Novo século, velho problema: tendência da mortalidade infantil e seus componentes no Nordeste brasileiro / New century, old problems: infant mortality trend and its components in the northeast region of Brazil

Resumo Introdução A mortalidade infantil ainda representa um desafio para os países em desenvolvimento. Objetivo Analisar a tendência da mortalidade infantil e seus componentes nos estados do Nordeste brasileiro entre 2001 e 2015. Método Estudo ecológico envolvendo quatro indicadores de mortalidade infantil: geral, neonatal precoce, neonatal tardia e pós-neonatal. Foi aplicado o modelo de regressão por pontos de inflexão (joinpoint regression). A tendência foi classificada em crescente, decrescente ou estacionária. Calculou-se o Percentual de Variação Anual (APC, Annual Percent Change), considerando Intervalo de Confiança de 95%. Resultados Foi observada tendência decrescente da mortalidade infantil geral no Nordeste (-3,9%) e em todos os estados, sendo Pernambuco com maior redução (-5,2%). Na mortalidade neonatal precoce, somente o Maranhão apresentou tendência estacionária (-0,2%). Na mortalidade neonatal tardia, Maranhão, Piauí, Paraíba e Sergipe apresentaram padrão estacionário. A mortalidade pós-neonatal foi a que apresentou maior redução, tendo destaque Alagoas (-8,6%) e Pernambuco (-7,6%). No Nordeste, esse componente apresentou variação anual de -6,1%. A partir do final da primeira década, a mortalidade pós-neonatal apresentou padrão estacionário no Nordeste, destacando-se Maranhão, Ceará, Rio Grande do Norte e Sergipe. Conclusão Embora tenha sido verificada redução da mortalidade infantil no Nordeste do Brasil, o comportamento estacionário em alguns estados configura motivo de preocupação, tendo em vista que os valores ainda são muito elevados quando comparados aos de locais desenvolvidos.

Abstract Background Infant mortality still represents a challenge for developing countries. Objective To assess the infant mortality trend and its components in the Brazilian Northeast states between 2001 and 2015. Method Ecological study consisting of four indicators of infant mortality were analyzed as following: general, early neonatal, late neonatal and post-neonatal mortalities. A regression analysis was applied to fit the inflection point (joinpoint regression). The trends were classified as increasing, decreasing or stationary. The Annual Percent Change (APC) was calculated considering a 95% confidence interval. Results Decreasing trend of overall infant mortality in the Northeast region (-3.9%) could be measured; the state of Pernambuco showed the greatest reduction (-5.2%). Regarding the early neonatal mortality, only the state of Maranhão showed stationary trends (-0.2%). With respect to the late neonatal mortality, the states of Maranhão, Piauí, Paraíba and Sergipe showed stationary pattern. The post-neonatal mortality presented the greatest reduction, being highlighted the values of this significant reduction in the states of Alagoas (-8.6) and Pernambuco (-7.6). Considering the entire region, this component showed an APC of -6.1%. At the end of the first decade, post-neonatal mortality showed a stationary pattern over the Northeast region, with the highest values in the states of Maranhão, Ceará, Rio Grande do Norte and Sergipe. Conclusion Although it has been a reduction in infant mortality in Northeastern Brazil, the stationary pattern in some states produced reasons for concern, considering that rates are still very elevated when compared to developed areas.

Maternal mortality and social vulnerability in a Northeast State in Brazil: a spatial-temporal approach / Mortalidade materna e vulnerabilidade social no Estado de Alagoas no Nordeste brasileiro: uma abordagem espaço-temporal

Abstract Objectives: to analyze the epidemiological profile and the spatial-temporal dynamics on maternal mortality in Alagoas and its relationship with social vulnerability and income inequality. Methods: a mixed ecological study involving maternal deaths who resided in Alagoas from 1996 to 2016. Sociodemographic variables (age, race/color, education, marital status), clinical (type of obstetric cause, death by category and ICD group) were analyzed, besides the indicators (Maternal Mortality Ratio-MMR, Social Vulnerability Index and Gini Index). For the temporal analysis, we used the inflection point regression model and for the spatial analysis, the local empirical Bayesian model, Moran Global and Local statistics, and the bivariate local spatial autocorrelation analysis. Results: a total of 586 deaths (47.63/100 thousand live births) were registered, with a trend of MMR growth (APC 2.8%), with a heterogeneous distribution between health regions and cities. The profile was characterized by the predominance of young, black / mixed skin color women with low schooling. Eight cities were considered priority. There was spatial correlation with the Social Vulnerability Index and income inequality. Conclusions: identifying priority areas may contribute to planning and targeting interventions.

Resumo Objetivos: analisar o perfil epidemiológico e a dinâmica espaço-temporal da mortalidade materna em Alagoas e sua relação com a vulnerabilidade social e a desigualdade de renda. Métodos: estudo ecológico misto envolvendo os óbitos maternos de residentes em Alagoas de 1996 a 2016. Foram analisadas variáveis sociodemográficas (faixa etária, raça/cor, escolaridade, estado civil), clínicas (tipo de causa obstétrica, óbito por categoria e grupo de CID), além de indicadores (Razão de Mortalidade Materna-RMM, Índice de Vulnerabilidade Social e Índice de Gini). Para a análise temporal utilizou-se o modelo de regressão por pontos de inflexão e para a análise espacial o modelo bayesiano empírico local, a estatística de Moran Global e Local e a análise de autocorrelação espacial local bivariável. Resultados: foram registrados 586 óbitos (47,63/100 mil nascidos vivos), com tendência de crescimento da RMM (APC 2,8%), com distribuição heterogênea entre as regiões de saúde e municípios. O perfil foi caracterizado pelo predomínio de mulheres jovens, pretas/pardas e de baixa escolaridade. Oito municípios foram considerados prioritários. Houve correlação espacial com o Índice de Vulnerabilidade Social e de desigualdade de renda. Conclusões: a identificação de áreas prioritárias pode contribuir para o planejamento e direcionamento de intervenções.

Syphilis among pregnant women in Northeast Brazil from 2008 to 2015: a trend analysis according to sociodemographic and clinical characteristics.

INTRODUCTION: The number of syphilis cases among pregnant women in Brazil has increased. This study aimed to analyze the temporal trend of syphilis indicators among pregnant women in Northeast Brazil. METHODS: A time-series study was performed. RESULTS: We observed an increase in the detection rate of syphilis among pregnant women, those aged 15-19 years, and those of brown ethnicity. A strong correlation was observed between the detection rate of syphilis and family health strategy coverage. CONCLUSIONS: Despite an increase in primary care coverage, The increase in cases of syphilis among pregnant women is still considered a challenge.

Syphilis among pregnant women in Northeast Brazil from 2008 to 2015: a trend analysis according to sociodemographic and clinical characteristics

Abstract INTRODUCTION: The number of syphilis cases among pregnant women in Brazil has increased. This study aimed to analyze the temporal trend of syphilis indicators among pregnant women in Northeast Brazil. METHODS: A time-series study was performed. RESULTS: We observed an increase in the detection rate of syphilis among pregnant women, those aged 15-19 years, and those of brown ethnicity. A strong correlation was observed between the detection rate of syphilis and family health strategy coverage. CONCLUSIONS: Despite an increase in primary care coverage, The increase in cases of syphilis among pregnant women is still considered a challenge.

Social determinants of mortality due to visceral leishmaniasis in Brazil (2001-2015): an ecological study

Abstract INTRODUCTION We aimed to analyze the relationship between visceral leishmaniasis mortality and social determinants of health (SDH). METHODS This was an ecological study of all leishmaniasis-related deaths in Brazil, from 2001 to 2015. We analyzed 49 indicators of human development and social vulnerability. The association was tested using the classical and spatial regression model. RESULTS Mortality was associated with indicators that expressed low human development and high social vulnerability: lack of garbage collection, low schooling, unemployment rate, low per capita income, and income inequality (Gini index). CONCLUSIONS: There was an association between high mortality by leishmaniasis and low SDH.

Social determinants of mortality due to visceral leishmaniasis in Brazil (2001-2015): an ecological study.

INTRODUCTION: We aimed to analyze the relationship between visceral leishmaniasis mortality and social determinants of health (SDH). METHODS: This was an ecological study of all leishmaniasis-related deaths in Brazil, from 2001 to 2015. We analyzed 49 indicators of human development and social vulnerability. The association was tested using the classical and spatial regression model. RESULTS: Mortality was associated with indicators that expressed low human development and high social vulnerability: lack of garbage collection, low schooling, unemployment rate, low per capita income, and income inequality (Gini index). CONCLUSIONS: There was an association between high mortality by leishmaniasis and low SDH.

Mortality in motorcycle accidents in Alagoas (2001-2015): temporal and spatial modeling before and after the "lei seca"

SUMMARY OBJECTIVE To analyze the epidemiological profile and the Spatio-temporal distribution of mortality in motorcycle accidents in Alagoas before (2001-2007) and after the "Lei seca" (2008-2015). METHODS This is a mixed ecologic study. All deaths in the state with the codes V20-V29 (ICD-10) as the basic cause were included in the study. Sociodemographic variables and mortality rates per sex were analyzed. For the temporal analysis, the inflection point regression model was used. For spatial analysis, the rates were smoothed by the Local Empirical Bayesian Model and, subsequently, the Global and Local Moran statistic was used to identify the spatial clusters of risk. RESULTS There were 1458 deaths caused by motorcycle accidents in the period studied; the following characteristics about the victims stand out: male (91.29%), economically active age (82.93%), and brown race (78.12%). In the male population, there was a growth trend between 2001 and 2007 (19.0%, p<0.001), and a decline from 2008 (-11.2%, p<0.001). Spatial modeling showed that the areas with the highest risk of mortality are located in the agreste and sertão of the state (p = 0.01). CONCLUSION Mortality in motorcycle accidents is an important public health problem in Alagoas, with an emphasis on male mortality and geographic concentration within the state.

RESUMO OBJETIVO Analisar o perfil epidemiológico e a distribuição espaço-temporal da mortalidade em acidentes motociclísticos em Alagoas antes (2001-2007) e após a lei seca (2008-2015). MÉTODOS Estudo ecológico misto. Foram incluídos no estudo todos os óbitos ocorridos no estado que tiveram como causa básica os códigos V20-V29 (CID-10). Foram analisadas as variáveis sociodemográficas e as taxas de mortalidade calculadas segundo sexo. Para a análise temporal, empregou-se o modelo de regressão por pontos de inflexão. Para análise espacial, as taxas foram suavizadas pelo Modelo Bayesiano Empírico Local e, posteriormente, foi empregada a estatística de Moran Global e Local para a identificação dos aglomerados espaciais de risco. RESULTADOS Foram registrados 1.458 óbitos em acidentes motociclísticos no período estudado, destacando-se: sexo masculino (91,29%), idade economicamente ativa (82,93%) e raça parda (78,12%). Na população masculina, verificou-se tendência de crescimento entre 2001 e 2007 (19,0%; p<0,001) e de declínio a partir de 2008 (-11,2%; p<0,001). A modelagem espacial mostrou que as áreas de maior risco de mortalidade estão situadas no agreste e sertão do estado (p=0,01). CONCLUSÃO A mortalidade em acidentes motociclísticos é um importante problema de saúde pública em Alagoas, com destaque para a mortalidade masculina e concentração geográfica no interior do estado.

Mortality in motorcycle accidents in Alagoas (2001-2015): temporal and spatial modeling before and after the "lei seca".

OBJECTIVE: To analyze the epidemiological profile and the Spatio-temporal distribution of mortality in motorcycle accidents in Alagoas before (2001-2007) and after the "Lei seca" (2008-2015). METHODS: This is a mixed ecologic study. All deaths in the state with the codes V20-V29 (ICD-10) as the basic cause were included in the study. Sociodemographic variables and mortality rates per sex were analyzed. For the temporal analysis, the inflection point regression model was used. For spatial analysis, the rates were smoothed by the Local Empirical Bayesian Model and, subsequently, the Global and Local Moran statistic was used to identify the spatial clusters of risk. RESULTS: There were 1458 deaths caused by motorcycle accidents in the period studied; the following characteristics about the victims stand out: male (91.29%), economically active age (82.93%), and brown race (78.12%). In the male population, there was a growth trend between 2001 and 2007 (19.0%, p<0.001), and a decline from 2008 (-11.2%, p<0.001). Spatial modeling showed that the areas with the highest risk of mortality are located in the agreste and sertão of the state (p = 0.01). CONCLUSION: Mortality in motorcycle accidents is an important public health problem in Alagoas, with an emphasis on male mortality and geographic concentration within the state.

E o Passado é uma Roupa que Não nos Serve Mais: uma Reflexão sobre Integração Ensino-Saúde-Comunidade em Curso Médico do Nordeste / And the Past is a Garment that no Longer Suits us: Reflecting on Teaching-Health-Community Integration in a Medical Course in Northeast Brazil

RESUMO A formação médica, assim como a sociedade brasileira, tem passado por importantes transformações. Tais mudanças buscam atender as demandas sociais e sanitárias contemporâneas, sobretudo no que diz respeito a uma formação voltada à realidade sociossanitária local. Em razão disso, a formação deve buscar desenvolver competências, habilidades e atitudes em um cenário de integração do ensino com a saúde e a comunidade. O curso de Medicina da Universidade Federal de Alagoas, campus Arapiraca, iniciado no ano de 2015, resulta do processo de expansão das escolas médicas do País e do processo de interiorização das ações dessa universidade. O curso está estruturado em três eixos (tutoria, habilidades médicas e integração ensino-saúde-comunidade). Neste texto, pretende-se apresentar o processo de trabalho do eixo de Integração Ensino-Saúde-Comunidade (Iesc), seus principais avanços e os desafios envolvidos no processo de formação. O Iesc tem como missão promover a aproximação entre o acadêmico e a realidade sociossanitária local a fim de garantir uma formação médica capaz de oferecer uma assistência integral, respeitosa, ética, crítica e humanística, considerando o sujeito e o contexto em que está inserido, sua cultura, crença, hábitos e costumes. Em 2017, para cumprir sua missão, o eixo reestruturou o currículo do curso de modo que a formação ocorra no ciclo básico (primeiro e segundo anos), passando pelo ciclo intermediário (terceiro e quarto anos) e alcançando o internato (quinto e sexto anos). Nossa experiência tem mostrado que o aprendizado significativo deve nascer da prática, isto é, do processo de experimentações com a realidade. É nítido o maior envolvimento dos nossos estudantes quando incluímos atividades com finalidades práticas bem definidas. Nossa sistemática de trabalho envolve reuniões mensais, quando são discutidos os principais problemas e elaboradas estratégias de condução do eixo, padronização de cadernos de curso e estratégias avaliativas, processo de formação continuada dos docentes, como parte do plano bianual de qualificação e inclusão de avaliação por parte dos acadêmicos, com o semestre em curso. A variedade de estratégias pedagógicas, todas ancoradas nas metodologias ativas de ensino-aprendizagem, contribui para o maior envolvimento dos nossos estudantes nas aulas. Os principais desafios são consolidar a inserção na rede de saúde local e qualificar o corpo docente no uso de metodologias ativas em todos os processos de aprendizagem.

ABSTRACT Both medical education and Brazilian society as a whole have undergone significant transformations in recent years. These changes seek to meet contemporary social and sanitary demands, especially with regard to a training focused on the local socio-sanitary reality. Medical training should therefore seek to develop skills, abilities and attitudes in a setting where teaching is integrated with health care and the community. The medical course of the Federal University of Alagoas, Arapiraca campus, was founded in 2015, resulting from the expansion of medical schools in Brazil and the internalization of the University's actions. The course is structured on three axes (tutoring, medical skills and teaching-health-community integration). This text intends to present the work process of the Teaching-Health-Community Integration (LESC) axis, its main advances and the challenges involved in the training process. The mission of LESC is to place the academic into closer contact with the local socio-sanitary reality in order to ensure a medical training that offers comprehensive, respectful, ethical, critical and humanistic care, considering the subject and his or her context, culture, beliefs, habits and customs. To fulfill this mission, in 2017 the course curriculum was restructured so as to split the training into the basic cycle (1 st and 2 nd years), the intermediate cycle (3 rd and 4 th years) and, finally, medical internship (5 th and 6 th years). Our experience has shown that meaningful learning must come from practice, that is, from the process of experimentation with reality. Our students are distinctly more involved and interested when we include activities with well-defined practical purposes. Our work system involves monthly meetings, where major issues are discussed and strategies developed for conducting LESC, the standardization of course books and evaluation strategies, a continuing education program for teachers, as part of the biannual qualification plan and the inclusion of student-led evaluation during the semester. The variety of teaching strategies, all anchored in active learning methodologies, encourages greater involvement of our students in class. The main challenges can be summarised as consolidating student insertion into the local health care network and qualifying the teachers in their use of active methodologies in all learning processes.