Camila Giugliani

Evaluation of the Impact of the Baby-Friendly Hospital Initiative on Rates of Breastfeeding

The Baby-Friendly Hospital Initiative (BFHI) is based on the Ten Steps to Successful Breast-Feeding, a program which summarize the practices that maternity wards need to adopt to support breastfeeding.1 There are more than 16 000 Baby-Friendly Hospitals throughout the world, and of these, more than 200 are located in Brazil. Despite the abundance of studies evaluating each of the 10 steps or a combination of them, information on the impact of BFHI on the duration of breastfeeding is limited. Recently, a large randomized controlled trial including 31 hospitals in Belarus showed that an intervention based on BFHI principles increased breastfeeding rates, especially exclusive breastfeeding.2 The present study reproduced these results using a less complex study design.

Physiopathological Aspects of Corpus Luteum Defect in Infertile Patients with Mild/Minimal Endometriosis

AbstractPurpose: We describe a physiopathological model to the luteal insufficiency of infertile patients with mild/minimal endometriosis with normal hormone measurements in the early follicular phase. Methods: We designed a case-control study with 24 patients, 14 fertile with in-phase endometrium (control group) and 10 infertile with mild/minimal endometriosis and luteal insufficiency (study group). The histologic dating of endometrium was performed during cycle days 23–25 and serum TSH, FSH, LH, prolactin, and estradiol levels were measured during the early follicular phase (cycle day 3). Progesterone serum levels were measured in three different occasions during the luteal phase. Results: Patients with out-of-phase endometrium have lower estradiol levels (P = 0.031) and decreased progesterone secretion (P = 0.012) during the late luteal phase. Serum prolactin, TSH, FSH, and LH levels were similar between the groups (P > 0.05). Conclusions: The physiopathology of luteal phase defect in infertile patients with mild/minimal endometriosis is associated with a small and large luteal cells dysfunction, characterized by abnormal follicular phase (lower estradiol serum levels) and lower progesterone LH-dependent secretion.

Effectiveness of community health workers in Brazil: a systematic review.

The objective of this study is to assess the effectiveness of community health workers (CHWs) in Brazil. This systematic review included all studies that sought to assess interventions involving CHWs. Despite the low quality of evidence for most outcomes, analysis of the 23 publications included often found benefit for CHW intervention, best documented for frequency of child weighing, prevalence of breast-feeding, and delayed introduction of bottle-feeding. These findings and the current major role CHWs play in Brazil suggest that clarifying the benefit of CHW actions across a broad range of health care interventions should be a major research priority.

The impact of breast reduction surgery on breastfeeding performance.

The impact of reduction mammoplasty surgery on breastfeeding performance was measured comparing a group of 49 Brazilian women who had undergone breast reduction surgery using transposition techniques with 96 controls. As determined by survival analysis, the women who underwent reduction mammoplasty had a significantly shorter time of breastfeeding duration. The prevalence of exclusive breastfeeding at 1 and 4 months was 21% and 4%, respectively, for women with surgery, and 70% and 22%, respectively, for controls (P < .001). The prevalence of any breastfeeding at 1, 6, and 12 months was 58%, 16%, and 10% for women with mammoplasty, and 94%, 58%, and 42% for controls (P < .001). For women with surgery, the median duration of exclusive and any breastfeeding was 5 days and 2 months, respectively, and 3 months and 6 months for controls. The results of this study suggest that breast reduction surgery may have a negative impact on breastfeeding performance. J Hum Lact. 19(1):43-49. Impacto de la cirugía de reducción del seno en la lactancia materna El impacto de la cirugía mamoplastia de reducción en la lactancia materna se midió comparando un grupo de 49 brasileñas que habían tenido cirugía de reducción del seno utilizando las técnicas de transposición con 96 controles. Determinado por análisis de supervivencia, las mujeres que tuvieron la mamoplastia de reducción mostraron una duración mas corta de la lactancia materna. La prevalencia de la lactancia al 1 y 4 meses fue de 21% y 4% respectivamente para mujeres con cirugía, y 70% y 22% respectivamente para los controles (P < .001). La prevalencia de lactancia al 1, 6 y 12 meses fue de 58%, 16% y 10% para mujeres con mamoplasia, y 94%, 58% y 42% para los controles (P < .001). Las mujeres con cirugía mostraron una media en la duración de la lactancia materna exclusiva y algo de lactancia de 5 días y 2 meses respectivamente, y 3 meses y 6 meses para los controles. Los resultados de este estudio sugieren que la cirugía de reducción del seno tiene un impacto negativo en la lactancia materna.

The impact of a short-term intervention using the WHO guidelines for the management of severe malnutrition at a rural facility in Angola

Objective To measure the impact of practice review and in-service supervision based on WHO guidelines on outcomes of severely malnourished children in a rural facility with minimal resources staffed only by nurses. Design Intervention (January to August 2006) with historical comparison of outcomes (January to August 2005). Setting Therapeutic feeding centre in rural Angola. Patients All children admitted to the feeding centre during the study period. Intervention Médecins Du Monde implemented an intervention that consisted of weekly physician supervision of staff activities and establishment of a study group composed of nurses in the centre. Main outcome measures Routine practices in the centre and measured indicators for outcomes of admitted children, which were compared to indicators before the intervention. Results During the intervention the authors observed improved delivery of important tasks such as frequent feeding and avoidance of intravenous rehydration. Among the 379 children admitted during the intervention, compared to the 358 children admitted previously, successful treatment increased from 73.2% to 82.6% (RR 1.13; 95% CI 1.04 to 1.22) and fatalities decreased from 15.6% to 8.7% (RR 0.56; 95% CI 0.37 to 0.83). Conclusion This short-term intervention with in-service supervision based on the WHO guidelines in a setting of limited resources apparently contributed to a reduction in fatality rates. These findings support the view that such guidelines can be effectively implemented in under-resourced facilities in Angola and similar settings if they are introduced using an interactive approach and if in-service supervision continues to be provided.

Inclusion of medical genetics in primary health care: report of a pilot project in Brazil

Over the past few decades, several advances have been made in our knowledge of the genetic basis of diseases, prompting particular attention to the prevention and control of this determinant and to the adequate management of those affected or at risk of developing genetic conditions. The causes of genetic disease are manifold, and a variety of approaches are thus required for their prevention and to ensure better care of patients and families. In 2000, the World Health Organization (WHO) proposed that interventions for prevention and control of genetic disorders and congenital malformations should be added to the primary health care (PHC) framework (WHO 2000). The main characteristic of PHC is its status as the first contact to the health system, providing comprehensive, continuous care over time and coordinating the care received by individuals and families at the various points of care throughout the health system. Other defining characteristics of PHC include its family- and community-oriented nature and cultural competence (Starfield 1992). At the interface between genetics and PHC is the field of community genetics. In 1998, Leo ten Kate defined community genetics as “bringing genetic services to the community as a whole.” (ten Kate 1998) The author later expanded this definition, describing community genetics as “the art and science of the responsible and realistic application of health and disease-related genetics and genomics knowledge and technologies in human populations and communities to the benefit of individuals therein. Community genetics is multi-, inter- and transdisciplinary and aims to maximize benefits while minimizing the risk of harm, respecting the autonomy of individuals and ensuring equity” (ten Kate et al. 2010). Within this context, several efforts have been made in the direction of integrating basic knowledge of genetics into the framework of PHC. Education is viewed as the key for preparing primary care providers for a reality in which genetics will be present in the daily routine of health care and disease prevention (Khoury 2003). Genetic diseases contribute significantly to the population-wide disease burden, and primary care providers have an important role to play in their prevention and in the identification of patients that could benefit from referral to medical genetics services, as they will remain responsible for the care of these patients throughout the life course (Burke and Emery 2002). In 2009, the Brazilian government published its national policy for comprehensive clinical genetics care (Brasil 2009). This policy includes both specialty medical genetics care and primary care. In the latter setting, the policy provides for identification and follow-up of families with conditions related to congenital anomalies and genetically determined diseases. The objective of this study was to ascertain whether implementation of a medical genetics education program produced for primary care providers could contribute to the integration of concepts and attitudes related to the identification, management, and prevention of congenital malformations and genetic diseases into the care provided at primary health care units.

Community health workers programme in Luanda, Angola: an evaluation of the implementation process

BackgroundThe Community Health Workers (CHWs) Programme was launched in Luanda, Angola, in 2007 as an initiative of the provincial government. The aim of this study was to assess its implementation process.MethodsThis is a case study with documental analysis, CHWs reports data, individual interviews and focus groups.ResultsUntil June 2009, the programme had placed in the community 2,548 trained CHWs, providing potential coverage for 261,357 families. Analysis of qualitative data suggested an association of CHWs with improvements in maternal and child access to health care, as well as an increase in the demand for health services, generating further need to improve service capacity. Nevertheless, critical points for programme sustainability were identified.ConclusionsFor continuity and scaling up, the programme needs medium- and long-term technical, political and financial support. The results of this study may be useful in strengthening and reformulating the planning of the CHWs programme in Luanda and in Angola. Moreover, the lessons learned with this experience can also provide insight for the development of CHWs programmes in other parts of the world. By means of cooperation, Brazil has supported the implementation of this CHWs programme and can potentially contribute to its improvement.ResumoIntroduçãoO Programa de Agentes Comunitários de Saúde (PACS) de Luanda iniciou em Luanda, Angola, em 2007, como iniciativa do governo provincial. O objetivo deste estudo foi avaliar o seu processo de implantação.MétodosRealizamos um estudo de caso com análise documental, registros das fichas de avaliação dos ACS, entrevistas individuais e grupos focais.ResultadosAté junho de 2009, o PACS de Luanda chegou a 2.548 ACS treinados, proporcionando cobertura potencial para 261.357 famílias. Por meio dos dados qualitativos, observou-se associação do ACS com ampliação do acesso aos cuidados de saúde, principalmente de mães e crianças, e aumento da demanda nos serviços de saúde, gerando necessidade de maior capacidade de resposta. No entanto, pontos críticos em relação à sustentabilidade do programa foram identificados.ConclusõesPara sua continuidade e ampliação, o Programa precisa de suporte técnico e apoio político e financeiro a médio e longo prazo. Os resultados deste estudo podem ser direcionados para reforçar e reformular o planejamento das ações do PACS de Luanda e de Angola. Além disso, os aprendizados que partem desta experiência podem servir de subsídio para o desenvolvimento de programas de ACS em outras partes do mundo. Por meio da cooperação, o Brasil apoiou a implantação do PACS de Luanda e tem potencial para contribuir na sua evolução.

How to stop public health conferences becoming trade fairs

Reflecting the new wave of global public health, which now seems to be finally reoriented towards embracing its social mission and responsibilities, the 12th World Congress on Public Health, recently held in Istanbul, dedicated many of its sessions to ethics and the right to health. Indeed, the Congress title, ‘Making a Difference in Global Public Health: Education, Research and Practice’, sounded like a call to action. But faultless theory and socially responsible statements, set out and declared in Istanbul, were accompanied by corporate sponsorship which we see as inappropriate, and sessions that were in conflict with the interests of public health. This commentary reflects the views of a number of participants at the Congress about the corporate influence on public health conferences and, more generally, inappropriate corporate influence on public health teaching, research and practice.

Prevalence of use and potential impact of increased use of primary care interventions to prevent cardiovascular hospitalizations in patients with diabetes.

AIMS To estimate the reduction in hospitalizations due to cardiovascular complications of diabetes which could result from greater use of interventions of known effectiveness in a primary health care setting. METHODS In a representative survey of adults with diabetes in Porto Alegre, Brazil, we estimated current prevalence of interventions use (metformin, hypertension control, ACE inhibitors, statins, influenza vaccination, cardioprotective diet) and hospitalization rate. We calculated absolute risk reductions for interventions by applying relative risk reductions derived from literature to the baseline cardiovascular hospitalization rate. Increments in interventions use were obtained by subtracting current use prevalences from potential targets. We then modelled the number of diabetic patients needing primary health care coverage to prevent 1 hospitalization (disease impact number; DIN) and the total number of hospitalizations that might be prevented through this increased use. RESULTS In 5 years, for every 100 diabetic patients in the community, we ascertained 30 cardiovascular hospitalizations. Large gaps were observed between target and current use of interventions. With greater implementation, 48% of cardiovascular hospitalizations could possibly be prevented. CONCLUSIONS Major reduction in hospitalizations due to cardiovascular complications of diabetes could possibly be obtained through optimized use of effective treatments in primary health care settings such as this.

Validation of a tool to evaluate women's satisfaction with maternal breastfeeding for the Brazilian population

OBJECTIVE To perform the construct validity and the internal consistency of the Maternal Breastfeeding Evaluation Scale tool, aiming at its application in the Brazilian population. METHODS Cross-sectional study that applied the tool to 287 Brazilian women 30 days after childbirth. Main component analysis with varimax rotation was used for the factor analysis, verifying the number of subscales and the maintenance or extraction of the components. Four hypotheses were tested using the unpaired Students t-test for construct validation. The reliability analysis was performed using Cronbachs alpha coefficient. RESULTS The exploratory factor analysis identified the need to exclude an item and to reformulate the subscales. The results of the construct validity showed that all hypotheses proposed were confirmed: women who were breastfeeding, those who were exclusively breastfeeding, those who did not have problems related to breastfeeding, and those who intended to breastfeed for at least 12 months achieved significantly higher mean values in the scale. The tool showed adequate internal consistency (Cronbachs alpha=0.88, 95% CI: 0.86-0.90), as did the pleasure and fulfillment of the maternal role subscales (0.92, 95% CI: 0.91-0.93%); child growth, development, and satisfaction (0.70; 95% CI: 0.65-0.75); and maternal physical, social, and emotional aspects (0.75, 95% CI: 0.70-0.79). CONCLUSIONS The validation process of the Brazilian version of the Maternal Breastfeeding Evaluation Scale tool showed that it is valid and reliable tool to be applied to the Brazilian population.