The effects of a large-scale home visiting programme for child development on use of health services in Brazil

Partnership between early childhood development interventions and primary health care services can help catalyse health care uptake by socially vulnerable families. This study aimed to assess the real-life effects of a large-scale home visiting programme [Primeira Infância Melhor (PIM)] in Brazil on the use of preventive (prenatal visits, well child visits, dentist visits and vaccination) and recovery (emergency room visits and hospitalization) health services. A quasi-experiment nested in a population-based birth cohort study was conducted. The intervention group was firstly defined as all children enrolled in PIM up to age 6 months, and afterwards stratified between those enrolled during pregnancy or after birth up to 6 months. Children receiving PIM were matched with controls on propensity scores based on 27 confounders to estimate effects on health service use from prenatal to age 2 years. Double adjustment was applied in outcome Quasi-Poisson regressions. No evidence was found for effects of PIM starting anytime up to 6 months (262 pairs), or for the children enrolled only after birth (133 pairs), on outcomes occurring after age 6 months. When the programme started during pregnancy (129 pairs), there was a 13% higher prevalence of adequate prenatal visits (prevalence ratio = 1.13; 95% confidence interval 1.01-1.27), but no effect on use of any other health service. Sensitivity analyses suggested longer participation in the programme with reduced visitor turnover might improve its impact on prenatal visits. Integration between PIM and primary health care was not adequate to affect overall patterns of contacts with health services. Nevertheless, prenatal home visits showed potential to increase health service contact during a sensitive period of development, indicating the need to start such programmes before birth, when there is more time for maternal care, and family engagement in a network of services is facilitated.

Towards a better understanding of real-world home-visiting programs: a large-scale effectiveness study of parenting mechanisms in Brazil

BACKGROUND

The scale-up of parenting programmes to support early childhood development (ECD) is poorly understood. Little is known about how and when early interventions are most effective. Sustainability of ECD programming requires a better understanding of the mechanisms of real-world interventions. We examined the effects on caregiving practices of Primeira Infância Melhor (PIM), a state-wide home-visiting programme in Brazil.

METHODS

This propensity score matched, longitudinal, quasiexperimental study uses data from the 2015 Pelotas Birth Cohort. We matched children who received PIM at any age with other cohort children on 25 key covariates. Sensitivity, guidance and responsiveness were assessed using video-recorded play tasks. Coerciveness and the parent-child relationship were assessed using the Parenting and Family Adjustment Scales. All parenting outcomes were examined at age 4 years. Separate moderation analyses were conducted for each effect modifier: family income, child age and duration of participation.

RESULTS

Out of 4275 children in the cohort, 797 were enrolled in PIM up to age 4 years. 3018 children (70.6%) were included in the analytic sample, of whom 587 received PIM and 2431 were potential controls. We found a positive effect of PIM on responsiveness (β=0.08, 95% CIs 0.002 to 0.16) and sensitivity (β=0.10, 95% CIs 0.02 to 0.19). No effect was found for any secondary outcomes. Moderation analyses revealed a stronger positive effect on sensitivity for low-income parents (β=0.18, 95% CIs 0.03 to 0.34).

CONCLUSION

A state-wide, home-visiting programme in Brazil improved aspects of responsive caregiving. Effects were more pronounced for low-income families, suggesting benefits of purposeful targeting.

Viral coinfection in hospitalized patients during the COVID-19 pandemic in Southern Brazil: a retrospective cohort study

PURPOSE

Since the worldwide spread of SARS-CoV-2, different strategies have been followed to combat the pandemic and limit virus transmission. In the meantime, other respiratory viruses continued to circulate, though at decreased rates.

METHODS

This study was conducted between June and July 2022, in a hospital in the metropolitan region of Rio Grande do Sul state, in the southernmost state of Brazil. The 337 hospitalized patients included those with respiratory symptoms without delimitation of age. Reverse transcription-quantitative real-time polymerase chain reaction detected 15 different respiratory viruses and confirmed coinfections in the samples. Different statistical tests were applied to evaluate the association between associations of clinical characteristics and coinfection.

RESULTS

Sampling corresponds to 337 selected and 330 patients analyzed. The principal clinical outcome found was hospital discharge in 309 (94%) cases, while 21 (6%) resulted in death. The principal viral agents related to coinfections were Human rhinovirus, Human enterovirus, and Respiratory syncytial virus. The most frequent viral agent detected was SARS-CoV-2, with 60 (18%) infections, followed by 51 (15%) cases of Respiratory syncytial virus B (15%) and 44 (13%) cases of Human rhinovirus 1. Coinfection was mainly observed in children, while adults and the elderly were more affected by a single infection. Analyzing COVID-19 vaccination, 175 (53%) were unvaccinated while the remainder had at least one dose of the vaccine.

CONCLUSIONS

This study presents information to update the understanding of viral circulation in the region. Furthermore, the findings clarify the behavior of viral infections and possible coinfections in hospitalized patients, considering different ages and clinical profiles. In addition, this knowledge can help to monitor the population's clinical manifestations and prevent future outbreaks of respiratory viruses.

Effects of the Pelotas (Brazil) Peace Pact on violence and crime: a synthetic control analysis

Background

City-led interventions are increasingly advocated to achieve the UN's Sustainable Development Goal to reduce violence for all. We used a new quantitative evaluation method to examine whether a flagship programme, called the "Pelotas Pact for Peace" (the Pacto), has been effective in reducing violence and crime in the city of Pelotas, Brazil.

Methods

We used synthetic control methodology to assess the effects of the Pacto from August 2017 to December 2021, and separately before and during the COVID-19 pandemic. Outcomes included monthly rates of homicide and property crime, and yearly rates of assault against women and school drop-out. We constructed synthetic controls (counterfactuals) based on weighted averages from a donor pool of municipalities in Rio Grande do Sul. Weights were identified using pre-intervention outcome trends and confounders (sociodemographics, economics, education, health and development, and drug trafficking).

Findings

The Pacto led to an overall 9% reduction in homicide and 7% reduction in robbery in Pelotas. These effects were not uniform across the full post-intervention period as clear effects were only seen during the pandemic period. A 38% reduction in homicide was also specifically associated with the criminal justice strategy of Focussed Deterrence. No significant effects were found for non-violent property crimes, violence against women, and school dropout, irrespective of the post-intervention period.

Interpretation

City-level interventions that combine public health and criminal justice approaches could be effective in tackling violence in Brazil. Continued monitoring and evaluation efforts are increasingly needed as cities are proposed as key opportunities for reducing violence for all.

Funding

This research was funded by the Wellcome Trust [grant number: 210735_Z_18_Z].

Obesity and COVID-19 in-hospital fatality in southern Brazil: impact by age and skin color

OBJECTIVES

To estimate the relative risk (RR) of death associated with obesity, the attributable fraction in the exposed/with obesity (AF_o), and the hospitalized population attributable risk (hospitalized PAR) associated with obesity of death among all adults and among Black and non-Black adults hospitalized for severe COVID-19 in the state of Rio Grande do Sul, Brazil.

METHODS

This retrospective cohort study of prognostic factors analyzed all cases of adults hospitalized for severe COVID-19 in the state of Rio Grande do Sul, Brazil. The occurrence of obesity was measured using secondary data from hospital teams’ surveillance records. The outcome assessed was hospital deaths caused by severe COVID-19. Poisson regression was used to estimate RRs and 95% confidence intervals (95%CI).

RESULTS

The study sample consisted of 100,099 patients hospitalized for severe COVID-19, most of whom were White (84.7%) and male (54.7%). The effect of obesity was strongly modified by age, being higher in younger age groups. For the 18–39-year-old age group, RR = 2.54 (95%CI: 2.33–2.77), and in individuals 70 years and above, RR = 1.09 (95%CI: 1.05–1.13). For the 18–39-year-old age range, AF_o = 60.6% and AF_o = 42.5% in individuals 40–59 years old. For all hospitalizations, Hospitalized PAR measuring obesity for individuals 18–39 years old was 25.3%, while in the 40–59-year-old range, the hospitalized PAR = 11.2%. The hospitalized PAR was 31.7% in the Black population aged 18–39 years and 24.8% in non-Blacks. The hospitalized PAR was also larger in Blacks aged 40-59 years.

CONCLUSIONS

Obesity largely impacted in-hospital case-fatality rates among young adults and Black people contaminated by COVID-19. These data highlight the extent of the risk concerning obesity, a highly prevalent chronic condition.

Effectiveness of a large-scale home visiting programme (PIM) on early child development in Brazil: quasi-experimental study nested in a birth cohort

BACKGROUND

A large-scale parenting programme with weekly home visits (Primeira Infância Melhor (PIM)) has been implemented in the south of Brazil for nearly two decades, but lacks evaluation of its effects on early childhood development (ECD). This quasi-experimental study aimed to assess the effects of PIM in real-life settings within a population-based birth cohort study.

METHODS

Data from the 2015 Pelotas Birth Cohort Study and the state programme information system were linked to identify study children who received PIM. Propensity score matching was used to create a comparable control group (using one-to-one matching) to estimate the effect of PIM on ECD measured at age 4 years. First, the impact of any enrolment in PIM was evaluated; then the intervention group was stratified according to whether enrolment occurred during pregnancy or after birth. Double adjustment was applied in linear regression to analyse child development scores, and Poisson regression for delayed development (below the 10th percentile of whole cohort). Effect modification due to family income was explored.

RESULTS

There was no evidence that any enrolment in PIM (601 pairs) by age 4 years was associated with child development. However, PIM starting during pregnancy (estimated for 121 pairs) predicted higher development scores (0.27 SD; 95% CI 0.02 to 0.52), and 71% lower prevalence of delayed development (prevalence ratio=0.29; 95% CI 0.13 to 0.69), compared with the control group. There was strong statistical evidence (p=0.003, test of interaction) that the effect of PIM starting in pregnancy was larger than when starting after birth (480 pairs). The effect of PIM starting during pregnancy was found to be restricted to poorer families.

CONCLUSIONS

In a real-life setting, PIM was effective only when starting during pregnancy and only for poorer families. A higher-quality programme might be more effective with a broader population.

Identificação das Regiões de Saúde do Rio Grande do Sul, Brasil, prioritárias para ações de Vigilância em Saúde

Resumo O presente artigo identifica as Regiões de Saúde do Rio Grande do Sul (RS) prioritárias com vistas a implementar ações para o fortalecimento da Vigilância em Saúde. Estudo descritivo com dados da série histórica de 11 (onze) indicadores de Vigilância em Saúde do Caderno de Diretrizes, Objetivos, Metas e Indicadores 2016, do Ministério da Saúde pactuados pela Comissão Intergestores Bipartite/RS. Os indicadores selecionados são sintetizados para produzir um Indicador Composto de Avaliação da Vigilância em Saúde (ICAVES) para cada uma das 30 Regiões de Saúde do estado, criando valores que variam de 0 (pior) a 1 (melhor), tendo como método de cálculo o utilizado para a construção do Índice de Desenvolvimento Humano (IDH). Os menores índices do indicador composto estão nas Regiões de Saúde: 20-Rota da Produção e 19-Região do Botucaraí. As Regiões de Saúde 20 e 19 são prioritárias para o fortalecimento das ações de âmbito coletivo da Vigilância em Saúde e o gerenciamento de riscos e agravos à saúde considerando a equidade horizontal como diretriz do Sistema Único de Saúde.