Joaquim Gonçalves Valente

Cobertura do exame de Papanicolaou no Brasil e seus fatores determinantes: uma revisão sistemática da literatura

PURPOSE: to present an overview of the coverage of the Pap smear in Brazil, emphasizing the determinant factors associated with failure of women to submit to the test. METHODS: the literature was reviewed using the LILACS (Latin-American and Caribbean Literature in Sciences of the Health), MEDLINE - 1966 to 2004 (International Literature in Sciences of the Health), PAHO (Collection of the Library of the Pan-American Organization of Health), and WHOLIS (System of Information of the Library of OMS) databases. The review was enlarged through the search of bibliographical references of relevant studies, request for published and unpublished studies by specialists, and other sources. Articles that fulfilled the following criteria were selected: to be a cross-sectional study, carried out in Brazil, including information about periodicity of the Pap test (some time in life or in the last three years) and/or containing information about factors associated with failure of women to submit to the test. Duplicates and articles without summary were excluded. A total of 13 articles fulfilling these criteria were selected. RESULTS: there are few studies on the coverage of Pap smear in Brazil. Most of them are concentrated in the big cities of the South and Southeast regions of the country. Besides the shortage, little methodological standardization exists in relation to the sampling and profile of the investigated women, which turns difficult the comparison among them. These methodological differences must have contributed to the great variability found in the coverage. However, in spite of all of the problems, a trend of time series increase is observed in the percentage of women who had at least one Pap smear in life. The two studies accomplished in the eighties showed coverage of 55.0 and 68.9% some time in life, while a household survey carried out in 2002 and 2003 presented values that varied from 73.4 to 92.9%; however, two studies of national inclusion presented estimates below 70.0% in the last three years. On the other hand, some variables were associated with the womens failure to submit to the Pap smear: low socioeconomic level, low education, low family income, and to belong to the younger age groups. CONCLUSION: the data here presented point to regional inequalities in the coverage of the Pap smear in the Brazilian female population and to the need of intervention targeted to those factors associated with womens failure to submit to the Pap smear.

Evaluation of waist circumference to predict general obesity and arterial hypertension in women in Greater Metropolitan Belo Horizonte, Brazil

This study examined the capacity of waist circumference (WC) to identify subjects with overweight (BMI >/=25) and obesity (BMI >/=30), in agreement with internationally recommended levels of action. Data were obtained from 791 women, 15-59 years old. After identifying overweight and obesity according to WC values, sensitivity and specificity were calculated to verify whether WC could be a good risk predictor for hypertension. Associations were tested by linear regression and logistic regression, controlling for confounding. WC cut-off points of 80cm and 88cm correctly identified 89.8% and 88.5% of women with overweight and obesity, respectively. Abdominal obesity (WC >/=88cm) was statistically associated with hypertension in the multivariate analysis (OR = 2.88; 95% CI: 1.77-4.67). Hypertension was identified with a sensitivity of 63.8% and 42.8%, and with a specificity of 68.0% and 83.3%, for WC >/=80 and >/=88, respectively. The proposed cut-off points for abdominal obesity can potentially distinguish individuals at risk for future obesity, but has only moderate power to predict individuals with high blood pressure.

Acurácia da circunferência da cintura e da relação cintura/quadril como preditores de dislipidemias em estudo transversal de doadores de sangue de Cuiabá, Mato Grosso, Brasil

This study evaluated the accuracy of anthropometric fat location indices (waist circumference and waist-to-hip ratio) as predictors of dyslipidemia, in addition to defining their respective cut-offs. The sample consisted of 416 healthy male blood donors from 20 to 58 years of age at the Blood Center in Cuiabá, capital of Mato Grosso State, Brazil. Serum lipids were determined through the enzymatic method. Data analysis through the ROC curve identified the best indicator and the cut-off with the largest statistically significant area under the ROC curve. The best cut-off points for waist-to-hip ratio and waist circumference were 0.90 and 85cm, respectively. The area under the ROC curve between waist circumference and high cholesterol/HDL relation included the 0.50 value, so waist circumference could not be considered a predictor of dyslipidemia. The best sensitivity and specificity were in the youngest group. Waist-to-hip ratio was a better predictor of dyslipidemia than waist circumference, although the latter showed better discriminating power to detect hypertriglyceridemia. The most accurate cut-off points were lower than those set by the World Health Organization.

Factors related to inadequate cervical cancer screening in two Brazilian state capitals

OBJETIVO: Analisar fatores associados a nao-realizacao do exame de Papanicolaou. METODOS:Estudo transversal, de base populacional, com amostragem por conglomerados com dois estagios de selecao e autoponderada em 2002. As participantes foram mulheres de 25 a 59 anos de idade nos tres anos anteriores a pesquisa, nos municipios de Fortaleza (CE) e Rio de Janeiro (RJ). Os dados foram analisados por regressao de Poisson por meio de modelo hierarquico. RESULTADOS: O percentual de mulheres nao submetidas ao exame de Papanicolaou foi de 19,1% (IC 95%: 16,1;22,1) em Fortaleza e 16,5% (IC 95%: 14,1;18,9) no Rio de Janeiro. As maiores razoes de prevalencia para a nao-realizacao do exame nas duas localidades foram entre mulheres com baixa escolaridade, de menor renda per capita, com idade mais avancada, nao-casadas e que nunca foram submetidas a mamografia, ao exame clinico das mamas e aos exames de glicemia e colesterolemia. Alem disso, as fumantes foram menos submetidas ao exame de Papanicolaou quando comparadas as demais mulheres, sendo a diferenca estatisticamente significativa somente no Rio de Janeiro. CONCLUSOES: Os achados apontam a necessidade de intervencao principalmente em mulheres de piores condicoes socioeconomicas e de acesso a saude, com idade mais avancada e nao-casadas. As atividades de educacao para o diagnostico precoce e para o rastreamento em mulheres sintomaticas e assintomaticas devem ser priorizadas com garantia de acesso aos metodos de diagnostico e tratamento adequados.OBJECTIVE To analyze factors associated with cervical cancer screening failure. METHODS Population-based cross-sectional study with self-weighted two-stage cluster sampling conducted in the cities of Fortaleza (Northeastern Brazil) and Rio de Janeiro (Southeastern Brazil) in 2002. Subjects were women aged 25-59 years in the last three years prior to the study. Data were analyzed through Poisson regression using a hierarchical model. RESULTS The proportion of women who did not undergo the Pap smear test in Fortaleza and Rio de Janeiro was 19.1% (95% CI: 16.1;22.1) and 16.5% (95% CI: 14.1;18.9), respectively. Higher prevalence ratios of cervical cancer screening failure in both cities were seen among women with low education and low per capita income, old age, unmarried, who never underwent mammography, clinical breast examination, and blood glucose and cholesterol level testing. Smokers also had lower screening rates compared to non-smoker women and this difference was only statistically significant in Rio de Janeiro. CONCLUSIONS The study findings point to the need of intervention focusing particularly women in worse socioeconomic conditions and access to healthcare, old-aged and unmarried. Education activities must prioritize screening of asymptomatic women and early diagnosis for symptomatic women and access to adequate diagnostic methods and treatment should be provided.

Correção da magnitude da mortalidade por câncer do colo do útero no Brasil, 1996-2005

OBJECTIVE To develop a methodology for correction of reported cervical cancer deaths in Brazil. METHODS Data on 9,607,177 cancer deaths were obtained from the Brazilian National Mortality Database for the period between 1996 and 2005. For correction of underreporting of deaths, factors generated by the Global Burden of Disease Study in Brazil-1998 were used. Proportional distribution was used in order to correct the categories of unknown, incomplete or ill-defined death diagnosis. The corrections were applied to each Brazilian state and the results were presented for Brazil nationwide, macroregions, and geographical areas (capital, other cities of metropolitan areas and interior cities) as percent variability of cervical mortality rates before and after correction. Corrections were analyzed by multivariate linear regression with interaction terms between macroregion and geographical area. RESULTS After correction, cervical cancer mortality rates showed an increment of 103% nationwide, ranging between 35% (Southern region capitals) and 339% (Northeastern region interior cities). The reallocation of cervical cancer deaths not otherwise specified resulted in greater mortality rate increments. The percent correction by year of death revealed steady trends nationwide. CONCLUSIONS The study results showed that the proposed methodology was appropriate for the correction of cervical cancer mortality rates in Brazil. It evidenced that cervical cancer mortality is even higher than that reported.OBJETIVO: Desenvolver uma metodologia para correcao da magnitude dos obitos por câncer do colo do utero no Brasil. METODOS: Os dados sobre os 9.607.177 obitos foram obtidos do Sistema de Informacao sobre Mortalidade, para o periodo de 1996 a 2005. Para a correcao do sub-registro, foram utilizados os fatores de expansao gerados pelo Projeto Carga Global de Doenca no Brasil - 1998. Para correcao das categorias de diagnosticos desconhecidos, incompletos ou mal definidos de obitos, foi aplicada redistribuicao proporcional. Os dados ausentes de idade foram corrigidos por imputacao. As correcoes foram aplicadas por Unidade Federativa e os resultados apresentados para o Brasil, regiao e areas geograficas (capital, demais municipios das regioes metropolitanas e interior) por meio do percentual de variabilidade da magnitude das taxas, antes e apos a correcao dos obitos. O comportamento das correcoes foi analisado por modelo de regressao linear multivariada com termos de interacao entre regiao do Pais e area geografica. RESULTADOS: As taxas corrigidas de mortalidade por câncer do colo do utero no Brasil mostraram um acrescimo de 103,4%, variando de 35% para as capitais da regiao Sul a 339% para o interior da regiao Nordeste. A redistribuicao dos obitos por câncer de utero sem especificacao de localizacao anatomica promoveu os maiores acrescimos na magnitude das taxas. Os percentuais de correcao, segundo ano de ocorrencia do obito, mostraram tendencia estacionaria no Brasil. CONCLUSOES: Os resultados permitem concluir que a metodologia proposta foi adequada para corrigir a magnitude das taxas de mortalidade por câncer do colo do utero no Pais, mostrando que a mortalidade por esse câncer e ainda maior do que o observado nos informes oficiais.

Death certificates as a marker for under-recording of AIDS cases

This study aimed to estimate and evaluate the under-recording of AIDS cases that evolved to death. From 1991 to 1995, the Mortality Information System recorded 9,213 adult deaths due to AIDS, related by name, date of birth, and date of death to 15,505 AIDS recorded by the Disease Data Registration System from 1982 to 1996. This procedure showed that 51.9% of AIDS deaths recorded in the period were not recorded as AIDS cases as they should have been. Univariate and multivariate analysis showed that women had a greater chance of under-recording than men (OR = 1.27). A lower probability of proper recording was observed in individuals with less schooling, and illiterates had a two-fold chance of not being properly recorded, as compared to individuals with college degrees. Deaths that occurred in health facilities classified as private units had a greater probability of not being recorded than those occurring elsewhere (mainly those classified as public reference units) (OR = 2.58). Deaths occurring in the city of Rio de Janeiro had a greater probability of under-recording than those in other cities (OR = 2.20).

Consumo de bebida alcoólica e adiposidade abdominal em doadores de sangue

OBJECTIVE To evaluate the association between alcohol consumption and abdominal fat. METHODS Cross-sectional study carried out in a sample of male blood donors (n=1,235), aged 20-59 years, in the city of Cuiabá, Central-West Brazil, between August 1999 and January 2000. Waist circumference and waist-to-hip ratio were indicators of abdominal fat, adjusted for total adiposity. Weight, height, waist and hip circumferences were measured. Alcohol consumption was evaluated using a questionnaire collecting information on type, frequency, and amount of consumption. The association between alcohol consumption and abdominal fat was assessed through multiple linear regression models adjusted for age, physical activity, smoking, and percent of body fat. RESULTS After adjustment, waist circumference and waist-to-hip ratio were positively associated with beer (p=0.02) and total alcohol consumption (p=0.01; p=0.03, respectively). Waist circumference was positively associated with spirit consumption (p=0.04). CONCLUSIONS Alcohol intake, particularly beer, was positively associated to abdominal fat.OBJETIVO: Analisar a associacao entre o consumo de bebidas alcoolicas e adiposidade abdominal. METODOS: Estudo transversal com uma amostra de homens doadores de sangue (N=1.235), de 20 a 59 anos, em Cuiaba (MT), realizado de agosto/1999 a janeiro/2000. Os indicadores de adiposidade abdominal foram circunferencia da cintura e relacao cintura/quadril, ajustados pela adiposidade total. As medidas aferidas foram: peso, estatura, circunferencias da cintura e do quadril. O consumo de alcool foi avaliado utilizando-se um questionario sobre tipo, frequencia e quantidade da bebida consumida. A associacao entre o consumo de alcool e adiposidade abdominal foi analisada por regressao linear multipla, com os modelos ajustados para idade, atividade fisica, tabagismo e adiposidade total. RESULTADOS: Apos ajuste, a circunferencia da cintura e a relacao cintura quadril mantiveram-se associadas positivamente ao consumo de cerveja (p=0,02) e ao total de alcool consumido (p=0,01 e 0,03, respectivamente). O consumo de aguardente mostrou associacao somente com a circunferencia da cintura (p=0,04). CONCLUSOES: O consumo de alcool, particularmente de cerveja, associou-se com a localizacao abdominal de gordura.

Menarca, gravidez precoce e obesidade em mulheres brasileiras selecionadas em um Centro de Saúde de Belo Horizonte, Minas Gerais, Brasil

The aim of this study was to investigate obstetric variables potentially associated with obesity among 486 Brazilian childbearing-age women aged 15-59 residing in the municipality of Belo Horizonte, Minas Gerais State. Body fat (BF) was measured through impedance analysis, and obesity was defined as BF > 30%. The association between obstetrics factors and obesity was evaluated through multivariate logistic regression. The following variables remained in the logistic regression after adjustments for total income, smoking, alcohol consumption, and physical activity: age at menarche < 12 years (OR = 3.02; 95% CI: 1.62-5.61), age > 30 and < 39 (OR = 1.72; 95% CI: 1.01-2.92), age > 40 years (OR = 3.32; 95% CI: 1.76-6.27), age at first childbirth (OR = 1.99; 95% CI: 1.07-3.68), and the following interaction: age group > 30 and < 39 and age at menarche (OR = 0.27; 95% CI: 0.09-0.83). It appears that obstetric factors affect obesity through a complex network of interrelations that involve the covariates studied above. It is important to support efficient programs to prevent obesity, as well as family planning programs emphasizing a reduction in the prevalence of teenage pregnancies.

Magnitude da mortalidade por câncer do colo do útero na Região Nordeste do Brasil e fatores socioeconômicos

OBJETIVO: Analisar a tendencia temporal da mortalidade por câncer do colo do utero segundo dados de obito corrigidos ou nao e verificar a associacao entre essas informacoes e indicadores socioeconomicos selecionados em mulheres com 20 anos ou mais residentes no Nordeste do Brasil (capital e interior) no periodo de 1996 a 2005. METODOS: Foram incluidos no estudo os obitos por câncer do colo do utero captados do Sistema de Informacoes sobre Mortalidade (SIM) e aqueles identificados como sendo decorrentes dessa neoplasia apos processo de correcao. Atraves de regressao linear simples, foram analisadas as tendencias temporais da mortalidade e as correlacoes com os indicadores socioeconomicos selecionados atraves de correlacao de Pearson (r). RESULTADOS: As maiores taxas de mortalidade por câncer do colo do utero sem correcao corresponderam as capitais e as menores foram observados no interior dos estados. Por outro lado, os maiores coeficientes de mortalidade corrigidos foram observados para o interior dos estados e os menores para as capitais, invertendo o quadro. Da mesma forma, as menores taxas de mortalidade sem correcao foram observadas nos estados com maior pobreza, analfabetismo, fecundidade e mortalidade infantil, enquanto as maiores taxas de mortalidade sem correcao foram observadas nas regioes com melhores indicadores sociais. As taxas corrigidas mostraram associacao negativa com os indicadores que assinalam melhores condicoes de vida, e positiva com os indicadores que descrevem piores condicoes de vida. CONCLUSOES: A utilizacao de dados nao corrigidos de mortalidade pode levar a subestimacao do câncer do colo de utero e comprometer as interpretacoes de analises comparativas sobre a magnitude, distribuicao e fatores associados a essa doenca. A magnitude desse câncer merece ser reavaliada, pelo menos no Nordeste do Brasil. Contudo, os resultados demonstram que ja ha resultados positivos da deteccao precoce na regiao.

Correction for reported cervical cancer mortality data in Brazil, 1996-2005.

OBJECTIVE To develop a methodology for correction of reported cervical cancer deaths in Brazil. METHODS Data on 9,607,177 cancer deaths were obtained from the Brazilian National Mortality Database for the period between 1996 and 2005. For correction of underreporting of deaths, factors generated by the Global Burden of Disease Study in Brazil-1998 were used. Proportional distribution was used in order to correct the categories of unknown, incomplete or ill-defined death diagnosis. The corrections were applied to each Brazilian state and the results were presented for Brazil nationwide, macroregions, and geographical areas (capital, other cities of metropolitan areas and interior cities) as percent variability of cervical mortality rates before and after correction. Corrections were analyzed by multivariate linear regression with interaction terms between macroregion and geographical area. RESULTS After correction, cervical cancer mortality rates showed an increment of 103% nationwide, ranging between 35% (Southern region capitals) and 339% (Northeastern region interior cities). The reallocation of cervical cancer deaths not otherwise specified resulted in greater mortality rate increments. The percent correction by year of death revealed steady trends nationwide. CONCLUSIONS The study results showed that the proposed methodology was appropriate for the correction of cervical cancer mortality rates in Brazil. It evidenced that cervical cancer mortality is even higher than that reported.OBJETIVO: Desenvolver uma metodologia para correcao da magnitude dos obitos por câncer do colo do utero no Brasil. METODOS: Os dados sobre os 9.607.177 obitos foram obtidos do Sistema de Informacao sobre Mortalidade, para o periodo de 1996 a 2005. Para a correcao do sub-registro, foram utilizados os fatores de expansao gerados pelo Projeto Carga Global de Doenca no Brasil - 1998. Para correcao das categorias de diagnosticos desconhecidos, incompletos ou mal definidos de obitos, foi aplicada redistribuicao proporcional. Os dados ausentes de idade foram corrigidos por imputacao. As correcoes foram aplicadas por Unidade Federativa e os resultados apresentados para o Brasil, regiao e areas geograficas (capital, demais municipios das regioes metropolitanas e interior) por meio do percentual de variabilidade da magnitude das taxas, antes e apos a correcao dos obitos. O comportamento das correcoes foi analisado por modelo de regressao linear multivariada com termos de interacao entre regiao do Pais e area geografica. RESULTADOS: As taxas corrigidas de mortalidade por câncer do colo do utero no Brasil mostraram um acrescimo de 103,4%, variando de 35% para as capitais da regiao Sul a 339% para o interior da regiao Nordeste. A redistribuicao dos obitos por câncer de utero sem especificacao de localizacao anatomica promoveu os maiores acrescimos na magnitude das taxas. Os percentuais de correcao, segundo ano de ocorrencia do obito, mostraram tendencia estacionaria no Brasil. CONCLUSOES: Os resultados permitem concluir que a metodologia proposta foi adequada para corrigir a magnitude das taxas de mortalidade por câncer do colo do utero no Pais, mostrando que a mortalidade por esse câncer e ainda maior do que o observado nos informes oficiais.