Revista Panamericana De Salud Publica-pan American Journal of Public Health最新文献

Objective: Tobacco use is a major modifiable risk factor for the four main noncommunicable diseases (NCDs) globally-cardiovascular diseases, chronic respiratory conditions, cancer, and diabetes. Addressing tobacco use through cessation interventions is therefore a cornerstone of comprehensive NCD prevention and control efforts. In this context, strengthening cessation support within primary health care has emerged as a high-impact and cost-effective strategy to accelerate progress toward NCD targets.

Methods: Despite advances in tobacco control, cessation support remains insufficiently implemented across much of the Region of the Americas. This article examines progress made between 2007 and 2024 in implementing the World Health Organization (WHO)-recommended tobacco cessation measures, with a focus on the availability, cost coverage, and integration of services within health systems.

Results: Only 7 of the 35 countries in the Americas achieved the highest level of cessation support, which combines national free quit lines, the availability of nicotine replacement therapy (NRT), and the provision of cessation services with partial or full cost coverage. Although these countries represent over 70% of the population, disparities persist-particularly in the Caribbean and in lower-middle-income countries. Findings show that NRT and other pharmacological treatments are inconsistently available, treatment costs are often not covered, and quit lines operate in only 40% of countries. These gaps underscore the urgent need for stronger policies, sustainable financing, and improved health system coordination.

Conclusion: Tobacco cessation must be prioritized as an essential health service, integrated into national NCD strategies, and supported by legal and institutional frameworks guaranteeing equitable access. Strengthening cessation is essential to reducing tobacco use and its health and economic burden across the Americas.

Objective: To assess patient-reported experiences of access to services along the Cardio-Cerebrovascular and Metabolic Comprehensive Healthcare Pathways (CVD-RIAS) among patients with hypertension and/or diabetes in two primary health care networks in Bogotá, highlighting achievements and identifying remaining challenges to integrated care.

Methods: Cross-sectional descriptive analysis using baseline data from patients with confirmed hypertension and/or type 2 diabetes enrolled in CVD-RIAS. In-person surveys and linked clinical records were used to examine access experiences across consultations, tests, prescriptions, and medication delivery. Results were stratified by age, education, income, and Charlson Comorbidity Index.

Results: Of 1 258 patients, 85.5% reported no access issues for hypertension or diabetes care. Most (80%) rated contact frequency positively; most contacted were general physicians and pharmacies. Most patients contacted at least one professional (99.6%), received diagnostic tests (88%,) and obtained some or all prescribed medications (97.3%). Sixty percent accessed specialists, mostly through the assigned network. Median specialist wait was two months, longer for high-risk and higher-income patients. Perceptions were split: 45% found wait times reasonable, 45% did not. Ratings of contact frequency, wait times, and access to referred services varied by sociodemographic characteristics. Overall, patient care pathways were aligned with milestones defined in CVD-RIAS.

Conclusions: The CVD-RIAS model is achieving goals of expanding access to services, aligning care delivery with clinical risk, and fostering positive patient experiences. These findings reflect progress toward risk-based, integrated service delivery. Remaining gaps - incomplete medication supply and difficulties accessing referred services - underscore the need for efforts to enhance coordination and equity.

Objective: Maternity waiting homes (MWHs) are residential facilities where pregnant women live during the last few weeks of their gestation and can easily be transported to a hospital equipped to provide obstetric emergency care or skilled birth attendance. The expansion of MWHs has been associated with the prevention of obstetric complications. This paper examines how MWHs have been implemented across Latin America, analyzing their evolution, the specific needs they address in different countries, and their impact on maternal and neonatal health outcomes throughout the region.

Methods: The methodology of this study was based on a comprehensive narrative review of the literature available from the online databases PubMed, Google Scholar, EBSCOhost, and SciELO in Spanish, English, and Portuguese, using a keyword search that included the Latin American region and country names, and on discussions with key informants in Cuba.

Results: The findings show that, in Latin America, MWHs were first implemented in Cuba in 1962, followed years later by Chile, Nicaragua, Guatemala, Honduras, Peru, Brazil, Panama, Paraguay, Mexico, and Colombia. In all these countries, MWHs were established as a strategy to reduce maternal mortality, albeit through various funding models and with varying levels of quality and consistency of services. Community engagement, cultural responsiveness, funding sustainability, women's autonomy, breadth and quality of services, and the evolution of MWHs beyond their original purpose are among the emergent themes in our findings. While countries such as Chile, Panama, and Peru have modified MWH designs and operations to incorporate indigenous traditional birthing practices and cultural preferences, countries such as Brazil, Cuba, and Paraguay have focused on practices that prioritize numerical outcomes over women's experiences and autonomy.

Conclusions: The findings suggest a critical gap between the theoretical design of MWH programs and their practical implementation. The evolution of MWHs suggests that they address a spectrum of needs beyond their original purposes, such as providing culturally responsive maternal support and psychosocial and early childhood support. MWHs may be effective in reducing maternal and neonatal mortality when incorporated as part of wider maternal health strategies. Countries with persistently high maternal mortality, especially those with significant geographical barriers to care, could benefit from incorporating MWHs. Remarkably, we did not find MWHs in any of the countries with the highest maternal mortality ratios in the region: Haiti, Venezuela, Bolivia, Jamaica, and the Dominican Republic.

Objective: To explore healthcare stakeholders' experiences of care coordination during cancer diagnosis in Chile, Colombia, and Ecuador, including how these experiences are influenced by factors related to the countries' public subsystems.

Methods: A qualitative study was conducted based on 115 semi-structured interviews with healthcare professionals and administrative personnel in both primary care (n = 40) and secondary/tertiary care (n = 46) as well as managers and policymakers (n = 29). Thematic analysis, guided by a care coordination framework, was performed first per country and then across countries.

Results: The analysis points to limited transfer of clinical information causing repeated tests as well as poor clinical management coordination in terms of delayed referrals from primary care and restricted access to specialized care, altogether contributing to diagnostic delays. Self-reinforcing loops of barriers for care coordination included fragmented clinical information systems, poor skills and training among healthcare professionals, as well as insufficient diagnostic equipment in all three study countries, scarcity of specialized healthcare professionals and functioning of the prioritization system for certain cancers in Chile, and working conditions and insurance companies' management of care in Colombia. Informal communication strategies and personal networks emerged as adaptive responses to these challenges, facilitating coordination in some cases but also risking data security and consistency in care.

Conclusions: The study highlights the urgent need for political prioritization of cancer care coordination, including investments in unified clinical record systems, training of healthcare professionals, and diagnostic infrastructure. It also emphasizes the importance of recognizing healthcare stakeholders' responses to barriers.

Objective: Using real-world parameters, to estimate the number of procedures associated with cervical cancer to be incorporated with the implementation of organized screening with HPV-DNA testing, and to project these estimates within Brazil's Unified Health System (SUS).

Methods: This is a descriptive study using data from the PREVENTIVO program in Indaiatuba, a municipality in the state of São Paulo (2017-2023), which used HPV-DNA testing to screen women aged 25 to 64 years. Based on data regarding test performance, reflex cytology, colposcopy, biopsy, cervical excisions, and referral to high-complexity care, the annual need for these procedures was estimated considering national guidelines and coverage by the supplementary private health system. These estimates were compared with the number of procedures performed nationwide in 2024 in the context of opportunistic screening with cytology (Pap smear).

Results: HPV-DNA test positivity was 12.7% (3.4% for HPV16/18 and 9.3% for other high-risk HPV types). The estimated number of annual procedures to implement the program in Brazil in 2025 included: 8.2 million HPV DNA tests, 759,000 reflex cytology tests, 506,000 colposcopies, 355,000 biopsies, and 127,000 excisional procedures. Considering the current supply, there were shortfalls in all states and regions, especially for colposcopy, biopsy, and excision, with differences of up to -96.5% relative to estimated demand.

Conclusion: The transition to screening with HPV DNA testing requires restructuring the supply of procedures in the SUS. The parameters presented here support regionalized planning, promoting efficient resource allocation and reducing inequities in access.

Objectives: This study sought to analyze the current state of the training for and practice of family medicine and family and community medicine to identify gaps and opportunities to implement strategic actions to strengthen the health workforce.

Methods: This paper reports the results of an observational, analytical, cross-sectional study carried out in countries in the World Health Organization's Region of the Americas in 2024. A 22-item survey was administered to members of professional associations of family medicine and family and community medicine practitioners, and a 12-item survey was administered to specialists in this field. Nineteen professional associations and 291 specialists took part in the study. The data were analyzed using descriptive statistics and content analysis.

Results: Training in family medicine and family and community medicine is primarily conducted through specialization (68.4%, 13/19) and residency programs (63.2%, 12/19), and a competency exam is required in 63.2% (12/19) of the 23 countries included in the study, represented by 19 professional associations. Training programs cover topics relevant to professional practice, but progress needs to be made, especially in addressing emerging topics. There are few opportunities for continuing education, as reported by 53.7% (29/54) of specialists in Central America, the Latin Caribbean and Mexico, and 35.0% (79/226) in South America. There is a gap in actions aimed at improving working conditions, with policies for well-being and retention implemented in only 36.8% (7/19) of the countries. In addition, responses to open-ended questions indicated that many professionals had a heavy workload, and that their jobs were insecure and precarious, as well as that remuneration was incompatible with their functions, that infrastructure was inadequate, and there was a lack of resources for practice. Despite sampling limitations related to the non-probabilistic design of the study and the unequal participation among countries, it nonetheless provides valuable evidence about training and practice in family and community medicine in the Region of the Americas.

Conclusions: Although the practice of family medicine and family and community medicine has been established for more than three decades in the Region, the field faces significant implementation challenges. Strategic investments are needed to strengthen the recognition and perceived value of family and community medicine as a specialty, ensure adequate working conditions and improve the quality of education. Strengthening family and community medicine by undertaking coordinated actions across multiple stakeholders is crucial for building resilient health systems grounded in primary health care.

Objective: To evaluate the post-pandemic regulatory preparedness of countries of the Region of the Americas for emergency authorization of vaccines as of August 2024 and propose recommendations for future public health emergencies.

Methods: Special report describing the mechanisms for emergency use authorization of vaccines established in the regulatory frameworks of Latin American and English-speaking Caribbean countries.

Results: Most of the countries (64%) included in this analysis did not make any changes in their regulations for emergency situations following the COVID-19 pandemic. Special import permits constitute the most common established mechanism for emergency authorization (82%). Regulatory reliance-based mechanisms were found in a minority of countries (32%), as were emergency use authorization, provisional marketing authorization, or fast-track registration mechanisms (23%). Only reliance-based mechanisms were found to use risk criteria based on the source from which vaccines were obtained.

Conclusions: This analysis reflects the need to strengthen the Region's regulatory systems to address future public health emergencies and facilitate access to necessary vaccines. Furthermore, regulatory systems should adopt a regulatory approach based on risk criteria, with distinct procedures and requirements, as well as strengthen cooperation with other National Regulatory Authorities (NRAs) at the regional and global levels, to achieve greater regulatory efficiency.

As part of a regional initiative to improve care for noncommunicable diseases (NCD) in vulnerable territories, a specific module of the Essential Conditions Evaluation (ECE) tool of the Pan American Health Organization (PAHO) was developed and implemented in 15 health facilities in Camiri and the Guaraní Kereimba Iyaambae Indigenous Autonomous Government (GAIGKI) in the Bolivian Chaco region between February and May 2024. The objective was to detect gaps, document strengths, and generate useful evidence for territorial planning.The instrument included 50 variables grouped into 10 key dimensions, in line with the technical frameworks of the World Health Organization (WHO) and PAHO. It was implemented through a participatory methodology, led by PAHO and previously trained local teams. The analysis made it possible to tailor the assessment to the priorities of the territory, focusing on hypertension, diabetes, cancer, and mental disorders.The results revealed gaps in governance, financing, human resources, and information systems in both municipalities. Camiri stood out for its basic equipment and clinical follow-up; GAIGKI, for local planning and the availability of specialized personnel. Both municipalities showed progress in basic tests, essential medicines, and the continuity of care.The experience demonstrated the technical feasibility of the module, its cultural relevance, and its potential for integration into national surveillance systems. With technical and financial support from PAHO, intersectoral coordination and community participation were promoted, generating key input to improve the integrated management of NCDs in primary health care in rural and Indigenous contexts.

Childhood cancer mortality is disproportionately higher in low- and middle-income countries than high-income countries. The World Health Organization Global Initiative for Childhood Cancer aims for a survival of 60% by 2030. This initiative prioritizes timely diagnosis, access to standardized therapy and supportive care, and prompt management of treatment-related complications. Collaborative work is linked to better performance of health systems and delivery of high-quality care. While collaborative strategies between high- and lower-income countries can advance cancer care in low- and middle-income countries, local and regional initiatives are essential to improve clinical outcomes. The high treatment-related mortality in children with cancer in low- and middle-income countries highlights the critical need to collaborate. To decrease treatment-related mortality in children with cancer in Colombia, a new model of transdisciplinary collaboration was built among Colombian scientific societies (pediatrics, pediatric hematology/oncology, infectious diseases, critical care), academic institutions, grassroots foundations, and the Colombian Childhood Cancer Clinical Outcomes Surveillance System: VIGICANCER. The network supports resource and knowledge exchange to tackle public health challenges related to accessing cancer care for children. It enables the design of targeted and tiered multilevel interventions to enhance quality of care for Colombian children and adolescents with cancer. This transdisciplinary network aims to improve survival in Colombian children with cancer and close the gap with high-income countries by establishing data-informed targets and developing a strategic roadmap to address sepsis, the most actionable cause of treatment-related mortality. Our ultimate goal is to reduce the number of years of life lost, thereby supporting societal progress in Latin America.

Objective: To compare sociodemographic and clinical characteristics and the outcome severity between confirmed cases of Oropouche fever and dengue in the state of Espírito Santo, Brazil.

Methods: A cross-sectional study used secondary data from the state health surveillance system of Espírito Santo, 2024-2025. The study includes laboratory-confirmed cases of Oropouche fever and dengue. The authors calculated absolute and relative frequencies of variables. Pearson's chi-square and Fisher's exact tests assessed differences. Firth's penalized logistic regression estimated odds ratios (OR) for severe manifestations and death, with 95% confidence intervals (95% CI).

Results: A total of 12 135 OF cases and 18 018 dengue cases were confirmed. Compared with dengue cases, Oropouche fever was more prevalent among males (53.5%), white individuals (56.3%), and residents of rural and peri-urban areas (52.1%). Fever (84.5% vs. 78.7%), headache (83.9% vs. 72.1%), and myalgia (76.5% vs. 67.5%) were the most common symptoms in both groups, with significantly higher proportions among Oropouche fever cases. Dengue cases showed higher odds of progressing to severe disease (OR 15.35; 95% CI 10.60-22.23) and death (OR 2.09; 95% CI 1.10-3.98).

Conclusion: Oropouche fever and dengue presented overlapping clinical profiles; however, Oropouche fever was more frequent in rural and peri-urban areas. Dengue was associated with greater severity and lethality. These findings underscore the importance of surveillance to support strategies for monitoring, clinical management, and control, while accounting for the distinct epidemiological and clinical profiles of Oropouche fever and dengue.