Alexandra Brentani

The effects of a people-centred model on longitudinality of care and utilization pattern of healthcare services—Brazilian evidence

Brazil is experiencing a time of change in pattern of care: from ‘traditional’ to Family Health Strategy (FHS), a model guided by the principles of people, family and community-centred medicine. The heterogeneity in care currently offered affects the primary care impact. This study aims to evaluate the longitudinality of care and correlate this primary care principle to the utilization pattern of care among patients hospitalized due to preventable conditions, comparing the two care models currently offered in Brazil. It is a cross-sectional, analytical and descriptive study with a quantitative approach. The sample consisted of 501 patients from 0 to 14 years old. Data was collected in 2011 and the Primary Care Assessment Tool (PCATool-Brazil) child version was used. Bivariate and multivariate analyses were performed including patient-related variables (age, maternal education, income and type of diagnosis) and care model. From the hospitalizations occurred during the period, 65.2% were Ambulatory Care Sensitive Conditions. Patients evaluated ‘longitudinality’ as regular. Both the care continuity dimension and the utilization pattern of care services showed a link with the care model offered. Findings suggest that the FHS care model, based on the assumptions of people-centred medicine, was associated with better ratings of care continuity, which was reflected in a more appropriate utilization pattern of care services.

No Association between Low Birth Weight and Cardiovascular Risk Factors in Early Adulthood: Evidence from Sao Paulo, Brazil

Background A growing literature suggests that low birth weight increases the risk of poor health outcomes in adulthood. We tested this hypothesis among young adults living in São Paulo State, Brazil. Methods and Findings To identify the effects of low birth weight on young adulthood outcomes, a medical assessment of 297 individuals born between 1977 and 1989 was conducted at a primary care unit in São Paulo State, Brazil. We analyzed body mass index (BMI), waist-hip ratio, blood pressure, fasting glucose and total cholesterol levels using linear and logistic regressions. Low birth was negatively associated with BMI (β = −2.0, 95% CI: −3.69, −0.27, p = 0.02), fasting glucose levels (β = −1.9, 95% CI: −3.9, −0.07, p = 0.05), waist-hip ratio (β = −0.03, 95% CI: −0.07, −0.01, p = 0.10), systolic blood pressure (β = −3.32, 95% CI: −7.60, 0.96, p = 0.12), and total cholesterol levels (β = −3.19, 95% CI: −16.43, 10.05, p = 0.636). Low birth weight was also associated with lower odds of young adults being overweight and obese, but neither association was statistically significant. Weight gain in the first 12 months of life was associated with higher adult BMI (β = 0.79, 95% CI: −0.0455, 1.623, p = 0.064) and blood pressure (β = 2.79, 95% CI: 0.22, 5.35, p = 0.034). No associations were found between low birth weight and early life (catch-up) growth. Conclusions Low birth weight was not associated with poor health outcomes among young adults in Brazil. These results appear inconsistent with the original Barker hypothesis, but will need to be corroborated in larger samples with longer follow-ups to allow a more general evaluation of the validity of the hypothesis in low and middle income countries.

Georeferenced and secure mobile health system for large scale data collection in primary care

INTRODUCTION Mobile health consists in applying mobile devices and communication capabilities for expanding the coverage and improving the effectiveness of health care programs. The technology is particularly promising for developing countries, in which health authorities can take advantage of the flourishing mobile market to provide adequate health care to underprivileged communities, especially primary care. In Brazil, the Primary Care Information System (SIAB) receives primary health care data from all regions of the country, creating a rich database for health-related action planning. Family Health Teams (FHTs) collect this data in periodic visits to families enrolled in governmental programs, following an acquisition procedure that involves filling in paper forms. This procedure compromises the quality of the data provided to health care authorities and slows down the decision-making process. OBJECTIVES To develop a mobile system (GeoHealth) that should address and overcome the aforementioned problems and deploy the proposed solution in a wide underprivileged metropolitan area of a major city in Brazil. METHODS The proposed solution comprises three main components: (a) an Application Server, with a database containing family health conditions; and two clients, (b) a Web Browser running visualization tools for management tasks, and (c) a data-gathering device (smartphone) to register and to georeference the family health data. A data security framework was designed to ensure the security of data, which was stored locally and transmitted over public networks. RESULTS The system was successfully deployed at six primary care units in the city of Sao Paulo, where a total of 28,324 families/96,061 inhabitants are regularly followed up by government health policies. The health conditions observed from the population covered were: diabetes in 3.40%, hypertension (age >40) in 23.87% and tuberculosis in 0.06%. This estimated prevalence has enabled FHTs to set clinical appointments proactively, with the aim of confirming or detecting cases of non-communicable diseases more efficiently, based on real-time information. CONCLUSION The proposed system has the potential to improve the efficiency of primary care data collection and analysis. In terms of direct costs, it can be considered a low-cost solution, with an estimated additional monthly cost of U

Cost-effectiveness analysis of cisplatin-based chemoradiation to treat patients with unresectable, nonmetastatic head and neck cancer in Brazil.

0.040 per inhabitant of the region covered, or approximately U

Sex differences in DNA methylation of the cord blood are related to sex-bias psychiatric diseases

0.106 per person, considering only those currently enrolled in the system.

A pilot study of a Community Health Agent-led type 2 diabetes self-management program using Motivational Interviewing-based approaches in a public primary care center in Sao Paulo, Brazil

The purpose of this study was to analyze the cost‐effectiveness of cisplatin‐based chemoradiation compared to radiation therapy (RT) alone to treat patients with advanced head and neck cancer in Brazil.

Rollout of community-based family health strategy (programa de saude de familia) is associated with large reductions in neonatal mortality in São Paulo, Brazil

Sex differences in the prevalence of psychiatric disorders are well documented, with exposure to stress during gestation differentially impacting females and males. We explored sex-specific DNA methylation in the cord blood of 39 females and 32 males born at term and with appropriate weight at birth regarding their potential connection to psychiatric outcomes. Mothers were interviewed to gather information about environmental factors (gestational exposure) that could interfere with the methylation profiles in the newborns. Bisulphite converted DNA was hybridized to Illumina HumanMethylation450 BeadChips. Excluding XYS probes, there were 2,332 differentially methylated CpG sites (DMSs) between sexes, which were enriched within brain modules of co-methylated CpGs during brain development and also differentially methylated in the brains of boys and girls. Genes associated with the DMSs were enriched for neurodevelopmental disorders, particularly for CpG sites found differentially methylated in brain tissue between patients with schizophrenia and controls. Moreover, the DMS had an overlap of 890 (38%) CpG sites with a cohort submitted to toxic exposition during gestation. This study supports the evidences that sex differences in DNA methylation of autosomes act as a primary driver of sex differences that are found in psychiatric outcomes.

Time to change focus? Transitioning from higher neonatal to higher stillbirth mortality in São Paulo State, Brazil

BackgroundRates of noncommunicable diseases (NCDs) such as type 2 diabetes are escalating in low and middle-income countries such as Brazil. Scalable primary care-based interventions are needed to improve self-management and clinical outcomes of adults with diabetes. This pilot study examines the feasibility, acceptability, and outcomes of training community health agents (CHAs) in Motivational Interviewing (MI)-based counseling for patients with poorly controlled diabetes in a primary care center in São Paulo, Brazil.MethodsNineteen salaried CHAs participated in 32 h of training in MI and behavioral action planning. With support from booster training sessions, they used these skills in their regular monthly home visits over a 6 month period with 57 diabetes patients with baseline HbA1cs > 7.0%. The primary outcome was patients’ reports of the quality of diabetes care as measured by the Portuguese version of the Patient Assessment of Chronic Illness Care (PACIC) scale. Secondary outcomes included changes in patients’ reported diabetes self-management behaviors and in A1c, blood pressure, cholesterol and triglycerides. We also examined CHAs’ fidelity to and experiences with the intervention.ResultsPatients reported improvements over the 6 month period in quality of diabetes care received (PACIC score improved 33 (+/−19) to 68 (+/−21) (p < .001)). They reported increases in physical activity (p = .001), consumption of fruits and vegetables (p < .001) and medication adherence (p = .002), but no decreases in consumption of high-fat foods (p = .402) or sweets (p = .436). Participants had mean 6-month A1c levels 0.34% points lower than at baseline (p = .08) and improved mean LDL (−16.1 mg/dL, p = .005) and triglyceride levels (−38.725 mg/dL, p = .002). Of the 16 CHAs observed in fidelity assessments, 13 were categorized as medium- or high-performing on MI skills, while 3 were low-performing. CHAs expressed enthusiasm about learning new skills, and many described a shift from advice-giving to encouraging patients to define their own goals.ConclusionIn resource-scarce settings, it is essential to fully utilize existing primary care resources to stem the epidemic of diabetes and other NCDs. Our pilot results support the potential of training CHAs to incorporate effective diabetes self-management support into their routine patient encounters.Trial registrationNCT02994095 12/14/2016 Registered retrospectively.

Perspectives and experiences of community health workers in Brazilian primary care centers using m-health tools in home visits with community members

Rationale Several recent studies suggest that Brazil’s Estratégia Saude de Familia (Family Health Strategy-FHS) has contributed to declines in mortality at the national and regional level. Comparatively little is known whether this approach is effective in urban populations with relatively easy access to health services. Objectives To use detailed medical data collected as part of São Paulo’s Western Region project to examine whether the FHS program had an impact on child health in São Paulo, Brazil. Results No associations were found between FHS and birth weight (OR 1.03, 95% CI 0.93–1.29), gestational length (OR 0.98, 95% CI 0.83–1.15) or stillbirth (OR 1.51, 95% CI 0.75–3.03). FHS eligibility was associated with a 42% reduction in the odds of child mortality (OR 0.58, 95% CI 0.34, 0.91), with largest effect sizes for the early neonatal period (OR 0.18, 95% CI 0.04–0.79). Conclusions Community based health delivery platforms may be a highly effective way to reduce neonatal mortality in urban areas of low and middle income countries, even when access to general health services is almost universal.

Perinatal Mortality, maternal age and Adverse birth Outcomes in Brazil

Background Differential trends in mortality suggest that stillbirths may dominate neonatal mortality in the medium to long run. Brazil has made major efforts to improve data collection on health indicators at granular geographic levels, and provides an ideal environment to test this hypothesis. Our goals were to examine levels and trends in stillbirths and neonatal deaths and the extent to which the mortality burden caused by stillbirths dominates neonatal mortality at the municipality- and state-level. Methods We used data from the Brazilian Ministry of Health’s repository on births, fetal, and neonatal deaths (2010–2014) to calculate stillbirth and neonatal mortality rates for São Paulo state’s 645 municipalities. Results At the state level, 7.9 per 1000 pregnancies ended in stillbirth (fetal death >22 weeks gestation or fetal weight >500g), but this varied from 0.0 to 28.4 per 1000 across municipalities. 7.9 per 1000 live births also died within the first 28 days. 42% of municipalities had a higher stillbirth rate than neonatal mortality rate, and in 61% of areas with low neonatal mortality (<8.0 per 1000), stillbirth rates exceeded neonatal mortality rates. Conclusions This analysis suggests large variability and inequality in mortality outcomes at the sub-national level. The results also imply that stillbirth mortality may exceed neonatal mortality in Brazil and similar settings in the next few decades, which suggests a need for a shift in policy. This work further underscores the importance of continued research into causes and prevention of stillbirth.