Célia Landmann Szwarcwald

AIDS e infecção pelo HIV no Brasil: uma epidemia multifacetada

The HIV/AIDS epidemic is a dynamic unstable global phenomenon, constituting a veritable mosaic of regional sub-epidemics. As a consequence of the deep inequalities that exist in Brazilian society, the spread of HIV infection has revealed an epidemic of multiple dimensions undergoing extensive epidemiological transformations. Initially restricted to large urban centers and markedly masculine, the HIV/AIDS epidemic is currently characterized by heterosexualization, feminization, interiorization and pauperization. The evolution of the profile of AIDS in Brazil is above all due to the geographical diffusion of the disease from large urban centers towards medium and small municipalities in the interior, to the increase in heterosexual transmission and the persistent growth of cases among injecting drug users. The increase in transmission through heterosexual contact has resulted in substantial growth of cases among women, which has been pointed out as the most important characteristic of the epidemics current dynamic in Brazil.

Population-based evidence of a strong decline in the prevalence of smokers in Brazil (1989-2003)

OBJECTIVE To evaluate the evolution in smoking indicators in the adult Brazilian population between 1989 and 2003. METHODS We compared age-adjusted prevalence ratios and means for smoking indicators, stratified by age, sex and sociodemographic variables, obtained from two comparable household surveys that used probabilistic sampling of the Brazilian population aged > 18 years (n = 34 808 in 1989 and n = 5000 in 2003). FINDINGS Between 1989 and 2003, there was a substantial decrease in the prevalence of smoking (from 34.8% to 22.4%; age-adjusted prevalence ratio, 0.65; 95% confidence interval, CI, 0.60-0.70) and a modest reduction in the mean number of cigarettes smoked per day (from 13.3 to 11.6; age-adjusted difference, -1.8; 95% CI, -2.6 - -1.0). Reductions in the prevalence and intensity of smoking were greater among males, younger age groups and higher socioeconomic strata. CONCLUSION The prevalence of smoking in the adult Brazilian population declined by 35% between 1989 and 2003, or an average of 2.5% per year. This exceptional reduction surpasses those seen in other countries that implemented wide-ranging and rigorous policies for controlling smoking during the same period. The more intense decline in smoking in younger age groups was consistent with the concentration of efforts of the Brazilian tobacco control programme to prevent the onset of smoking among youths and the total prohibition of cigarette advertising. We recommend the intensification of programme initiatives targeting women and less economically favoured population strata.

Methodological concerns and recommendations on policy consequences of the World Health Report 2000

Celia Almeida MDa, Paula Braveman MDc, Marthe R Gold MDd, Celia L Szwarcwald DrPhb, Jose Mendes Ribeiro MDa, Americo Miglionico MSe, John S Millar MDf, Silvia Porto PhDa, Nilson do Rosario Costa PhDa, Vincente Ortun Rubio PhDg, Malcolm Segall MRCPh, Barbara Starfield MDi, Claudia Travessos MDb, Alicia Uga PhDa, Joaquim Valente MDa and DrFrancisco Viacava MDb/ a National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil/ b Health Information Department, Center for Scientific and Technological Information, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil/c Department of Family and Community Medicine, University of California, San Francisco, USA/d Department of Community Health and Social Medicine, City University of New York Medical School, New York, USA/e Consultant to Ministry of Health, Montevideo, Uruguay/ f Canadian Institute for Health Information, Ottawa, Canada/ g Department of Economics, Universitat Pompeu Fabra, Barcelona, Spain/h Health Unit, Institute of Development Studies, Sussex, UK/ i Johns Hopkins Medical Institutions, Baltimore, USA

AIDS e pauperização: principais conceitos e evidências empíricas

O artigo discute as estrategias metodologicas que vem sendo usadas na analise das inter-relacoes entre a vulnerabilidade ao HIV/AIDS e as desigualdades sociais, o preconceito e a marginalizacao, ressaltando-se as dificuldades metodologicas e as estrategias alternativas de investigacao encontradas. Os principais achados da literatura internacional e brasileira foram revistos, enfatizando-se os temas: dimensoes economicas e macropoliticas da difusao do HIV/ AIDS; papel do consumo e da politica de drogas; desigualdade e preconceito de genero; desigualdade e preconceito racial/origem etnica; interacao com as demais infeccoes sexualmente transmissiveis e sua relacao com a pobreza; padroes de assistencia a saude e HIV/AIDS, em especial, acesso a anti-retrovirais; e violacao dos direitos humanos. Apesar da restrita producao academica brasileira e dos dilemas metodologicos envolvidos no exame das inter-relacoes entre variaveis psicossociais, culturais, socio-politicas e vulnerabilidade ao HIV/AIDS, tais temas devem ser investigados em detalhe - considerando especificidades sociais e culturais do Brasil - e beneficiados pelas novas estrategias de pesquisa.This paper discusses methodologies for analyzing relations between social inequalities, marginalization, prejudice, and vulnerability to HIV/AIDS, highlighting current difficulties and alternative research strategies. It also reviews the international and Brazilian literature, emphasizing: economic and macropolitical dimensions in the spread of HIV/AIDS; the role of drug policies and consumption; gender inequalities and prejudice; racial/ethnic inequalities and prejudice; and interaction with other STIs and their relationship to poverty; HIV/AIDS and health care standards, especially access to antiretroviral therapy; and human rights violations. Despite current methodological dilemmas in analyzing relations between psychosocial, cultural, and sociopolitical variables and vulnerability to HIV/AIDS and the limited Brazil literature, such themes merit further investigation, addressing Brazilian social and cultural specificities and profiting from recently developed research strategies.

Socio-demographic determinants of self-rated health in Brazil

Self-rated health has been used extensively in epidemiologic studies, not only due to its importance per se but also due to the validity established by its association with clinical conditions and with greater risk of subsequent morbidity and mortality. In this study, the socio-demographic determinants of good self-rated health are analyzed using data from the World Health Survey, adapted and carried out in Brazil in 2003. Logistic regression models were used, with age and sex as covariables, and educational level, a household assets index, and work-related indicators as measures of socioeconomic status. Besides the effects of sex and age, with consistently worst health perception among females and among the eldest, the results showed pronounced socioeconomic inequalities. After adjusting for age, among females the factors that contributed most to deterioration of health perception were incomplete education and material hardship; among males, besides material hardship, work related indicators (manual work, unemployment, work retirement or incapable to work) were also important determining factors. Among individuals with long-term illness or disability, the socioeconomic gradient persisted, although of smaller magnitude.

Uma metodologia de avaliação do desempenho do sistema de saúde brasileiro

Este artigo e uma sintese de alguns dos principais resultados das discussoes realizadas ao longo de 18 meses entre pesquisadores de diversas instituicoes, afiliadas a Abrasco, e procura contribuir para a formulacao de uma metodologia que permita: a) compreender quais sao e como se inter-relacionam os fatores que influenciam a eficiencia, a efetividade e a equidade no desempenho do SUS; b) melhorar a formulacao de politicas e c) monitorar as desigualdades no acesso e na qualidade dos servicos recebidos pelos diferentes grupos sociais no Brasil. A metodologia desenvolvida nutre-se de elementos utilizados nas propostas de avaliacao de desempenho dos sistemas de saude canadense, australiano, ingles e a da OPS e tem o formato de um painel de controle (dashboard), onde podem ser visualizadas simultaneamente diferentes dimensoes da avaliacao. O artigo descreve a experiencia na adaptacao e desenvolvimento da metodologia e fornece sugestoes no sentido de aplica-la para melhorar a formulacao da politica de saude no Brasil.

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%.

Experiência de gravidez na adolescência, fatores associados e resultados perinatais entre puérperas de baixa renda

This paper compares socioeconomic characteristics, prenatal care, and life styles of three groups of post-partum women, one consisting of adolescents (< 20 years) and the other two of women 20-34 years old, classified according to their history of pregnancy during adolescence. A sample of 3,508 post-partum women was selected from public hospitals in the city of Rio de Janeiro, Brazil, and interviewed just after childbirth. To verify the hypothesis of homogeneity of proportions, chi-square tests (c2) were used. Comparing the three groups, the most adverse conditions were found among the 20-34-year-old mothers with a history of pregnancy during adolescence. These women have the least schooling, the highest rates of smoking and use of illegal drugs during pregnancy, and the fewest prenatal appointments. According to this study, prenatal care proved to be an effective compensatory policy for the prevention of prematurity and low birth weight, especially among adolescent mothers.

Amostras complexas em inquéritos populacionais: planejamento e implicações na análise estatística dos dados

A avaliacao do desempenho dos sistemas de saude das nacoes vem ganhando importância crescente entre os gestores do setor saude. Entre os instrumentais de avaliacao do desempenho de saude, destacam-se os inqueritos nacionais de saude, cada vez mais utilizados para avaliar o estado de saude da populacao e a assistencia de saude prestada do ponto de vista do usuario. A maioria dos inqueritos nacionais de saude nao usa amostragem aleatoria simples, em parte por restricoes orcamentarias, em parte por limites de tempo associado a coleta de dados. Em geral, utiliza-se combinacao de varios metodos probabilisticos de amostragem para selecao de uma amostra representativa da populacao, chamada de desenho complexo de amostragem. Entre os metodos de amostragem mais utilizados conjuntamente, destacam-se a amostra aleatoria simples, a amostragem estratificada, e a amostragem por conglomerados. Resultante desse processo, a preocupacao subsequente e a analise de dados provenientes de amostras complexas. Este artigo trata de questoes relacionadas a analise estatistica de dados obtidos atraves de pesquisas com desenhos complexos de amostragem. Apresentam-se os problemas que ocorrem quando a analise estatistica nao incorpora a estrutura do plano amostral. Ao ignorar o desenho de amostragem, a analise estatistica tradicional, sob a suposicao de amostragem aleatoria simples, pode produzir incorrecoes tanto para as estimativas medias como para as respectivas variâncias, comprometendo os resultados, os testes de hipoteses e as conclusoes da pesquisa. Para a exemplificacao dos metodos, e utilizada a Pesquisa Mundial de Saude (PMS), realizada no Brasil em 2003.

Birth in Brazil: national survey into labour and birth

BackgroundCaesarean section rates in Brazil have been steadily increasing. In 2009, for the first time, the number of children born by this type of procedure was greater than the number of vaginal births. Caesarean section is associated with a series of adverse effects on the women and newborn, and recent evidence suggests that the increasing rates of prematurity and low birth weight in Brazil are associated to the increasing rates of Caesarean section and labour induction.MethodsNationwide hospital-based cohort study of postnatal women and their offspring with follow-up at 45 to 60 days after birth. The sample was stratified by geographic macro-region, type of the municipality and by type of hospital governance. The number of postnatal women sampled was 23,940, distributed in 191 municipalities throughout Brazil. Two electronic questionnaires were applied to the postnatal women, one baseline face-to-face and one follow-up telephone interview. Two other questionnaires were filled with information on patients’ medical records and to assess hospital facilities. The primary outcome was the percentage of Caesarean sections (total, elective and according to Robson’s groups). Secondary outcomes were: post-partum pain; breastfeeding initiation; severe/near miss maternal morbidity; reasons for maternal mortality; prematurity; low birth weight; use of oxygen use after birth and mechanical ventilation; admission to neonatal ICU; stillbirths; neonatal mortality; readmission in hospital; use of surfactant; asphyxia; severe/near miss neonatal morbidity. The association between variables were investigated using bivariate, stratified and multivariate model analyses. Statistical tests were applied according to data distribution and homogeneity of variances of groups to be compared. All analyses were taken into consideration for the complex sample design.DiscussionThis study, for the first time, depicts a national panorama of labour and birth outcomes in Brazil. Regardless of the socioeconomic level, demand for Caesarean section appears to be based on the belief that the quality of obstetric care is closely associated to the technology used in labour and birth. Within this context, it was justified to conduct a nationwide study to understand the reasons that lead pregnant women to submit to Caesarean sections and to verify any association between this type of birth and it’s consequences on postnatal health.