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Ramos RDSPDS, Carneiro GR, Oliveira ALSD, Cunha TND, Ramos VP. Incidence of congenital syphilis according to inequalities and living conditions in the city of Recife, Pernambuco, Brazil. REVISTA BRASILEIRA DE SAÚDE MATERNO INFANTIL 2021. [DOI: 10.1590/1806-93042021000300004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Abstract Objectives: to analyze the variation in the incidence rates of congenital syphilis according to the spatial distribution of Life Condition Index (LCI) among neighborhoods in the city of Recife-PE. Methods: an ecological study, developed from 3,234 cases of congenital syphilis notified in the Sistema de Informação de Agravos de Notificação (Severe Disease Notification Information System), between 2007 and 2016. LCI was built from seven variables related to the dimensions of the environment, education and income, aggregated at the neighborhood levels and spatially distributed in four strata: very high, high, low and very low. The correlation between the rates of congenital syphilis in the strata and LCI was investigated by applying the Spearman correlation coefficient and demonstrated by means of scatter graphics. Results: the mean rate on disease incidence was 6.8 cases per thousand live births. There was a higher incidence in the strata of very low and low living conditions, as well as in Districts that presented poor sanitary conditions and low schooling for the head of the family (District VII), higher proportion of illiteracy among 10 and 14 year olds (District II) and low income of the head of the household (Districts I, II and VII). Conclusions: this study showed the persistence of health inequalities in areas with worse living conditions.
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Pina JC, Alves LS, Arroyo LH, Arcêncio RA, Gondim EC, Furtado MCDC, de Mello DF. Using geo-spatial analysis for assessing the risk of hospital admissions due to community-acquired pneumonia in under-5 children and its association with socially vulnerable areas (Brazil). BMC Pediatr 2020; 20:502. [PMID: 33138791 PMCID: PMC7606062 DOI: 10.1186/s12887-020-02398-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 10/21/2020] [Indexed: 12/22/2022] Open
Abstract
Background The concentration of under-5 child morbidity and mortality due to pneumonia in developing countries reflects the social inequities. This study aimed to map and assess the spatial risk for hospitalization due to Community-Acquired Pneumonia in children under 5 years of age and its association with vulnerable areas. Methods Ecological study in the city of Ribeirão Preto, state of São Paulo, Brazil. The study population consisted of hospitalized under-5 children, diagnosed with community-acquired pneumonia, in Ribeirão Preto-São Paulo-Brazil, from 2012 to 2013. Data were collected in different databases, by a trained team, between March 2012 and August 2013 and from the 2010 Demographic Census of the Brazilian Institute of Geography and Statistics. The 956 urban census tracts were considered as the units of analysis. The incidence of cases per 10,000 inhabitants was calculated by census tracts during the study period. For the identification of the spatial risk clusters, the Kernel density estimator and the Getis-Ord Gi* technique were performed. Generalized additive models were used to verify the association between areas with social vulnerability and the occurrence of childhood pneumonia. Results The study included 265 children under the age of five, hospitalized due to community-acquired pneumonia. A concentration of cases was identified in the regions with greater social vulnerability (low income, poor housing conditions and homelessness), as well as a lower occurrence of cases in the most developed and economically privileged area of the city. The majority of the children lived in territories served by traditional primary healthcare units, in which the health surveillance and family and community focus are limited. It is important to highlight that the tracts with the highest degrees of vulnerability, such as those identified as high vulnerability (urban) and very high vulnerability (subnormal urban clusters). Conclusions The results contribute to the comprehension of the social factors involved in child hospitalization due to pneumonia, based on the analysis of the spatial distribution. This approach revealed a strategic tool for diagnosing the disparities as well presenting evidences for the planning in health and strength health care system in achieving equity, welfare and social protection of children. Supplementary Information Supplementary information accompanies this paper at 10.1186/s12887-020-02398-x.
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Affiliation(s)
- Juliana Coelho Pina
- Federal University of Santa Catarina, Campus Universitário Reitor João David Ferreira Lima, Trindade, Florianópolis, SC, CEP: 88040-900, Brazil.
| | - Luana Seles Alves
- University of São Paulo at Ribeirão Preto College of Nursing, Avenida dos Bandeirantes, 3900, Monte Alegre, Ribeirão Preto, SP, CEP: 14040-902, Brazil
| | - Luiz Henrique Arroyo
- University of São Paulo at Ribeirão Preto College of Nursing, Avenida dos Bandeirantes, 3900, Monte Alegre, Ribeirão Preto, SP, CEP: 14040-902, Brazil
| | - Ricardo Alexandre Arcêncio
- University of São Paulo at Ribeirão Preto College of Nursing, Avenida dos Bandeirantes, 3900, Monte Alegre, Ribeirão Preto, SP, CEP: 14040-902, Brazil
| | - Ellen Cristina Gondim
- University of São Paulo at Ribeirão Preto College of Nursing, Avenida dos Bandeirantes, 3900, Monte Alegre, Ribeirão Preto, SP, CEP: 14040-902, Brazil
| | - Maria Cândida de Carvalho Furtado
- University of São Paulo at Ribeirão Preto College of Nursing, Avenida dos Bandeirantes, 3900, Monte Alegre, Ribeirão Preto, SP, CEP: 14040-902, Brazil
| | - Débora Falleiros de Mello
- University of São Paulo at Ribeirão Preto College of Nursing, Avenida dos Bandeirantes, 3900, Monte Alegre, Ribeirão Preto, SP, CEP: 14040-902, Brazil
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André SR, Nogueira LMV, Rodrigues ILA, Cunha TND, Palha PF, Santos CBD. Tuberculosis associated with the living conditions in an endemic municipality in the North of Brazil. Rev Lat Am Enfermagem 2020; 28:e3343. [PMID: 32876291 PMCID: PMC7458573 DOI: 10.1590/1518-8345.3223.3343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 04/29/2020] [Indexed: 11/23/2022] Open
Abstract
Objective: to analyze the association between the occurrence of new tuberculosis cases and the Adapted Living Condition Index, and to describe the spatial distribution in an endemic municipality. Method: this is an analytical and ecological study that was developed from new cases in residents of an endemic municipality in the North Region of Brazil. The data were obtained from the Notifiable Diseases Information System and from the 2010 Demographic Census. The Adapted Living Conditions Index was obtained by factor analysis and its association with the occurrence of the disease was analyzed by means of the chi-square test. The type I error was set at 0.05. Kernel estimation was used to describe the density of tuberculosis in each census sector. Results: the incidence coefficient was 97.5/100,000 inhabitants. The data showed a statistically significant association between the number of cases and socioeconomic class, with the fact that belonging to the highest economic class reduces the chance of the disease occurring. The thematic maps showed that tuberculosis was distributed in a heterogeneous way with a concentration in the Southern region of the municipality. Conclusion: tuberculosis, associated with precarious living conditions, reinforces the importance of discussion on social determinants in the health-disease process to subsidize equitable health actions in risk areas, upon a context of vulnerability.
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Affiliation(s)
- Suzana Rosa André
- Departamento de Enfermagem Comunitária, Escola da Enfermagem Magalhães Barata, Universidade do Estado do Pará, Belém, PA, Brazil
| | - Laura Maria Vidal Nogueira
- Departamento de Enfermagem Comunitária, Escola da Enfermagem Magalhães Barata, Universidade do Estado do Pará, Belém, PA, Brazil
| | - Ivaneide Leal Ataíde Rodrigues
- Departamento de Enfermagem Comunitária, Escola da Enfermagem Magalhães Barata, Universidade do Estado do Pará, Belém, PA, Brazil
| | - Tarcísio Neves da Cunha
- Programa Nacional de Cooperação Acadêmica da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), MICROARS Consultoria e Projetos, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro Fredemir Palha
- PAHO/WHO Collaborating Centre at Nursing Research Development, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Claudia Benedita Dos Santos
- PAHO/WHO Collaborating Centre at Nursing Research Development, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
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Leal BDN, Mesquita CR, Nogueira LMV, Rodrigues ILA, Oliveira LFD, Caldas RJC. Spatial analysis on tuberculosis and the network of primary health care. Rev Bras Enferm 2019; 72:1197-1202. [DOI: 10.1590/0034-7167-2017-0897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 04/26/2018] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Objective: to analyze the spatial distribution of new cases of tuberculosis compared to the location of the Primary Healthcare Units that performed the compulsory notification. Method: ecological study conducted in Belém, Pará, with 5,294 new cases of tuberculosis notified to Sistema de Informação de Agravos de Notificação for the period from 2010 to 2014. The cases were georeferenced using the software applications ArcGis 10.2 and TerraView 4.2.2. The techniques of Kernel density and global Moran geostatistics were used. Results: the incidence of tuberculosis cases did not vary significantly between the years studied, however there was a variation in incidence between neighborhoods. Health units that exhibited higher number of notifications can suffer great influence of migration from nearby neighborhoods. Conclusion: the spatial dynamics of tuberculosis associated with health services allows to know the areas with increased risk of tuberculosis and the density of notifications of health units.
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Sales CMM, Sanchez MN, Ramalho W, Bertolde AI, Maciel ELN. Social determinants of tuberculosis via a zero-inflated model in small areas of a city in Southeastern Brazil. Rev Soc Bras Med Trop 2018; 51:638-643. [PMID: 30304270 DOI: 10.1590/0037-8682-0015-2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 07/27/2018] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION This study aimed to analyze social factors involved in the spatial distribution and under-reporting of tuberculosis (TB) in the city of Vitória, Espírito Santo State, Brazil. METHODS This was an ecological study of the reported cases of TB between 2009 and 2011, according to census tracts. The outcome was TB incidence for the study period and the variables of exposure were proportions of literacy, inhabitants with an income of up to half the minimum monthly wage (MMW), and inhabitants associated with sewer mains or with access to safe drinking water. We used a zero-inflated process, zero-inflated negative binomial regression (ZINB), and selected an explanatory model based on the Akaike Information Criterion (AIC). RESULTS A total of 588 cases of tuberculosis were reported in Vitória during the study period, distributed among 223 census tracts (38.6%), with 354 (61.4%) tracts presenting zero cases. In the ZINB model, the mean value of p i was 0.93, indicating that there is a 93% chance that an observed false zero could be due to sub-notification. CONCLUSIONS It is important to prioritize areas exhibiting determinants that influence the occurrence of TB in the municipality of Vitória. The zero-inflated model can be useful to the public health sector since it identifies the percentage of false zeros, generating an estimate of the real epidemiological condition of TB in Vitória.
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Affiliation(s)
- Carolina Maia Martins Sales
- Programa de Pós-Graduação em Saúde Coletiva, Universidade Federal do Espírito Santo, Vitória, ES, Brasil.,Laboratório de Epidemiologia, Universidade Federal do Espírito Santo, Vitória, ES, Brasil
| | | | - Walter Ramalho
- Campus Ceilândia, Universidade de Brasília, Brasília, DF, Brasil
| | - Adelmo Inácio Bertolde
- Laboratório de Epidemiologia, Universidade Federal do Espírito Santo, Vitória, ES, Brasil.,Departamento de Estatística, Universidade Federal do Espírito Santo, Vitória, ES, Brasil
| | - Ethel Leonor Noia Maciel
- Programa de Pós-Graduação em Saúde Coletiva, Universidade Federal do Espírito Santo, Vitória, ES, Brasil.,Laboratório de Epidemiologia, Universidade Federal do Espírito Santo, Vitória, ES, Brasil
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Ichihara MYT, Ramos D, Rebouças P, Oliveira FJ, Ferreira AJF, Teixeira C, Allik M, Katikireddi SV, Barreto ML, Leyland AH, Dundas R. Area deprivation measures used in Brazil: a scoping review. Rev Saude Publica 2018; 52:83. [PMID: 30183845 PMCID: PMC6122878 DOI: 10.11606/s1518-8787.2018052000933] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 05/30/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To describe and assess currently used area-based measures of deprivation in Brazil for health research, to the purpose of informing the development of a future small area deprivation index. METHODS We searched five electronic databases and seven websites of Brazilian research institutions and governmental agencies. Inclusion criteria were: studies proposing measures of deprivation for small areas (i.e., finer geography than country-level) in Brazil, published in English, Portuguese or Spanish. After data-extraction, results were tabulated according to the area level the deprivation measure was created for and to the dimensions of deprivation or poverty included in the measures. A narrative synthesis approach was used to summarize the measures available, highlighting their utility for public health research. RESULTS A total of 7,199 records were retrieved, 126 full-text articles were assessed after inclusion criteria and a final list of 30 articles was selected. No small-area deprivation measures that have been applied to the whole of Brazil were found. Existing measures were mainly used to study infectious and parasitic diseases. Few studies used the measures to assess inequalities in mortality and no studies used the deprivation measure to evaluate the impact of social programs. CONCLUSIONS No up-to-date small area-based deprivation measure in Brazil covers the whole country. There is a need to develop such an index for Brazil to measure and monitor inequalities in health and mortality, particularly to assess progress in Brazil against the Sustainable Development Goal targets for different health outcomes, showing progress by socioeconomic groups.
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Affiliation(s)
- Maria Yury Travassos Ichihara
- Fundação Oswaldo Cruz. Instituto Gonçalo Moniz. Centro de Integração de Dados e Conhecimentos para a Saúde. Salvador, BA, Brasil
| | - Dandara Ramos
- Fundação Oswaldo Cruz. Instituto Gonçalo Moniz. Centro de Integração de Dados e Conhecimentos para a Saúde. Salvador, BA, Brasil
| | - Poliana Rebouças
- Fundação Oswaldo Cruz. Instituto Gonçalo Moniz. Centro de Integração de Dados e Conhecimentos para a Saúde. Salvador, BA, Brasil.,Universidade Federal da Bahia. Instituto de Saúde Coletiva. Salvador, BA, Brasil
| | - Flávia Jôse Oliveira
- Fundação Oswaldo Cruz. Instituto Gonçalo Moniz. Centro de Integração de Dados e Conhecimentos para a Saúde. Salvador, BA, Brasil.,Universidade Federal da Bahia. Instituto de Saúde Coletiva. Salvador, BA, Brasil
| | - Andrêa J F Ferreira
- Fundação Oswaldo Cruz. Instituto Gonçalo Moniz. Centro de Integração de Dados e Conhecimentos para a Saúde. Salvador, BA, Brasil.,Universidade Federal da Bahia. Instituto de Saúde Coletiva. Salvador, BA, Brasil
| | - Camila Teixeira
- Fundação Oswaldo Cruz. Instituto Gonçalo Moniz. Centro de Integração de Dados e Conhecimentos para a Saúde. Salvador, BA, Brasil.,Universidade Federal da Bahia. Instituto de Saúde Coletiva. Salvador, BA, Brasil
| | - Mirjam Allik
- University of Glasgow. MRC/CSO Social and Public Health Sciences Unit. Glasgow, Scotland
| | | | - Mauricio L Barreto
- Fundação Oswaldo Cruz. Instituto Gonçalo Moniz. Centro de Integração de Dados e Conhecimentos para a Saúde. Salvador, BA, Brasil.,Universidade Federal da Bahia. Instituto de Saúde Coletiva. Salvador, BA, Brasil
| | - Alastair H Leyland
- University of Glasgow. MRC/CSO Social and Public Health Sciences Unit. Glasgow, Scotland
| | - Ruth Dundas
- University of Glasgow. MRC/CSO Social and Public Health Sciences Unit. Glasgow, Scotland
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Crispim JDA, Touso MM, Yamamura M, Popolin MP, Garcia MCDC, Santos CBD, Palha PF, Arcêncio RA. Cultural adaptation of the Tuberculosis-related stigma scale to Brazil. CIENCIA & SAUDE COLETIVA 2018; 21:2233-42. [PMID: 27383356 DOI: 10.1590/1413-81232015217.10582015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/24/2015] [Indexed: 11/21/2022] Open
Abstract
The process of stigmatization associated with TB has been undervalued in national research as this social aspect is important in the control of the disease, especially in marginalized populations. This paper introduces the stages of the process of cultural adaptation in Brazil of the Tuberculosis-related stigma scale for TB patients. It is a methodological study in which the items of the scale were translated and back-translated with semantic validation with 15 individuals of the target population. After translation, the reconciled back-translated version was compared with the original version by the project coordinator in Southern Thailand, who approved the final version in Brazilian Portuguese. The results of the semantic validation conducted with TB patients enable the identification that, in general, the scale was well accepted and easily understood by the participants.
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Affiliation(s)
- Juliane de Almeida Crispim
- Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo. Av. Bandeirantes 3900, Vila Monte Alegre. 14040-902 Ribeirão Preto SP Brasil.
| | - Michelle Mosna Touso
- Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo. Av. Bandeirantes 3900, Vila Monte Alegre. 14040-902 Ribeirão Preto SP Brasil.
| | - Mellina Yamamura
- Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo. Av. Bandeirantes 3900, Vila Monte Alegre. 14040-902 Ribeirão Preto SP Brasil.
| | - Marcela Paschoal Popolin
- Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo. Av. Bandeirantes 3900, Vila Monte Alegre. 14040-902 Ribeirão Preto SP Brasil.
| | - Maria Concebida da Cunha Garcia
- Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo. Av. Bandeirantes 3900, Vila Monte Alegre. 14040-902 Ribeirão Preto SP Brasil.
| | - Cláudia Benedita Dos Santos
- Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo. Av. Bandeirantes 3900, Vila Monte Alegre. 14040-902 Ribeirão Preto SP Brasil.
| | - Pedro Fredemir Palha
- Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo. Av. Bandeirantes 3900, Vila Monte Alegre. 14040-902 Ribeirão Preto SP Brasil.
| | - Ricardo Alexandre Arcêncio
- Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo. Av. Bandeirantes 3900, Vila Monte Alegre. 14040-902 Ribeirão Preto SP Brasil.
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Yamamura M, Santos Neto M, Chiaravalloti Neto F, Arroyo LH, Ramos ACV, de Queiroz AAR, Belchior ADS, Dos Santos DT, Crispim JDA, Pinto IC, Uchôa SADC, Fiorati RC, Arcêncio RA. Areas with evidence of equity and their progress on mortality from tuberculosis in an endemic municipality of southeast Brazil. Infect Dis Poverty 2017; 6:134. [PMID: 29020981 PMCID: PMC5637336 DOI: 10.1186/s40249-017-0348-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 08/08/2017] [Indexed: 11/30/2022] Open
Abstract
Background In Brazil, people still fall ill and die from tuberculosis (TB), and this can be explained by the significant impasse in the equity of distribution of therapeutic resources to the population as a whole. The aim was to identify geographical areas which have shown progress in terms of equity (of income, schooling and urban occupancy) and test its effect on mortality from TB in a municipality of southeast Brazil. Methods It is an ecological study considering TB as the basic cause for deaths registered between 2006 and 2013 on the Mortality Information System and other variables obtained through the Demographic Census of the Brazilian Institute of Geography and Statistics (2010). The geographical area for analysis comprised the areas of coverage of the health services. Social indicators have been constructed through the Principal Component Analysis (PCA). The cases were geocoded and the annual mortality rate from TB was calculated with smoothing using the local empirical Bayesian method. Multiple linear regression was then performed. There was confirmation of the existence of spatial dependence of residue through the application of the Global Moran I test, and application of the Models with Global Spatial Effects, to identify the best standard of spatial regression. Results The mortality rates ranged from 0.00 to 2.8 deaths per 100,000 people, per year. In the PCA, three indicators were constructed, and designated as indicators of income, social inequality, and social equity. In multiple linear regression, the indicator of social equity was statistically significant (P < 0.0001) but had a negative association, an adjusted R2 of 28.36% and with spatial dependence (Moran I = 0.21, P = 0.003455). The best model to deal with existing spatial dependence was the Spatial Lag Model. Conclusions The better social conditions have shown progress in reducing mortality from TB, thereby reinforcing the achievement of Sustainable Development Goals. In addition, cartography was also applied, which can be replicated in other scenarios throughout the world, using a scope distinct from that of works traditionally produced in that it places the emphasis on social equity. Electronic supplementary material The online version of this article (doi:10.1186/s40249-017-0348-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mellina Yamamura
- School of Nursing of the University of São Paulo, Ribeirão Preto Campus (EERP/USP), Ribeirão reto, SP, Brazil.
| | | | | | - Luiz Henrique Arroyo
- School of Nursing of the University of São Paulo, Ribeirão Preto Campus (EERP/USP), Ribeirão reto, SP, Brazil
| | - Antônio Carlos Vieira Ramos
- School of Nursing of the University of São Paulo, Ribeirão Preto Campus (EERP/USP), Ribeirão reto, SP, Brazil
| | | | - Aylana de Souza Belchior
- School of Nursing of the University of São Paulo, Ribeirão Preto Campus (EERP/USP), Ribeirão reto, SP, Brazil
| | - Danielle Talita Dos Santos
- School of Nursing of the University of São Paulo, Ribeirão Preto Campus (EERP/USP), Ribeirão reto, SP, Brazil
| | - Juliane de Almeida Crispim
- School of Nursing of the University of São Paulo, Ribeirão Preto Campus (EERP/USP), Ribeirão reto, SP, Brazil
| | - Ione Carvalho Pinto
- School of Nursing of the University of São Paulo, Ribeirão Preto Campus (EERP/USP), Ribeirão reto, SP, Brazil
| | | | - Regina Célia Fiorati
- School of Medicine of the University of São Paulo, Ribeirão Preto Campus (FMRP/USP), Ribeirão Preto, SP, Brazil
| | - Ricardo Alexandre Arcêncio
- School of Nursing of the University of São Paulo, Ribeirão Preto Campus (EERP/USP), Ribeirão reto, SP, Brazil
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Ramos ACV, Yamamura M, Arroyo LH, Popolin MP, Chiaravalloti Neto F, Palha PF, Uchoa SADC, Pieri FM, Pinto IC, Fiorati RC, de Queiroz AAR, Belchior ADS, dos Santos DT, Garcia MCDC, Crispim JDA, Alves LS, Berra TZ, Arcêncio RA. Spatial clustering and local risk of leprosy in São Paulo, Brazil. PLoS Negl Trop Dis 2017; 11:e0005381. [PMID: 28241038 PMCID: PMC5344525 DOI: 10.1371/journal.pntd.0005381] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 03/09/2017] [Accepted: 02/02/2017] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Although the detection rate is decreasing, the proportion of new cases with WHO grade 2 disability (G2D) is increasing, creating concern among policy makers and the Brazilian government. This study aimed to identify spatial clustering of leprosy and classify high-risk areas in a major leprosy cluster using the SatScan method. METHODS Data were obtained including all leprosy cases diagnosed between January 2006 and December 2013. In addition to the clinical variable, information was also gathered regarding the G2D of the patient at diagnosis and after treatment. The Scan Spatial statistic test, developed by Kulldorff e Nagarwalla, was used to identify spatial clustering and to measure the local risk (Relative Risk-RR) of leprosy. Maps considering these risks and their confidence intervals were constructed. RESULTS A total of 434 cases were identified, including 188 (43.31%) borderline leprosy and 101 (23.28%) lepromatous leprosy cases. There was a predominance of males, with ages ranging from 15 to 59 years, and 51 patients (11.75%) presented G2D. Two significant spatial clusters and three significant spatial-temporal clusters were also observed. The main spatial cluster (p = 0.000) contained 90 census tracts, a population of approximately 58,438 inhabitants, detection rate of 22.6 cases per 100,000 people and RR of approximately 3.41 (95%CI = 2.721-4.267). Regarding the spatial-temporal clusters, two clusters were observed, with RR ranging between 24.35 (95%CI = 11.133-52.984) and 15.24 (95%CI = 10.114-22.919). CONCLUSION These findings could contribute to improvements in policies and programming, aiming for the eradication of leprosy in Brazil. The Spatial Scan statistic test was found to be an interesting resource for health managers and healthcare professionals to map the vulnerability of areas in terms of leprosy transmission risk and areas of underreporting.
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Affiliation(s)
- Antônio Carlos Vieira Ramos
- Graduate Program in Public Health Nursing, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Mellina Yamamura
- Graduate Program Interunit Doctoral Program in Nursing, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Luiz Henrique Arroyo
- Graduate Program in Public Health Nursing, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Marcela Paschoal Popolin
- Graduate Program in Public Health Nursing, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Francisco Chiaravalloti Neto
- Department of Epidemiology, School of Public Health of the University of São Paulo, São Paulo, São Paulo, Brazil
| | - Pedro Fredemir Palha
- Maternal-Infant Nursing and Public Health Department, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | | | | | - Ione Carvalho Pinto
- Maternal-Infant Nursing and Public Health Department, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Regina Célia Fiorati
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School of the University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Ana Angélica Rêgo de Queiroz
- Graduate Program Interunit Doctoral Program in Nursing, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Aylana de Souza Belchior
- Graduate Program Interunit Doctoral Program in Nursing, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Danielle Talita dos Santos
- Graduate Program Interunit Doctoral Program in Nursing, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Maria Concebida da Cunha Garcia
- Graduate Program Interunit Doctoral Program in Nursing, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Juliane de Almeida Crispim
- Graduate Program in Public Health Nursing, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Luana Seles Alves
- Graduate Program in Public Health Nursing, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Thaís Zamboni Berra
- Graduate Program in Public Health Nursing, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Ricardo Alexandre Arcêncio
- Maternal-Infant Nursing and Public Health Department, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
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Pinto ML, da Silva TC, Gomes LCF, Bertolozzi MR, Villavicencio LMM, Azevedo KMDFA, de Figueiredo TMRM. Occurrence of tuberculosis cases in Crato, Ceará, from 2002 to 2011: a spatial analisys of specific standards. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2016; 18:313-25. [PMID: 26083505 DOI: 10.1590/1980-5497201500020003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 09/30/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to analyze the spatial distribution of tuberculosis in Crato, Ceará, Brazil, from 2002 to 2011, aiming to check for a point pattern. METHODS This is an ecological, temporal trend and hybrid design study, with a quantitative approach. A total of 261 cases of tuberculosis were geo-referenced and 20 (7.1%) were considered as losses due to the lack of address. The profile of patients in 10 years of study was in accordance with the following pattern: men aged between 20 and 59 years, with low schooling, affected by the pulmonary form of tuberculosis and who were cured from the disease. RESULTS The analysis of the spatial distribution of tuberculosis points out that in the period of study, new cases of the disease were not distributed on a regular basis, indicating a clustered spatial pattern, confirmed by the L-function. The map with the density of new cases estimated by the Kernel method showed that the "hot" areas are more concentrated in the vicinity of the central urban area. CONCLUSION The study allowed pointing out areas of higher and lower concentration of tuberculosis, identifying the spatial pattern, but it also recognized that the disease has not reached all of the population groups with the same intensity. Those who were most vulnerable were the ones who lived in regions with higher population densities, precarious living conditions, and with intense flow of people.
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Affiliation(s)
| | | | | | - Maria Rita Bertolozzi
- Nursing Public Health Department, Nursing School, Universidade de São Paulo, São Paulo, SP, Brazil
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11
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Yamamura M, de Freitas IM, Santo M, Chiaravalloti F, Popolin MAP, Arroyo LH, Rodrigues LBB, Crispim JA, Arcêncio RA. Spatial analysis of avoidable hospitalizations due to tuberculosis in Ribeirao Preto, SP, Brazil (2006-2012). Rev Saude Publica 2016; 50:20. [PMID: 27191156 PMCID: PMC4902087 DOI: 10.1590/s1518-8787.2016050006049] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 06/09/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To describe the spatial distribution of avoidable hospitalizations due to tuberculosis in the municipality of Ribeirao Preto, SP, Brazil, and to identify spatial and space-time clusters for the risk of occurrence of these events. METHODS This is a descriptive, ecological study that considered the hospitalizations records of the Hospital Information System of residents of Ribeirao Preto, SP, Southeastern Brazil, from 2006 to 2012. Only the cases with recorded addresses were considered for the spatial analyses, and they were also geocoded. We resorted to Kernel density estimation to identify the densest areas, local empirical Bayes rate as the method for smoothing the incidence rates of hospital admissions, and scan statistic for identifying clusters of risk. Softwares ArcGis 10.2, TerraView 4.2.2, and SaTScan™ were used in the analysis. RESULTS We identified 169 hospitalizations due to tuberculosis. Most were of men (n = 134; 79.2%), averagely aged 48 years (SD = 16.2). The predominant clinical form was the pulmonary one, which was confirmed through a microscopic examination of expectorated sputum (n = 66; 39.0%). We geocoded 159 cases (94.0%). We observed a non-random spatial distribution of avoidable hospitalizations due to tuberculosis concentrated in the northern and western regions of the municipality. Through the scan statistic, three spatial clusters for risk of hospitalizations due to tuberculosis were identified, one of them in the northern region of the municipality (relative risk [RR] = 3.4; 95%CI 2.7-4,4); the second in the central region, where there is a prison unit (RR = 28.6; 95%CI 22.4-36.6); and the last one in the southern region, and area of protection for hospitalizations (RR = 0.2; 95%CI 0.2-0.3). We did not identify any space-time clusters. CONCLUSIONS The investigation showed priority areas for the control and surveillance of tuberculosis, as well as the profile of the affected population, which shows important aspects to be considered in terms of management and organization of health care services targeting effectiveness in primary health care.
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Affiliation(s)
- Mellina Yamamura
- Programa de Pós-Graduação em Saúde Pública. Escola de Enfermagem de Ribeirão Preto. Universidade de São Paulo. Ribeirão Preto, SP, Brasil
| | - Isabela Moreira de Freitas
- Programa de Pós-Graduação em Saúde Pública. Escola de Enfermagem de Ribeirão Preto. Universidade de São Paulo. Ribeirão Preto, SP, Brasil
| | - Marcelino Santo
- Departamento de Enfermagem. Universidade Federal do Maranhão. Imperatriz, MA, Brasil
| | - Francisco Chiaravalloti
- Departamento de Epidemiologia. Faculdade de Saúde Pública. Universidade de São Paulo. São Paulo, SP, Brasil
| | - Marcela Antunes Paschoal Popolin
- Programa de Pós-Graduação em Saúde Pública. Escola de Enfermagem de Ribeirão Preto. Universidade de São Paulo. Ribeirão Preto, SP, Brasil
| | - Luiz Henrique Arroyo
- Programa de Pós-Graduação em Saúde Pública. Escola de Enfermagem de Ribeirão Preto. Universidade de São Paulo. Ribeirão Preto, SP, Brasil
| | | | - Juliane Almeida Crispim
- Programa de Pós-Graduação em Saúde Pública. Escola de Enfermagem de Ribeirão Preto. Universidade de São Paulo. Ribeirão Preto, SP, Brasil
| | - Ricardo Alexandre Arcêncio
- Departamento de Enfermagem Materno Infantil e Saúde Pública. Escola de Enfermagem de Ribeirão Preto. Universidade de São Paulo. Ribeirão Preto, SP, Brasil
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12
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Ranzani OT, Carvalho CRR, Waldman EA, Rodrigues LC. The impact of being homeless on the unsuccessful outcome of treatment of pulmonary TB in São Paulo State, Brazil. BMC Med 2016; 14:41. [PMID: 27006009 PMCID: PMC4804546 DOI: 10.1186/s12916-016-0584-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 02/18/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) is a major public health problem requiring complex treatment, the success of which depends on biological, social, and institutional factors. São Paulo State (SPS), in Brazil, has a high TB burden. Because of high socioeconomic heterogeneity and chaotic urbanisation, homelessness might play an important role in the TB burden in SPS. Our aim was to determine the association between homelessness and outcome of treatment of pulmonary TB (PTB) in SPS. METHODS A historical cohort from the routine SPS TB database for 2009-2013 was analysed. The study population was newly diagnosed adult patients with PTB. Homelessness was ascertained at notification or when treatment started. Our outcome was unsuccessful outcome of treatment. We used logistic regression to adjust for potential confounders and multiple imputation for missing data. RESULTS We analysed 61,817 patients; 1726 (2.8 %, 95%CI 2.7-2.9 %) were homeless. Homeless patients were concentrated in bigger cities, were more frequently middle-aged males, had black/brown skin colour, and had received less education (P < 0.001, for all). Alcohol and drug use was three times more frequent in homeless patients (43.2 % vs 14.4 %, 30.2 % vs. 9.4 %, P < 0.001, respectively). HIV testing was less common among the homeless, of whom 17.3 % were HIV positive compared with 8.5 % among the not homeless population (P < 0.001). Microbiologic confirmation was more frequent among the homeless (91.6 % vs. 84.8 %, P < 0.001). Unsuccessful outcome of treatment was 57.3 % among the homeless and 17.5 % among the not homeless (OR = 6.32, 95%CI 5.73-6.97, P < 0.001), mainly due to loss to follow-up (39 %) and death (10.5 %). After full-adjustment for potential confounders, homelessness remained strongly associated with lower treatment success (aOR = 4.96, 95 % CI 4.27-5.76, P < 0.001). HIV status interacted with homelessness: among HIV-infected patients, the aOR was 2.45 (95%CI 1.90-3.16, Pinteraction < 0.001). The population attributable fraction for the joint effect of homelessness, alcohol and drug use was almost 20 %. CONCLUSIONS Confirming our hypothesis, homelessness led to a marked reduction in the successful treatment of newly diagnosed pulmonary tuberculosis. Homelessness and associated conditions were important contributors to lack of treatment success in pulmonary tuberculosis in São Paulo. A multifaceted intervention must be implemented to target this vulnerable population.
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Affiliation(s)
- Otavio T Ranzani
- Pulmonary Division, Heart Institute (InCor), Medical School, University of São Paulo, Av. Dr. Arnaldo, 455, 2° andar, sala 2144, Post-code 01246903, São Paulo, Brazil. .,London School of Hygiene & Tropical Medicine (LSHTM), Keppel Street, Room G9a, Post-code WC1E 7HT, London, UK.
| | - Carlos R R Carvalho
- Pulmonary Division, Heart Institute (InCor), Medical School, University of São Paulo, Av. Dr. Arnaldo, 455, 2° andar, sala 2144, Post-code 01246903, São Paulo, Brazil
| | - Eliseu A Waldman
- Department of Epidemiology, Faculty of Public Health, University of Sao Paulo, Av. Dr. Arnaldo, 715, Post-code 01246904, São Paulo, Brazil
| | - Laura C Rodrigues
- London School of Hygiene & Tropical Medicine (LSHTM), Keppel Street, Room G9a, Post-code WC1E 7HT, London, UK
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Pereira AGL, Medronho RDA, Escosteguy CC, Valencia LIO, Magalhães MDAFM. Spatial distribution and socioeconomic context of tuberculosis in Rio de Janeiro, Brazil. Rev Saude Publica 2015; 49:48. [PMID: 26270014 PMCID: PMC4544397 DOI: 10.1590/s0034-8910.2015049005470] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 10/27/2014] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To analyze the spatial distribution of risk for tuberculosis and its socioeconomic determinants in the city of Rio de Janeiro, Brazil. METHODS An ecological study on the association between the mean incidence rate of tuberculosis from 2004 to 2006 and socioeconomic indicators of the Censo Demográfico (Demographic Census) of 2000. The unit of analysis was the home district registered in the Sistema de Informação de Agravos de Notificação (Notifiable Diseases Information System) of Rio de Janeiro, Southeastern Brazil. The rates were standardized by sex and age group, and smoothed by the empirical Bayes method. Spatial autocorrelation was evaluated by Moran’s I. Multiple linear regression models were studied and the appropriateness of incorporating the spatial component in modeling was evaluated. RESULTS We observed a higher risk of the disease in some neighborhoods of the port and north regions, as well as a high incidence in the slums of Rocinha and Vidigal, in the south region, and Cidade de Deus, in the west. The final model identified a positive association for the variables: percentage of permanent private households in which the head of the house earns three to five minimum wages; percentage of individual residents in the neighborhood; and percentage of people living in homes with more than two people per bedroom. CONCLUSIONS The spatial analysis identified areas of risk of tuberculosis incidence in the neighborhoods of the city of Rio de Janeiro and also found spatial dependence for the incidence of tuberculosis and some socioeconomic variables. However, the inclusion of the space component in the final model was not required during the modeling process.
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Affiliation(s)
| | - Roberto de Andrade Medronho
- Faculdade de Medicina, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | | | - Luis Iván Ortiz Valencia
- Instituto de Estudos em Saúde Coletiva, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
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Santos Neto M, Yamamura M, Garcia MCDC, Popolin MP, Rodrigues LBB, Chiaravalloti Neto F, Fronteira I, Arcêncio RA. Pulmonary tuberculosis in São Luis, State of Maranhão, Brazil: space and space-time risk clusters for death (2008-2012). Rev Soc Bras Med Trop 2015; 48:69-76. [PMID: 25860467 DOI: 10.1590/0037-8682-0290-2014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 02/10/2015] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The objective was to identify space and space-time risk clusters for the occurrence of deaths in a priority city for the control of tuberculosis (TB) in the Brazilian Northeast. METHODS Ecological research was undertaken in the City of São Luis/Maranhão. Cases were considered that resulted in deaths in the population living in the urban region of the city with pulmonary TB as the basic cause, between 2008 and 2012. To detect space and space-time clusters of deaths due to pulmonary TB in the census sectors, the spatial analysis scan technique was used. RESULTS In total, 221 deaths by TB occurred, 193 of which were due to pulmonary TB. Approximately 95% of the cases (n=183) were geocoded. Two significant spatial clusters were identified, the first of which showed a mortality rate of 5.8 deaths per 100,000 inhabitants per year and a high relative risk of 3.87. The second spatial cluster showed a mortality rate of 0.4 deaths per 100,000 inhabitants per year and a low relative risk of 0.10. A significant cluster was observed in the space-time analysis between 11/01/2008 and 04/30/2011, with a mortality rate of 8.10 deaths per 100,000 inhabitants per year and a high relative risk (3.0). CONCLUSIONS The knowledge of priority sites for the occurrence of deaths can support public management to reduce inequities in the access to health services and permit an optimization of the resources and teams in the control of pulmonary TB, providing support for specific strategies focused on the most vulnerable populations.
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Affiliation(s)
- Marcelino Santos Neto
- Centro de Ciências Sociais Saúde e Tecnologia, Universidade Federal do Maranhão, Imperatriz, MA, Brazil
| | - Mellina Yamamura
- Departamento de Enfermagem Materno-Infantil e Saúde Pública, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Maria Concebida da Cunha Garcia
- Departamento de Enfermagem Materno-Infantil e Saúde Pública, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Marcela Paschoal Popolin
- Departamento de Enfermagem Materno-Infantil e Saúde Pública, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | | | | | - Inês Fronteira
- Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Ricardo Alexandre Arcêncio
- Departamento de Enfermagem Materno-Infantil e Saúde Pública, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
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15
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Santos PCD, Silva ZPD, Chiaravalloti Neto F, Almeida MFD. Análise espacial dos aglomerados de nascimentos ocorridos em hospitais SUS e não SUS do município de São Paulo, Brasil. CIENCIA & SAUDE COLETIVA 2014; 19:235-44. [DOI: 10.1590/1413-81232014191.1943] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 11/05/2012] [Indexed: 11/22/2022] Open
Abstract
O objetivo deste estudo é avaliar a distribuição espacial de nascidos vivos (NV) do município de São Paulo (MSP), verificar se há dependência espacial, identificar possíveis diferenças no perfil dos nascimentos e avaliar as distâncias percorridas entre os domicílios e os hospitais do parto. Foram estudados os NV ocorridos em hospitais de alta complexidade, quatro SUS e quatro da rede não SUS no MSP em 2008. Foram georreferenciados 46.190 NV: 48,8% em hospitais SUS e 51,2% não SUS, estes representaram 27,9% do total de NV do MSP. Os NV de hospitais SUS formaram dois aglomerados com elevada proporção de domicílios com renda de 1/2 a 2SM, concentração de favelas e altas taxas de natalidade. Os NV de hospitais não SUS formaram um aglomerado na região central do MSP, onde há elevada proporção de domicílios com renda > 10 SM e baixa natalidade. Foram encontradas diferenças estaticamente significantes das características maternas, da gestação e do parto entre os NV de hospitais SUS e não SUS e da frequência de gemelaridade. Não houve diferença na prevalência de baixo peso e pré-termo. Os resultados mostraram existir diferenciais no perfil dos aglomerados de NV, que refletem as desigualdades das condições de vida do MSP.
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Harling G, Castro MC. A spatial analysis of social and economic determinants of tuberculosis in Brazil. Health Place 2013; 25:56-67. [PMID: 24269879 DOI: 10.1016/j.healthplace.2013.10.008] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 09/30/2013] [Accepted: 10/26/2013] [Indexed: 11/20/2022]
Abstract
We investigated the spatial distribution, and social and economic correlates, of tuberculosis in Brazil between 2002 and 2009 using municipality-level age/sex-standardized tuberculosis notification data. Rates were very strongly spatially autocorrelated, being notably high in urban areas on the eastern seaboard and in the west of the country. Non-spatial ecological regression analyses found higher rates associated with urbanicity, population density, poor economic conditions, household crowding, non-white population and worse health and healthcare indicators. These associations remained in spatial conditional autoregressive models, although the effect of poverty appeared partially confounded by urbanicity, race and spatial autocorrelation, and partially mediated by household crowding. Our analysis highlights both the multiple relationships between socioeconomic factors and tuberculosis in Brazil, and the importance of accounting for spatial factors in analysing socioeconomic determinants of tuberculosis.
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Affiliation(s)
- Guy Harling
- Department of Social and Behavioral Sciences, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA.
| | - Marcia C Castro
- Department of Global Health and Population, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA 02115, USA.
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