Ana Paula Scoleze Ferrer

Causes of hospitalization among children ages zero to nine years old in the city of São Paulo, Brazil

INTRODUCTION: The profile of child morbidity is an important parameter for defining and altering health policies. Studies about infant mortality are more numerous than those on morbidity, especially related to hospital admissions. The objective of this study is to describe the causes of admission in the public health system for children from zero to nine years of age in the city of São Paulo during the years 2002 to 2006 and compare these results to those from the national data. METHOD: Through a cross-sectional study, data were obtained from the Hospital Information System, which is available in the Information System of the Unified Health System - DATASUS. RESULTS: Within the period, 16% of the total admissions corresponded to children from zero to nine years of age, with most of the children being younger than one year of age. In the city of São Paulo, the admission coefficient increased 11%, and in Brazil, it decreased 14%. Respiratory diseases were the main causes of hospitalization. In São Paulo, the second most frequent causes of admission were diseases that originated during the perinatal period (15.9%), and in Brazil, the second most frequent cause of admission was infectious-parasitic diseases (21.7%). Admissions for perinatal diseases increased 32% in São Paulo and 6% in Brazil. While hospitalizations for diarrhea decreased in Brazil, an increase was recorded in the city of São Paulo for children under five years old. CONCLUSIONS: The findings of this study show a paradoxical increase in the number of hospitalizations during an expansion of primary attention, indicating that the rise was not associated with a significant improvement in the quality of service.

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.

Determinação do tamanho do fígado de crianças normais, entre 0 e 7 anos, por ultrassonografia

OBJECTIVE: The present study was aimed at sonographically determining the liver size in healthy newborns, infants and children under 7 years of age, correlating results with age, sex, height, body weight and body mass index. MATERIALS AND METHODS: A total of 584 healthy children subdivided into 11 age groups were evaluated with measurements of the left lobe craniocaudal diameter at the midsternal line, and the craniocaudal diameter of the right lobe posterior surface at the midclavicular line. The following tests were utilized for statistical analysis: a) Pearsons correlation coefficient (correlation study); b) non-paired Students t-test (comparison of measures between sexes); c) nonlinear regression models (nomograms). RESULTS: The liver size presented a progressive growth from the birth up to the age of 7, proportionally lower than the body growth, in correlation with age, height and body weight (r > 0.70). Correlation with the body mass index was not observed (r < 0.11). There was no significant difference in liver size between male and female individuals. CONCLUSION: Liver size was sonographically determined in healthy children under the age of 7 by means of a standardized method, demonstrating a strong correlation with age and anthropometric indicators. Nomograms demonstrate the typical variations of the liver size in the population evaluated with a different growth pattern for each hepatic lobe.

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

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.

Assessment of access to primary health care among children and adolescents hospitalized due to avoidable conditions

Introduction: Hospitalizations for ambulatory care-sensitive conditions (HACSC) are considered an indicator of the effectiveness of primary health care (PHC). High rates of HACSC represent problems in the access or the quality of health care. In Brazil, HACSC rates are high and there are few studies on the factors associated with it. Objective: To evaluate the access to PHC offered to children and adolescents hospitalized due to ACSC and analyze the conditioning factors. Method: Cross-sectional study with a quantitative and qualitative approach. Five hundred and one (501) users (guardians/caregivers) and 42 professionals of PHC units were interviewed over one year. Quantitative data were obtained using Primary Care Assessment Tool validated in Brazil (PCATool-Brazil), while qualitative data were collected by semi-structured interview. The independent variables were: age, maternal education, family income, type of diagnosis, and model of care offered, and the dependent variables were access and its components (accessibility and use of services). Results: Sixty-five percent (65.2%) of hospitalizations were ACSC. From the perspective of both users and professionals, access and its components presented low scores. Age, type of diagnosis, and model of care affected the results. Conclusion: The proportion of HACSC was high in this population. Access to services is inappropriate due to: barriers to access, appreciation of the emergency services, and attitude towards health needs. Professional attitudes and opinions reinforce inadequate ideas of users reflecting on the pattern of service use.

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

Overall and Sex-Specific Associations Between Fetal Adversity and Child Development at Age 1 Year: Evidence From Brazil

Abstract A growing body of epigenetic research suggests that in-utero adaptations to environmental changes display important sex-specific variation. We tested this heterogeneous adaptation hypothesis using data from 900 children born at the University Hospital in São Paulo, Brazil, between October 2013 and April 2014. Crude and adjusting linear models were used to quantify the associations between prematurity, being small for gestational age, and children’s physical and mental development at 12 months of age. Prematurity was negatively associated with neuropsychological development in final models (z score difference, −0.42, 95% confidence intervals: −0.71, −0.14), but associations did not vary significantly by sex. For being small for gestational age, associations with height-for-age, weight-for-age, and neuropsychological development were also negative, but they were systematically larger for male than for female infants (P < 0.05 for all). These results suggest that male fetuses may be more vulnerable to intrauterine adversity than female fetuses. Further research will be needed to better understand the mechanisms underlying these sex-specific associations.