Gisele O’Dwyer

Avaliação dos serviços hospitalares de emergência do estado do Rio de Janeiro

This study aimed at the evaluation of urgency/emergency hospital units and recorded the relations of emergency units with users, other hospital services and the healthcare network and approached the size of the teams, the relations among the professionals, their qualification and income. It further describes the infrastructure of these services including basic organizational aspects. The aspect care was one component in this broader object. It is a descriptive study applying a questionnaire to the heads of the emergency services of a sample of 30 hospitals.The statements suggest the overcrowding of emergency services (in 80% of hospitals) deteriorating the work and care conditions to be due to the inefficiency of primary care and the healthcare network. The deficit of human resources was found larger than the lack of technology. The precarious employment relations were considered a factor hampering the qualification and retention of professionals. The most favorably evaluated items were: relationship with service heads, trust and expectations with regard to the service. The worst items were: wages, team size and labor medicine. The nvestment in human resources is indispensable. There is a need for public policies that articulate more efficient interventions given that those in force are defining the configuration of territories with their hierarchized and solidary networks.

O SAMU, a regulação no Estado do Rio de Janeiro e a integralidade segundo gestores dos três níveis de governo

O SAMU e uma politica prioritaria para o atual governo. O objetivo do estudo foi discutir o potencial de sua pratica de integralidade, analisando a assistencia as urgencias por meio de atores importantes da gestao. A metodologia baseou-se na Teoria da Estruturacao de Giddens, relacionando estrutura e acao, que foi investigada na consciencia discursiva. Foram entrevistados gestores dos tres entes federativos que versaram sobre a regulacao nos SAMU do estado do Rio de Janeiro. Os eixos de analise foram: o SAMU, suas caracteristicas, atribuicoes e a questao social; o medico, seu perfil, atitudes e a decisao clinica; e a assistencia em rede, a gestao e a regulacao. Foi indicado que nao havia assistencia integrada por conta da insuficiencia estrutural da atencao basica e da precariedade nos hospitais de referencia. A capacitacao profissional e os vinculos empregaticios precarios obstaculizavam a gestao nos SAMU. Havia inoperância dos comites gestores dos diversos niveis de atuacao, e nao havia producao de informacao. Foi destacado o privilegio da regulacao como observatorio do sistema e da atencao as urgencias para avaliar o desempenho da rede e para a regionalizacao da assistencia.

Interdependência federativa na política de saúde: a implementação das Unidades de Pronto Atendimento no estado do Rio de Janeiro, Brasil

This article addresses policymaking related to Emergency Care Units (ECU) in the State of Rio de Janeiro between 2007 and 2013, duly identifying the relationships between the various levels of government in this process. It prioritized the context of policy formulation, the factors that motivated the inclusion and maintenance of ECUs on the state agenda and the process of how the policy was implemented in the state. The study was based on the literature that defines the agenda and implementation of public policies and on contributions from historic institutionalism. The research involved analysis of documents, secondary data, and 51 interviews with people in positions of authority in state and municipal governments. The priority given to ECUs in the government agenda was the result of a confluence of historical, structural, political and institutional factors, as well as the current context. The results of this study indicate the existence of interdependence between levels of government, however federal coordination problems have prejudiced the integration of the various components of emergency health care in the state.This article addresses policymaking related to Emergency Care Units (ECU) in the State of Rio de Janeiro between 2007 and 2013, duly identifying the relationships between the various levels of government in this process. It prioritized the context of policy formulation, the factors that motivated the inclusion and maintenance of ECUs on the state agenda and the process of how the policy was implemented in the state. The study was based on the literature that defines the agenda and implementation of public policies and on contributions from historic institutionalism. The research involved analysis of documents, secondary data, and 51 interviews with people in positions of authority in state and municipal governments. The priority given to ECUs in the government agenda was the result of a confluence of historical, structural, political and institutional factors, as well as the current context. The results of this study indicate the existence of interdependence between levels of government, however federal coordination problems have prejudiced the integration of the various components of emergency health care in the state.

Handgrip Strength and Factors Associated in Poor Elderly Assisted at a Primary Care Unit in Rio de Janeiro, Brazil

Introduction Sarcopenia is a condition diagnosed when the patient presents low muscle mass, plus low muscle strength or low physical performance. Muscle weakness in the oldest (dynapenia) is a major public health concern because it predicts future all-cause mortality and is associated with falls, disability, cardiovascular mortality and morbidity. Grip strength is a simple method for assessment of muscle function in clinical practice. Objective To estimate the grip strength and identify factors associated with handgrip strength variation in elderly people with low socioeconomic status. Methods Cross-sectional study based on a multidimensional assessment of primary care users that were 60 years or older. The sample size was calculated using an estimated prevalence of depression in older adults of 20%. A kappa coefficient of 0.6 with a 95% confidence interval was used to generate a conservative sample size of 180 individuals. Procedures: tests and scales to assess humor, cognition (MMSE), basic (ADL) and instrumental activities (IADL) of daily living, mobility (Timed Up and Go), strength, height, Body Mass Index (BMI) and social support were applied. Questions about falls, chronic diseases and self-rated health (SRH) were also included. Statistical Analysis: Mean, standard deviation and statistical tests were used to compare grip strength means by demographic and health factors. A multivariate linear model was used to explain the relationship of the predictors with grip strength. Results The group was composed predominantly by women (73%) with a very low level of education (mean 3 years of schooling), mean age of 73.09 (± 7.05) years old, good mobility and without IADL impairment. Mean grip strength of male and female were 31.86Kg (SD 5.55) and 21.69Kg (SD 4.48) [p- 0.0001], respectively. Low grip strength was present in 27.7% of women and 39.6% of men. As expected, men and younger participants had higher grip strength than women and older individuals. In the adjusted model, age (p- 0.03), female sex (p- 0.0001), mobility (p- 0.05), height (p- 0.03) and depression (p- 0.03) were independently associated with low grip strength. For every second more in the mobility test, there was a mean decrease of 0.08 Kg in the grip strength. Elders with depression had a mean reduction of 1.74Kg in the grip strength in relation to those in the comparison groups. There was an average reduction of 8.36Kg in the grip strength of elderly females relative to males. For each year of age after 60 years, it was expected an average reduction of 0.11 Kg in the grip strength. Conclusion our results suggest that low grip strength is associated with age, female sex, height, depression and mobility problems in poor elderly. Grip strength can be a simple, quick and inexpensive means of stratifying elders’ risk of sarcopenia in the primary care setting. Efforts should be made to recognize weaker persons and the conditions associated to low grip strength in order to target early interventions to prevent frailty and disability.

Temporal and Spatial Evolution of Dengue Incidence in Brazil, 2001-2012

Background In Brazil, the incidence of dengue greatly increased in the last two decades and there are several factors impeding the control of the disease. The present study focused on describing the space-time evolution of dengue in Brazil from 2001 to 2012 and analyzing the relationship of the reported cases with socio-demographic and environmental factors. Methods The analytic units used in the preparation of thematic maps were municipalities. Statistical tests and multilevel regression models were used to evaluate the association between dengue incidence and the following factors: climate, diagnostic period, demographic density, percentage of people living in rural areas, Gross Domestic Product, Gini index, percentage of garbage collection and the rate of households with a sewage network. Results The largest accumulation of dengue cases in Brazil was concentrated on the Atlantic coast and in the interior part of São Paulo State. The risk of dengue in subtropical and tropical climates was 1.20–11 times lower than that observed in semi-arid climates. In 2009–2010 and 2011–2012, the risks were ten and six times higher than in 2003–2004, respectively. Conclusion Dengue is a common infection in the Brazilian population, with the largest accumulation of dengue cases concentrated on the Atlantic coast and in the interior area of São Paulo State. The high dengue rates observed in the Brazilian coastal region suggest that the cases imported from neighboring countries contribute to the spread of the disease in the country. Our results suggest that several socio-demographic and environmental factors resulted in the increase of dengue in the country over time. This is likely applicable to the occurrence of other arboviruses like Zika and chikungunya. To reverse the situation, Brazil must implement effective public policies that offer basic services such as garbage collection and sanitation networks as well as reduce vector populations.

An analysis of actions to promote health in underprivileged urban areas: a case in Brazil

BackgroundTwo policies stood out in the 2000s geared towards changing the care model adopted in Brazil: The National Policy on Primary Health Care, based on a family health care model, and the National Policy on Health Promotion.The aim of this study was to analyze health promotion actions developed by family health care teams in the municipality of Belford Roxo. This town was chosen by virtue of its “below average” level of primary health care services offered in relation to other municipalities in Rio de Janeiro state.MethodsThe following methodological strategies were employed: analysis of health systems, document analysis (2010 Annual Health Schedule and 2010 Annual Management Report), participant observation and interviews with nine health care professionals in the region of study, namely: the manager of the Regional Health Polyclinic (responsible for health care actions in the region), and nurses belonging to the eight family health teams. Giddens’ Theory of Structuration was used for analysis of the results.ResultsVarying levels of health care activity were found, indicating that the managers have been either unable or lacked the commitment to perform the proposed actions. From a structural point of view, 87.5% of the teams were incomplete. Also of particular note was the lack of any physicians in the teams, which, despite its detrimental effect, was regarded by the interviewees as “natural”.Strong political party influence in the area hindered relations between the team and the local population. Health education, especially through lectures was the main health promotion activity picked up in this study.No cross-sectorial or public participation actions were identified. Connections between the teams for sharing responsibilities were found to be very weak.ConclusionIn addition to political factors, there are also structural limitations such as a lack of human resources that overburdens the teams’ daily activities. From this point of view, the political context and lack of professionals were restrictive factors for health promotion.Belford Roxo is not necessarily representative of other experiences in Brazil. However, problems such as patronage, political manipulation, poverty and incipient cross-sectorial actions are common to other Brazilian towns and cities.

Temporal and spatial evolution of maternal and neonatal mortality rates in Brazil, 1997–2012

OBJECTIVE Maternal and neonatal mortality are important public health issues in low-income countries. This study evaluated spatial and temporal maternal and neonatal mortality trends in Brazil between 1997 and 2012. METHODS This study employed spatial analysis techniques using death records from the mortality information system. Maternal mortality rates per 100,000 and neonatal mortality rates (early and late) per 1000 live births were calculated by state, region, and period (1997-2000, 2001-2004, 2005-2008, and 2009-2012). Multivariate negative binomial models were used to explain the risk of death. RESULTS The mean Brazilian maternal mortality rate was 55.63/100,000 for the entire 1997-2012 period. The rate fell 10% from 1997-2000 (58.92/100,000) to 2001-2004 (52.77/100,000), but later increased 11% during 2009-2012 (58.69/100,000). Early and late neonatal mortality rates fell 33% (to 7.36/1000) and 21% (to 2.29/1000), respectively, during the 1997-2012 period. Every Brazilian region witnessed a drop in neonatal mortality rates. However, maternal mortality increased in the Northeast, North, and Southeast regions. CONCLUSION Brazils neonatal mortality rate has improved in recent times, but maternal mortality rates have stagnated, failing to meet the Millennium Development Goals. Public policies and intersectoral efforts may contribute to improvements in these health indicators.

Atenção pré-hospitalar móvel às urgências: análise de implantação no estado do Rio de Janeiro, Brasil

Mobile prehospital care is a key component of emergency care. The aim of this study was to analyze the implementation of the State of Rio de Janeiro’s Mobile Emergency Medical Service (SAMU, acronym in Portuguese). The methodology employed included document analysis, visits to six SAMU emergency call centers, and semistructured interviews conducted with 12 local and state emergency care coordinators. The study’s conceptual framework was based on Giddens’ theory of structuration. Intergovernmental conflicts were observed between the state and municipal governments, and between municipal governments. Despite the shortage of hospital beds, the SAMUs in periphery regions were better integrated with the emergency care network than the metropolitan SAMUs. The steering committees were not very active and weaknesses were observed relating to the limited role played by the state government in funding, management, and monitoring. It was concluded that the SAMU implementation process in the state was marked by political tensions and management and coordination weaknesses. As a result, serious drawbacks remain in the coordination of the SAMU with the other health services and the regionalization of emergency care in the state.

The increase in domestic violence in Brazil from 2009-2014

In recent decades, the rise violent phenomena in Brazil has reached epidemic proportions. However, the prevalence of domestic violence (DV) across different states in the country is not well established. The objective of this study was to describe the distribution of DV across Brazilian states from 2009 to 2014. An ecological study based on spatial analysis techniques was performed using Brazilian states as geographical units of analysis. A multilevel Poisson model was used to explain the risk of DV in Brazil according to age, sex, period (fixed effects), the Human Developing Index, and the victims residence state (random effects). The overall average rate of DV almost tripled from 2009-2010 to 2013-2014. The rate of DV in Brazil in the 2013-2014 period was 3.52 times greater than the 2009-2010 period. The risk of DV in men was 74% lower than in women. The increase of DV against women during period under study occurred mainly in the Southeast, South, and Midwest. DV was more frequent in adolescence and adulthood. DV is gradually increasing in recent years in Brazil. More legislation and government programs are needed to combat the growth of violence in society.

A integração das Unidades de Pronto Atendimento (UPA) com a rede assistencial no município do Rio de Janeiro, Brasil

No municipio do Rio de Janeiro, a implantacao das Unidades de Pronto Atendimento 24h (UPA) foi o fio condutor da politica de saude e modelo para estruturacao da rede de urgencia e emergencia (RUE). Este estudo analisou a integracao das UPAs na rede assistencial do municipio. Foram realizadas nove entrevistas, com gestores centrais e locais, analisadas a luz da Teoria da Estruturacao de Giddens. Resultados mostraram pouca integracao das UPAs, por deficiencias estruturais da rede de servicos e fragmentacao gerencial, pela ausencia de governanca unificada. Apesar do investimento politico e financeiro, essa estrategia nao logrou contornar os problemas de integracao entre as unidades de saude e, ainda, ressaltou a baixa prioridade governamental para a atencao basica. Assim, as UPAs pouco contribuiram para o desenvolvimento de redes de atencao a saude e para a reorientacao do modelo assistencial.