.8] for men and 37.6% [95% CI 34.3–40.8] for women in 2009; 46.1% [95% CI 42.6–49.7] for men and 38.5% [95% CI 35.6–41.4] for women in 2016). Life expectancy in less than good self-rated health increased for men (9.4 years [95% CI 8.4–10.3] in 2009; 11.5 years [95% CI 10.7–12.2]). Women expected to live a lower proportion of their remaining life without disabilities (65.3% [95% CI 61.2–69.4] for men and 44.9% [95% CI 41.9–47.9] for women in 2009; 71.9% [95% CI 68.7–75.0] for men and 61.1% [95% CI 58.5–63.8] for women in 2016). In 2016, disability-free life expectancy increased among women, but they still had a higher life expectancy with mild disability (2.8 years [95% CI 2.3–3.4] for men and 6.0 years [95% CI 5.4–6.7] for women).

Conclusions

Women expected to spend more years in less than good self-rated health and disabled. There was an expansion of life expectancy in less than good SRH among men and a compression of disability in both sexes. The high proportion of years expected to be lived in less than good self-rated health and gender differences in disability-free life expectancy of older adults should be addressed by public health policies in Chile.

Racial inequalities in public dental service utilization: Exploring individual and contextual determinants among middle-aged Brazilian adults

OBJECTIVES

To investigate differences between Pardos (mixed) and Blacks with their White counterparts in the use of public dental service among a sample of Brazilian adults taking into consideration the role of individual and contextual characteristics.

METHODS

A total of 6196 adults aged 35-44 years were sampled from the 2010 Brazilian National Oral Health Survey and nested in one of 27 Brazilian State Capitals. Binary multilevel logistic analyses were conducted. Use of public dental service in the last visit was the outcome, and self-reported colour/race (Pardo, Black, White) was the explanatory variable. Individual covariates were sex, level of education, family income, self-reported need for treatment, dental pain in the last 6 months, presence of decayed, filled and missing teeth. The State Capital covariates were proportion of Pardos/Blacks, Human Development Index, Gini coefficient, Integration of dental teams into Brazil Family Health Program and dentist per population rate.

RESULTS

Pardos and Blacks were 1.25 (95% CI 1.10-1.42) and 1.73 (95% CI 1.41-2.11) times, respectively, more likely to visit the public dental service than Whites. Adjustments for level of education and income were more relevant in affecting the estimates between groups than any other covariate, but differences persisted. Colour/race was independently associated with the type of service used in the last dental visit after fully adjusted for individual and State Capital characteristics.

CONCLUSIONS

Racial differences in dental service utilization were evident for middle-aged adults in Brazil. The results found highlight the importance of investments in public dental service as Pardos and Blacks relied more on this type of service than Whites.

Indigenous children and adolescent mortality inequity in Brazil: What can we learn from the 2010 National Demographic Census?

Indigenous peoples worldwide are highly disadvantaged compared to national baseline populations. Given historical challenges to accessing relevant data for Brazil, the present study innovates by using 2010 Brazilian National Demographic Census data to estimate mortality curves in Indigenous children and adolescents <20 years. The non-parametric smoothing approach TOPALS (tool for projecting age-specific rates using linear splines) was employed. Analyses included stratifications by sex, rural or urban residence, and geopolitical region. The mortality of children and adolescents classified as Indigenous was higher for all analyzed strata. Mortality of Indigenous and non-Indigenous individuals in rural areas was higher than those in urban areas in almost all strata analyzed. Mortality levels in the Indigenous segment exceed those of children and adolescents classified as non-Indigenous in all four geopolitical regions, with few exceptions. This is the first study to compare mortality curves of children and adolescents in Brazil according to social variables based on national census data. More Indigenous children and adolescents die than their non-Indigenous counterparts, including those classified as black or brown, in both rural and urban residential settings. Indigenous children and adolescents are consistently at the most disadvantaged end of a marked gradient of ethnic-racial inequality in Brazil, independently of sex, age, and geopolitical region.

Political struggles for a universal health system in Brazil: successes and limits in the reduction of inequalities

Background

Brazil is a populous high/middle-income country, characterized by deep economic and social inequalities. Like most other Latin American nations, Brazil constructed a health system that included, on the one hand, public health programs and, on the other, social insurance healthcare for those working in the formal sector. This study analyzes the political struggles surrounding the implementation of a universal health system from the mid-1980s to the present, and their effects on selected health indicators, focusing on the relevant international and national contexts, political agendas, government orientations and actors.

Main text

In the 1980s, against the backdrop of economic crisis and democratization, Brazil’s health reform movement proposed a Unified Health System (SUS), which was incorporated into the 1988 Constitution. The combination of a democratic system with opportunities for interaction between various developmental and social agendas and actors has played a key role in shaping health policy since then. However, the expansion of public services has been hampered by insufficient public funding and by the strengthening of the private sector, subsidized by the state. Private enterprises have expanded their markets and political influence, in a process that has accelerated in recent years. Despite these obstacles, SUS has produced significant health-status improvements and some (although incomplete) reductions in Brazil’s vast health inequalities.

Conclusions

We find that a combination of long-term structural and contingent factors, international agendas and interests, as well as domestic political struggles, explains the advances and obstacles to building a universal system in an economically important yet unequal peripheral country. Further consolidation of SUS and reduction of health inequalities hinge on the uncertain prospects for democracy and national development, on enlarging the political coalition to support a public and universal health system, and on strengthening the state’s ability to regulate the private sector.

Prevalence and co-occurrence of modifiable risk factors in adults and older people

OBJECTIVE

To estimate the co-occurrence of the major risk factors for chronic diseases in adults (18-59 years old) and older people (≥ 60 years old) living in Brazilian state capitals and the Federal District.

METHODS

Cross-sectional study with population-based data from 35,448 adults and 18,726 older people collected in the Sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (System of Surveillance of Risk and Protective Factors for Chronic Diseases by Telephone Survey – Vigitel) in 2015. The prevalence of each of the five risk factors (smoking, overweight, physical inactivity, alcohol and unhealthy diet) was estimated, as well as their co-occurrence for the different possible combinations, according to socioeconomic and health self-assessment variables. The independent associations were verified via multinomial logistic regression to obtain the estimates of the odds ratio (OR) and corresponding 95% confidence intervals.

RESULTS

At least two risk factors were present in 38.5% of the adults and 37.0% of the older participants. The male adults and older participants who did not have private health insurance and classified their health as average or poor/very poor were more likely to have two or more concurrent risk behaviors. The greater chance of co-occurrence of smoking and alcohol abuse in adults (adjusted OR = 3.52) and older people (adjusted OR = 2.94) stands out.

CONCLUSIONS

The subgroups with increased risk of developing multiple unhealthy behaviors and the most prevalent behaviors were identified. These findings are expected to contribute to the better targeting of health promotion and preventive care. It is worth noting that, for the adoption of healthy lifestyle habits, macro-social and inter-sectoral policies are more effective.