Revista de saude publica最新文献

Objective: To analyze the recrudescence of tuberculosis in the state of São Paulo after the COVID-19 pandemic, identifying temporal trends and spatial clusters of the disease.

Methods: An ecological study of tuberculosis cases reported on TBWeb in all São Paulo municipalities between January 2015 and December 2023. Time decomposition techniques, interrupted time series analysis by month and spatial analysis by municipality (global Moran index and Getis-Ord Gi*) were applied to identify trends, abrupt changes associated with the pandemic and clusters of high incidence, mortality, and treatment outcomes. The pre-pandemic (01/2015 to 01/2020), pandemic (02/2020 to 04/2022), and post-pandemic (05/2022 to 12/2023) periods were analyzed separately.

Results: There was an upsurge in tuberculosis in the post-pandemic period, with a 21.2% increase in the number of municipalities with an incidence > 110 cases per 100,000 inhabitants. There was a progressive increase in the mortality trend of 0.0026 (95%CI: 0.0016 to 0.0035) deaths per 100,000 inhabitants per month after the pandemic. There was a gradual drop of 0.67% (95%CI: -1.099 to -0.246) per month in the proportion of people cured after the pandemic. High incidence clusters persisted in the Presidente Prudente region in all periods, and new clusters in Marília and Registro after the pandemic. Areas with high mortality rates persisted in the regions of Taubaté, Baixada Santista, Grande São Paulo, Registro, Sorocaba and Campinas in all periods.

Conclusion: The recrudescence of tuberculosis in São Paulo in the post-pandemic context highlights the need for targeted strategies for early diagnosis, strengthening treatment and intensive monitoring in regions identified as clusters, especially those with vulnerable populations and structural challenges in health services.

Objective: To analyze hospitalizations, mortality, and costs related to cerebrovascular diseases in Brazil from 2017 to 2022 and to evaluate the impact of the COVID-19 pandemic on these numbers.

Methods: Data were collected from the Brazilian Unified Health System Information Technology Department via the Hospital and Mortality Information Systems. The 2010 censuses and the inter-census projections (2017 to 2022) of the Brazilian Institute of Geography and Statistics were searched for population data. The mortality rates and incidence of hospital admissions for cerebrovascular diseases were calculated by dividing the number of deaths and the number of hospital admissions due to cerebrovascular diseases by the total population at risk, multiplied by 100,000 inhabitants, respectively. The results were stratified by age groups, regions of Brazil, sex, and calendar years. Rates were standardized by age, following the direct method from the World Health Organization.

Results: Data on mortality from cerebrovascular diseases showed a significant reduction throughout Brazil in general and by sex. The Brazilian Northeast showed a decrease in overall mortality, especially in women, whereas its South showed stationary numbers. Hospitalization rates remain stable, with notable increases in the age groups for younger (from zero to four years of age) and female (from five to nine years of age). Hospitalization costs increased significantly throughout Brazil, with the highest increase in its Northeast, North, Southeast, and Midwest.

Conclusion: Mortality rates from cerebrovascular diseases decreased in Brazil, showing regional and age group variations and a worrying increase in young men. Despite stable hospitalizations, hospital costs significantly increased, indicating greater complexity of cases and reinforcing the need for more effective prevention and control strategies.

Objective: To analyze the temporal trend of the double burden of malnutrition in the Brazilian semi-arid and non-semi-arid regions, and to assess its spatial distribution in the Brazilian semi-arid region among children aged 5 to 9 years, between 2008 and 2022.

Methods: Ecological time-series study based on public reports, using macrodata of body mass index-for-age and height-for-age from the Sistema de Vigilância Alimentar e Nutricional (SISVAN - Brazilian Food and Nutritional Surveillance System). For temporal analysis of the prevalence of wasting, overweight, stunting, undernutrition, and the double burden of malnutrition in the semi-arid and non-semi-arid regions, Prais-Winsten regression models were used to estimate the annual percentage change (APC%) between 2008 and 2022. To evaluate spatial distribution in the Brazilian semi-arid region, maps showing the temporal evolution of the prevalence of overweight, undernutrition, and the double burden of malnutrition were constructed.

Results: Between 2008 and 2022, 48.7 million children aged 5 to 9 years were registered in SISVAN-Web for body mass index-for-age and height-for-age indices. Approximately 28.1% of these lived in the Brazilian semi-arid region. The prevalence of the double burden of malnutrition in the semi-arid region exceeded 20%, with an increasing trend among children aged 7 to 9 years (APC = 0.61%; p < 0.05). Overweight showed a rising trend, while undernutrition decreased across all strata except among the Indigenous population, which remained stable (APC = -1.12%; p > 0.05). APCs in the semi-arid region were higher than in the non-semi-arid region.

Conclusion: The study highlights a high prevalence of the double burden of malnutrition in the Brazilian semi-arid region, especially among children aged 7 to 9 years. Therefore, it is crucial to promote health actions and malnutrition prevention, strengthening existing policies and prioritizing the most vulnerable populations.

Objective: To identify barriers to the implementation of the World Health Organization Safe Childbirth Checklist in two reference maternity hospitals-one for high-risk and one for routine-risk childbirths-and to develop a causal model applicable to these contexts.

Methods: This qualitative, exploratory study was conducted in two public maternity hospitals that had been using the checklist, since its implementation in 2014. Data were collected through focus groups interviews and brainstorming sessions conducted in 2022 and 2023. Participants included healthcare professionals involved in childbirth care and members of the patient safety center. Content analysis categorized findings based on the five domains of the Consolidated Framework for Implementation Research (CFIR). A causal model was developed using a fishbone diagram to organize results by category.

Results: The identified barriers were classified into four of the five CFIR domains. In the Innovation domain, the checklist itself posed challenges due to its design, complexity, and adaptability to existing workflows. In the Inner Setting, barriers included a weak patient safety culture and infrastructure limitations. The Implementation Process domain revealed deficiencies such as inadequate planning, lack of stakeholder involvement, and absence of feedback and assessment mechanisms. Unlike the high-risk maternity hospital, the Outer Setting barrier -lack of policies supporting continuing education-was identified in the routine-risk facility.

Conclusions: Implementation of the checklist in the studied maternity hospitals is hindered by structural, cultural, and adaptation challenges. Limited investment in training represents a significant obstacle, highlighting the need for professional development programs. High staff turnover and the absence of specific protocols further compromise consistent use. Addressing these barriers requires comprehensive strategies to enhance adherence to and integration of the checklist in maternal-newborn care.

Objective: To describe the purchase of foods included in the new staple food basket by low-income households in Brazil, from 2017 to 2018.

Methods: Data on household food purchases were obtained from the 2017-2018 Household Budget Survey, conducted by the Instituto Brasileiro de Geografia e Estatística (Brazilian Institute of Geography and Statistics). Data from 13,706 low-income households (< ½ minimum wage per capita) were analyzed. Foods were identified based on an ordinance issued by the Ministry of Social Development and Fight Against Hunger, which specifies the composition of the new staple food basket. Estimates were expressed as a percentage of caloric intake.

Results: Foods introduced into the new staple food basket accounted for 84.1% of the total calories purchased by low-income households in Brazil, from 2017 to 2018, with significant participation in rural areas (88.0%) and in the North (88.2%) and Northeast (85.9%) regions. Among food groups, cereals (33.5%), sugars and oils/fats (21.3%), and meats and eggs (11.6%) presented the highest contributions. Rice, corn, and other grains contributed 19.7%, whereas beans accounted for 4.7% of calories. Poultry meat and beef were the most purchased foods in the meat and egg group, representing 5.0% and 4.0% of calories, respectively. Fruits contributed 1.9% and vegetables 0.7% of calories. We observed no major differences in food purchase regarding the race/skin color of the head of the household.

Conclusion: Analysis shows that in the 2017-2018 period, the foods included in the new staple food basket became the basis of low-income households' diet, reinforcing the cultural viability of its implementation.

Objective: The study analyzes the prices paid by Brazilian municipalities for medicines in 2016, 2018, and 2020, comparing municipal human development index, size, region, and purchase modality.

Methods: Economic Ratio indicator, adapted from that proposed for international analyses by the World Health Organization, was used and analyses were performed using data provided by municipalities to the National Database of Pharmaceutical Assistance Actions and Services.

Results: The study reveals that the most socially and economically vulnerable municipalities pay more for these medicines, especially in the North and Northeast regions, which can compromise access to and the efficiency of the Unified Health System. Moreover, the article shows that municipalities that purchased in association tend to pay lower prices, suggesting that consortia may be a strategy to mitigate price inequalities.

Conclusions: Based on the results obtained, we propose the adoption of regulatory, economic, and negotiation strategies to reduce these differences and ensure a more equitable distribution of medicines in Brazil.

Objective: To investigate the association between depressive symptoms and neighborhood perception among older adults living in urban areas.

Methods: This cross-sectional study included 7,115 individuals (≥ 50 years) from the baseline (2015-2016) of the Estudo Longitudinal da Saúde dos Idosos Brasileiros (ELSI-Brazil - Brazilian Longitudinal Study of Aging) who lived in urban areas and had self-reported responses (no proxy respondents), with complete data on the outcome. The outcome was assessed using the 8-item Center for Epidemiologic Studies-Depression Scale (CES-D-8) (cutoff ≥ 4), and the exposure variable was neighborhood perception related to participants' area of residence. Univariable and multivariable Poisson regression analyses were performed, with each exposure variable adjusted for sociodemographic characteristics and health conditions.

Results: The prevalence of depressive symptoms was 34.9%, being 43.8% among women and 24.5% among men. In the multivariable analysis, urban mobility issues, noise pollution, physical disorder, violence, lack of neighborhood pleasantness, low social cohesion, and perceived insecurity were significantly associated with a higher prevalence of depressive symptoms in the overall sample and among women. Among men, all variables except perceived insecurity were also significantly associated with higher prevalence of depressive symptoms.

Conclusion: The findings highlight the importance of intersectoral action across health, urban mobility, public safety, and urban planning policies to promote mental health among older adults living in urban areas.

Objective: To analyze the association between user dissatisfaction with the pharmaceutical services provided by the Brazilian Unified Health System (SUS) and nonadherence to medication use by patients with chronic non-communicable diseases.

Methods: A cross-sectional study with data from the service evaluation component of the Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos in Brazil, conducted from July to December 2014. In-person interviews were analyzed with SUS users aged 18 or over who had used medications for hypertension, diabetes, and dyslipidemia and had visited SUS pharmacies in the three months prior to the survey. The dependent variable was medication nonadherence, assessed through three measures: nonadherence due to lack of medication, nonadherence in the past seven days and declared nonadherence. The independent variable was dissatisfaction with the dimensions of pharmaceutical services (timeliness, availability, and accommodation), measured using item response theory. Logistic regression was performed to calculate crude and adjusted odds ratios (OR).

Results: A total of 2,448 users were evaluated. Nonadherence due to lack of medication was 31.6%; in the past seven days was 11.5%; and declared nonadherence 13.0%. Lack of access and forgetfulness were the main reasons for nonadherence in the past seven days. In the adjusted analysis, dissatisfaction with the "timeliness" dimension was associated with nonadherence in the past seven days (OR = 1.489; 95%CI: 1.023-2.168) and the "accommodation" dimension was associated with declared nonadherence (OR = 3.132; 95%CI: 2.266-4.329).

Conclusion: Dissatisfied users were more likely to be nonadherent to medication use across all service dimensions, and dissatisfaction with the availability and accommodation of pharmaceutical services was associated with nonadherence.

Objective: To analyze yellow fever mortality trends in Brazil, focusing on sexes differences and using an age-period-cohort model.

Methods: This ecological study analyzed yellow fever mortality data in Brazil from 1980 to 2019 sourced from Datasus. Population estimates were retrieved from the Instituto Brasileiro de Geografia e Estatística (Brazilian Institute of Geography and Statistics). Mortality data, including age, year of death, and cause (ICD-9: 060; ICD-10: A95), were analyzed using an age period cohort model. A Poisson distribution was assumed for mortality counts, and analyses were conducted using Holford's method and its adaptations on R.

Results: The results show that the incidence rate peaked at younger ages, such as 30 years (0.010/100,000 individuals, 95%CI: 0.008/100,000 to 0.013/100,000), followed by a gradual declining trend with increasing age, reaching 0.007/100,000 individuals (95%CI: 0.005/100,000 to 0.010/100,000) at 50 years onward. Regarding period, a substantial increase in the adjusted hazard ratio occurred over time, especially in 2015 (13.923 [95%CI: 11.095 to 17.471]), suggesting a significant elevation when compared with previous periods. Cohort analysis showed a trend of increasing risk until 1960 (RR = 1.000), followed by a marked reduction for more recent cohorts, such as 2010: RR = 0.056 (95%CI: 0.028 to 0.112). Vaccination analysis showed alternating periods of significant increases and decreases in vaccination rates.

Conclusions: Younger individuals showed higher mortality rates, with a gradual decline with advancing age. Period effects highlighted a pronounced resurgence in recent years, particularly during the 2015 epidemic, underscoring the influence of temporal factors such as outbreaks and vaccination campaigns. Cohort analysis showed a progressive decline in mortality risk among more recent birth cohorts, likely reflecting the impact of expanded immunization programs and improved public health measures. The proposed yellow fever vaccination trends in Brazil may explain some of the observed patterns.

Objective: Compare the overall survival of women with non-metastatic breast cancer who received neoadjuvant systemic therapy followed by surgery versus those who underwent surgery followed by adjuvant systemic therapy.

Methods: A nationwide retrospective cohort study was conducted using real-world data from 2008 to 2015 available on the Brazilian Unified Health System (SUS). Women aged ≥ 18 years with breast cancer undergoing surgery or neoadjuvant systemic therapy as their first treatment between 2008 and 2010 were included. Cohorts were matched using propensity score matching in a 1:1 ratio and assessed 5-year overall survival using Kaplan-Meier, compared by log-rank test and hazard ratios (HR) using Cox proportional HR model.

Results: A total of 23,331 women began treatment for breast cancer in SUS with neoadjuvant systemic therapy (n = 6,040) and surgery (n = 17,291). In the matched cohorts (n = 6,040 in both groups), more deaths occurred among those who received neoadjuvant systemic therapy compared with surgery as first treatment (37.3% and 19.6%, respectively; p < 0.001). Overall survival after five years was 0.641 in neoadjuvant systemic therapy and 0.816 in the surgery group (p < 0.001). For both groups, older patients (≥ 70 years) living in northern and midwestern Brazil, in municipalities with low and medium HDI, and self-declared as Black presented the lowest overall survival probabilities. Use of hormone therapy after surgery and conservative surgery instead of mastectomy were associated with higher survival. HR was 5.13 (95%CI: 2.95-8.88) in stage I, 1.57 (95%CI: 1.27-1.95) in stage II, and 1.38 (95%CI: 1.26-1.50) in stage III.

Conclusion: Women who underwent surgery as first treatment had a significantly higher 5-year overall survival compared with those who received neoadjuvant systemic therapy. Socioeconomic and demographic factors influenced survival outcomes.