José Carlos de Carvalho Leite

Proposta de metodologia para selecionar indicadores de desigualdade em saúde visando definir prioridades de políticas públicas no Brasil

Promover a saude com equidade e um grande desafio para os gestores publicos. A magnitude das desigualdades sociais em saude e os recursos escassos impoem que as prioridades para a gestao publica se fundamentem no conhecimento da situacao de saude e do impacto de politicas, programas, projetos e acoes sobre a saude e seus determinantes. Este artigo apresenta a proposta metodologica de construcao e selecao de indicadores de desigualdades em saude utilizada pela Pesquisa Avaliativa de Desigualdades em Saude no Rio Grande do Sul (PADS-RS) para auxiliar a definicao de prioridades para a gestao publica. Os indicadores foram construidos visando avaliar desigualdades em saude como diferencas na qualidade de vida e capacidades humanas socialmente determinadas. A metodologia baseia-se em principios de promocao ativa da equidade que orientam (1) o Sistema Unico de Saude Brasileiro, (2) as pesquisas avaliativas de desigualdades em saude realizadas no Reino Unido e (3) o metodo RAWP (Resources Allocation Working Party) de alocacao de recursos financeiros publicos em saude entre regioes e considera as peculiaridades dos sistemas oficiais de informacao no Estado e no Brasil.

Fatores de risco para sobrepeso em crianças no Sul do Brasil

Risk factors for overweight were investigated in a cross-sectional survey of children aged 12-59 months in the Southern Brazilian city of Porto Alegre (n = 2,660). Odds ratios (OR) for overweight, defined by weight/height > 2 z-scores of the NCHS standards, were estimated for socioeconomic and demographic conditions, social environment, and childhood health events. Prevalence of overweight was 6.5%. In the multivariate model, the odds of overweight were positively associated with maternal education (schooling > 12 years, OR = 2.36; 95%CI: 1.21-4.60; 9-11 years, OR = 2.07; 95%CI: 1.16-3.70) and family income per capita > 2 times the minimum wage (OR = 1.86; 95%CI: 1.13-3.08) and negatively associated with maternal work (OR = 0.72; 95%CI: 0.52-0.99). Odds were higher for children born large-for-gestational-age (OR = 2.29; 95%CI: 1.36-3.85) and lower for children born small (OR = 0.57; 95%CI: 0.33-0.99), as compared to those born with adequate birth weight for gestational age. Paternal schooling, parental occupation, and maternal age at the childs birth were associated with overweight in the unadjusted model only. Programs are needed to prevent overweight during childhood, with special attention to families and children at increased risk.

Desigualdade social e outros determinantes da altura em crianças: uma análise multinível

Estudo transversal de base populacional sobre altura de criancas de 12 a 59 meses (n = 2.632) foi realizado em Porto Alegre, Brasil. Usou-se regressao linear multinivel para investigar o efeito de condicoes socio-economicas, demograficas, de saude e dos ambientes fisico e social sobre a altura, medida em escores-z do padrao de altura para idade do National Center for Health Statisrics. A area de localizacao do domicilio foi classificada como bem e mal provida em infra-estrutura habitacional. A altura foi, em media, -0,18 escore-z, estando positivamente associada a escolaridade e qualificacao ocupacional dos pais, renda, qualidade de moradia, idade materna, intervalo interpartal e peso de nascimento, e negativamente relacionada a prematuridade, numero de menores de cinco anos no domicilio e hospitalizacao nos dois primeiros anos de vida. O efeito da educacao materna foi o dobro nas areas mal providas em infra-estrutura habitacional. O efeito positivo da qualificacao ocupacional dos pais foi evidente apenas nas areas mal providas. Provavelmente, a area de residencia modifica o efeito das condicoes socio-economicas sobre o crescimento. Programas habitacionais e de saneamento sao potencialmente uteis para diminuir o efeito de condicoes socio-economicas desfavoraveis sobre o crescimento da crianca.

Desenvolvimento de uma escala de auto-eficácia para adesão ao tratamento anti-retroviral

A 21-item scale of efficacy-expectation for adhesion to antiretroviral therapy in high-risk situations was developed by content analysis of interviews with HIV/AIDS patients undergoing and dropouts from therapy. Internal consistency and construct validity were examined in 60 patients attending at an ambulatory for patients in advanced stages of the disease (day-hospital). A score of self-efficacy for treatment adhesion was derived from the first component of the principal component analysis. The mean score was 0.25 among adherent patients and n0.33 among those who were non-adherent (t test, p < 0.046). The odds of treatment adhesion increased 2,07 times when the efficacy-expectation score increased by one unit (OR = 2,07; IC95% = 1,002 a 4,26). The internal consistency was high (Cronbach-alpha = 0.96). The scale demonstrated construct validity and reliability as a measure of self-efficacy for antiretroviral therapy in these patients.

Characteristics of HIV antiretroviral regimen and treatment adherence

The relationship between characteristics of HIV antiretroviral regimens and treatment adherence was studied in adolescent and adult patients who underwent antiretroviral therapy from January 1998 to September 2000, at the Service for Specialized Assistance in Pelotas. The patients were interviewed on two occasions, and the use of antiretrovirals during the previous 48 hours was investigated by a self-report. Adherence was defined as use of 95% or more of the prescribed medication. Social-demographic variables were collected through direct questionnaires. The antiretroviral regimen and clinical data were copied from the patients records. Associations between the independent variables and adherence were analyzed by means of logistic regression. The multivariate analysis included characteristics of the antiretroviral regimens, social-demographic variables, as well as perception of negative effects, negative physiological states, and adverse effects of the treatment. Among the 224 selected patients, 194 participated in our study. Their ages varied from 17 to 67 years; most patients were men, with few years of schooling and a low family income. Only 49% adhered to the treatment. Adherence to treatment regimens was reduced when more daily doses were indicated: three to four doses (odds ratio of adherence to treatment (OR)=0.47, 95% confidence interval (CI) 0.22-1.01) and five to six (OR=0.24, 95% CI 0.09-0.62); two or more doses taken in a fasting state (OR=0.59, 95% CI 0.11-0.68), and for patients who reported adverse effects to the treatment (OR=0.39, 95% CI 0.19-0.77). Most of the regimens with more than two daily doses of medication included at least one dose apart from mealtimes. The results suggest that, if possible, regimens with a reduced number of doses should be chosen, with no compulsory fasting, and with few adverse effects. Strategies to minimize these effects should be discussed with the patients.

Predictors of Undetectable Plasma Viral Load in HIV-Positive Adults Receiving Antiretroviral Therapy in Southern Brazil

Factors associated with undetectable viral load (<80 copies/ml) were investigated among non-pregnant adults in antiretroviral treatment in a specialized service for HIV/AIDS in Southern Brazil. Use of antiretrovirals was investigated in two interviews (one month interval). Clinical data were collected from the clinical records; viral load previous to adherence measurement was defined the viral load previous to the first interview; the final viral load, the viral load subsequent to the second interview (interval between measures approximately 6 months). Undetectable final viral load occurred in 48% of the patients and was positively associated with levels of treatment adherence (p<0.001), being 19% for less than 60% of adherence and about 60% for adherence greater than 80%. In the multivariate model, the odds of undetectable final viral load was four times greater for 80-94% and > or =95% of adherence (CI 95% 1,80-13,28; CI 95% 1,73-9,53), compared with less than 60% adherence; it was greater for less than 6 months in treatment (OR = 3.37; CI 95% 1.09-10.46); and smaller for viral load previous to adherence measurement 5.2 log10 (OR = 0.19; CI95% 0.06-0.58), adjusted for these variables and sex, age, clinical status, current immune status, group of drugs and interval between the two measurements of viral load. The crude odds were lower for age 16-24 years and use of Nucleoside Analog Reverse Transcriptase Inhibitors only, but these effects were not significant in the multivariate model. There was no evidence of effect of sex, clinical status, current immune status, and changes in treatment regimen. Treatment adherence gave the largest effect. Motivational interventions directed at adherence may improve treatment effectiveness.

Factors associated with post-diagnosis pregnancies in women living with HIV in the south of Brazil

Objectives To analyze the factors associated with the occurrence of pregnancies after the diagnosis of infection by HIV. Methods Cross-sectional study with women of a reproductive age living with HIV/AIDS cared for in the public services of the city of Porto Alegre, in southern Brazil. The data was analyzed from a comparison between two groups: women with and women without pregnancies after the diagnosis of HIV. Poisson regression models were used to estimate the reasons of prevalence (RP). Results The occurrence of pregnancies after the diagnosis of HIV is associated with a lower level of education (RP adjusted = 1.31; IC95%: 1.03–1.66), non-use of condoms in the first sexual intercourse (RP = 1.32; IC95%: 1.02–1.70), being 20 years old or less when diagnosed with HIV (RP = 3.48; IC95%: 2.02–6.01), and experience of violence related to the diagnosis of HIV (RP = 1.28; IC95%: 1.06–1.56). Conclusions The occurrence of pregnancies after the diagnosis of infection by HIV does not indicate the exercise of the reproductive rights of the women living with HIV/AIDS because these pregnancies occurred in contexts of great vulnerability.

Social inequalities in maternal opinion of child development in southern Brazil: Short Communications

Aims and methods: Concurrent validity of maternal opinion of child development was estimated in a cross‐sectional, population‐based survey of 6–59‐mo children (n=3025), using a standard measure devised from the Denver Developmental Screening Test. Results: Sensitivity, specificity and negative predictive value increased with maternal education and family income. Positive predictive value was higher in low‐income families and children with impairments, low birthweight and long hospital stays.