Carla Lourenço Tavares de Andrade

Saúde da família: limites e possibilidades para uma abordagem integral de atenção primária à saúde no Brasil

The article analyzes the implementation of the Family Health Strategy (FH) and discusses its potential to guide the organization of the Unified Health System in Brazil, based on the integration of FH to the health care network and intersectorial action, crucial aspects of a comprehensive primary health care. Four case studies were carried out in cities with high FH coverage (Aracaju, Belo Horizonte, Florianopolis e Vitoria), using as sources: semi-structured interviews with managers and surveys with health care professionals and registered families. The integration analysis highlighted the position of FH Strategy in the health services network, the integration mechanisms and the availability of information for continuity of care. Intersectoriality was researched in relation to the fields of action, scope, sectors involved, presence of forums, and team initiatives. The results point to advances in the integration of FH to the health care network, strengthening basic services as services that are regularly sought and used as a preferential first contact services, although there are still problems in the access to specialized care. The intersectorial initiatives were broader when defined as integrated municipal government policy for the construction of interfaces and cooperation between the diverse sectors.

Estimação da mortalidade infantil no Brasil: o que dizem as informações sobre óbitos e nascimentos do Ministério da Saúde?

A methodological approach to infant mortality estimation in Brazil based on vital information provided by Ministry of Health systems is presented. The study evaluated the available data to establish criteria for identifying municipalities with serious data deficiencies, proposing an adequacy index. All municipalities were classified in strata according to geographic region and adequacy of information. To estimate infant mortality by macro-geographic region, in 1998, direct calculation was performed in strata with adequate information. The United Nations model was used in the other geographic strata. The Brazilian North presented the most deficient information, with 63% of the municipalities presenting inadequate reporting (35% of the regional population), followed by the Northeast (29% of the population). In the South, only 1% of the population showed inadequate information. For the whole country, 12% of the population presented serious problems in completeness of death reports. The adequacy index varied from -28% in Maranhão to 94% in Rio de Janeiro. The infant mortality rate was estimated in the interval 30.7-32.6 per 1,000 live births and the completeness of infant deaths from 61.8% to 65.6%.

Income inequality, residential poverty clustering and infant mortality: a study in Rio de Janeiro, Brazil

In this paper, we propose an approach to investigate the hypothesis that the residential concentration of poverty affects health status more deeply than when poverty is randomly scattered in a given geographical area. To characterize the geographic pattern of poverty in the city of Rio de Janeiro, Brazil, an index that measures the heterogeneity of poverty concentration among sub-areas was proposed. We used census data and defined poverty by means of the household head monthly income. The 153 neighborhoods that compose the city were used as the geographic units, and the census tracts as the sub-areas. The proposed index measures differences of poverty concentration across census tracts within a neighborhood. The effects of geographic poverty clustering on infant mortality related variables (early neonatal mortality rate; post-neonatal mortality rate; proportion of adolescent mothers; and fertility rate among adolescents) were estimated by partial correlation coefficients, controlling for the neighborhood poverty rate. Our study revealed that intra-city variations of the post-neonatal mortality rate are associated with geographic patterns of poverty, and that pregnancy in adolescence is strongly and contextually correlated with intra-neighborhood poverty clustering, even after adjustment for the poverty rate. The evidence of relevant health differences associated with the spatial concentration of poverty supports the hypothesis that properties of the environment of residence contextually influence health. Our findings suggest that prevention of some infant mortality related problems has to be focused directly on features of communities, considering their physical, cultural and psychosocial characteristics, being of particular concern the health of communities segregated from the society at large by extreme poverty.

Desigualdades sócio-espaciais da adequação das informações de nascimentos e óbitos do Ministério da Saúde, Brasil, 2000-2002

This study analyzed socio-spatial inequalities in the adequacy of Ministry of Health data systems on live births (SINASC) and deaths (SIM) for estimating infant mortality at the municipal level in Brazil. Data from 2000-2002 for all municipalities were analyzed according to population size and geographic region. Five indicators were considered: age-standardized mortality rate; ratio of reported-to-estimated live births; relative mean deviation of the mortality rate; relative mean deviation of the birth rate; and proportion of deaths with undetermined causes. Adequacy criteria were established statistically for eight Brazilian States in which vital statistics were adequate. The results showed important socio-spatial inequalities: in general, the proportion of adequate vital statistics was higher in the Central-South of the country and in larger municipalities. The live birth data system received the best evaluation for three items. The mortality data system requires both a reduction in underreporting and improved data on cause of death in order to orient health programs focused on decreasing inequalities in infant mortality in Brazil.

Indicadores de atenção básica em quatro municípios do Estado do Rio de Janeiro, 2005: resultados de inquérito domiciliar de base populacional

O inquerito domiciliar de base populacional, realizado em quatro dos 22 municipios com mais de cem mil habitantes do Estado do Rio de Janeiro que implementaram o Projeto de Expansao e Consolidacao do Saude da Familia (Proesf), visa a institucionalizacao da avaliacao e monitoramento da atencao basica. Este estudo desenvolveu-se no contexto dos Estudos de Linha de Base (ELB) do Proesf. O instrumento utilizado e uma adaptacao do questionario aplicado anteriormente em âmbito nacional para avaliacao de desempenho de saude, sob a otica dos usuarios. As alteracoes voltaram-se para a avaliacao da atencao basica, com foco no Programa de Saude da Familia (PSF). Construiram-se indicadores de cobertura, qualidade de atendimento pre-natal, assistencia ao parto, saude infantil, prevencao de câncer de colo uterino e mama, assistencia a idosos e saude bucal. Destacaram-se os resultados observados na prevencao de câncer de colo de utero, pelas elevadas coberturas de exame ginecologico no periodo de tres anos, ficando evidente a fragilidade do sistema de saude em relacao ao tempo de entrega do resultado do exame. Reforca-se a importância de avaliar a qualidade da atencao basica recebida sob a otica do usuario, para o estabelecimento de metas e definicao de prioridades.

Cobertura do teste de Papanicolaou e fatores associados à não-realização: um olhar sobre o Programa de Prevenção do Câncer do Colo do Útero em Pernambuco, Brasil

This research aimed to assess coverage of Pap smear screening in the State of Pernambuco, Brazil, during the three years prior to the study, among women 18 to 69 years of age, and to identify factors associated with womens lack of participation in screening. This was a cross-sectional, population-based study, using data from a survey in 2005-2006 with 640 women, selected by three-stage cluster sampling. Information on 258 women was analyzed. Pap smear coverage was 58.7% for women 18 to 69 years of age and 66.2% for those 25 to 59. Single marital status, no history of childbirth, and not having consulted a physician in the previous year were associated with lack of Pap smear screening. In the multivariate analysis, low schooling also showed a significant effect. Pap smear coverage in Pernambuco was satisfactory, but insufficient to impact the epidemiological profile of cervical cancer. It is necessary to strengthen and upgrade health promotion activities in order to reduce the inequalities and encourage womens active participation in cervical cancer prevention.

Sistema de Informações sobre Mortalidade: estudo de caso em municípios com precariedade dos dados

The study was part of a survey conducted in clusters of Brazilian municipalities (counties) characterized by serious underreporting of deaths, with the objective of estimating infant mortality in these areas in 2000. The article discusses the principal sources of information on infant deaths in these municipalities, as well as some problems related to the implementation of the Mortality Data System (SIM). The methodology included an active search for deaths in previously registered official and unofficial sources, which identified 344 deaths not processed in the SIM (66% of total deaths). There were a low percentage of deaths processed in the SIM and coming from official sources (notary public offices and healthcare facilities), thus highlighting problems with reporting of deaths, issuing of death certificates, and data flows. The important contribution by the Community Health Agents Program/ Family Health Program points to the need for active data search in this source as a routine activity in municipalities with underreporting of data. Insufficient training of professionals and high staff turnover were major issues in the systems deficient implementation.

Mortalidade infantil no Brasil: Belíndia ou Bulgária?

Neste trabalho, descreve-se a evolucao da mortalidade infantil no Brasil na decada de 80. Diante da elevada proporcao de obitos nao registrados no Pais, a caracterizacao do risco de morrer entre as criancas menores de um ano de idade e realizada por um conjunto de indicadores de saude elaborados com base na distribuicao por causa de morte e por componente etario. Por meio de uma analise estatistica por componentes principais, desenvolve-se um indice sintetizador que permite expressar quantitativamente as diferentes situacoes de saude nas Unidades Federadas. Atraves desta escala de valores, dividindo-se o territorio nacional em tres grandes grupos, demonstra-se que a parte mais pobre persiste com padrao similar ao da India. Adicionalmente, a analise da mortalidade neonatal nos estados mais desenvolvidos mostra reducao pouco expressiva nos coeficientes na primeira semana de vida, demonstrando-se que o padrao observado, mesmo nos estados em situacao privilegiada em relacao aos demais, sequer se aproxima do que ocorre no mundo desenvolvido. De maneira geral, o confronto com a experiencia internacional leva a constatar que o declinio da mortalidade infantil na decada de 80 foi pobre, ficando evidente que o rumo a ser seguido envolve intervencoes especificas sobre ambos os componentes, o neonatal e o tardio.

Desigualdades sócio-econômicas do baixo peso ao nascer e da mortalidade perinatal no Município do Rio de Janeiro, 2001

Socioeconomic inequalities in early infant mortality have been evidenced in Brazil, with a greater mortality risk associated with the mothers socioeconomic status (SES). The aim of this paper is to identify socioeconomic inequalities in relation to low birth weight and perinatal mortality in the City of Rio de Janeiro, Brazil, discussing the appropriateness of the main health inequality indexes proposed in the international literature. As the information source, we use data collected in a survey of approximately 10,000 mothers selected for interview within 48 hours after delivery in public and private hospitals in the city. Using educational level and head of households income as indicators of SES, as well as population attributable risk and slope index of inequality as health inequality measures, the results show a steep socioeconomic gradient in the proportion of low birth weight, and especially in the perinatal mortality rate. The persistent association between socioeconomic indicators and adverse results in pregnancy indicates (at least partially) the health systems inefficacy in diminishing perinatal health inequalities in Rio de Janeiro.

Avaliação da adequação das informações de mortalidade e nascidos vivos no Estado de Pernambuco, Brasil

The Brazilian Ministry of Health has made important investments to improve the quality of information systems on mortality and live births. However, in most Brazilian States the infant mortality rate is still estimated by indirect methods, thus overlooking the progress in this area. The current article aimed to evaluate the adequacy of mortality and live birth data using indicators of coverage and regularity for both systems. Analysis of temporal trends in infant mortality coverage estimated by indirect methods revealed major inconsistencies in the temporal series. The adequacy indicators showed an important improvement in the coverage and regularity of vital information systems. The proportion of deaths from ill-defined causes also decreased, although at a slower rate. The improvement in recording of live births and deaths in the State of Pernambuco highlights the importance of reflecting on the use of direct methods to calculate infant mortality, at least in municipalities with adequate vital statistics.