Effects of Two Early Parenting Programmes on Child Aggression and Risk for Violence in Brazil: a Randomised Controlled Trial.

Violence is a major public health problem globally, with the highest rates in low- and middle-income countries (LMICs) in the Americas and southern Africa. Parenting programmes in high-income countries can diminish risk for violence, by reducing risk factors such as child aggression and harsh parenting, and increasing protective factors such as child cognitive development and school readiness. However, there is critical need to identify low-cost programmes with replicable benefits that work in real-world LMICs contexts. A three-arm, randomised, single-blind trial evaluated effects of two low-cost, group-based parenting programmes recommended for LMICs (ACT: Raising Safe Kids; DBS: dialogic book-sharing) on child aggression (primary outcome), child development, parenting, maltreatment, and stress. Participants were 369 children with medium-high levels of aggression (mean age 3.1 years at baseline) in poor households. Interventions were implemented in city health and education services in southern Brazil. Maternal reports, filmed observations, child tasks, and hair cortisol were assessed at baseline, 1-month post-intervention, and 8-month follow-up. Intention-to-treat analyses compared each of ACT and DBS with a control group. Three hundred sixty-eight (99.7%) participants completed follow-up assessments 8 months after the interventions. There was no effect of ACT (standardised mean difference, SMD 0.11, 95% CI - 0.05, 0.27) or DBS (SMD 0.05, 95% CI - 0.11, 0.21) on the primary outcome of child aggression. ACT reduced harsh parenting behaviour post-intervention (SMD - 0.23; 95% CI - 0.46, - 0.01), but not at follow-up. DBS improved book-sharing practices at both time points (e.g., maternal sensitivity at follow-up SMD 0.33; 95% CI 0.08, 0.57). There were no benefits of either programme for other parenting, child development, or stress outcomes. Two parenting programmes in Brazil had small effects on parenting practices but did not reduce child aggression or several other important risk/protective factors for violence. Effective early interventions that reduce violence in real-world LMIC settings are highly desirable but may be challenging to achieve.

Influence of parental physical activity on offspring's nutritional status: an intergenerational study in the 1993 Pelotas birth cohort.

OBJECTIVE: To investigate the influence of parental physical activity on offspring's nutritional status in the 1993 Pelotas (Brazil) birth cohort. DESIGN: Birth cohort study. SETTING: The main outcomes were overweight and obesity status of children. The main exposure was parental physical activity over time, measured during the 11, 15 and 18 years of age follow-ups. The exposure was operationalised as cumulative, and the most recent measure before the birth of child. We adjusted Poisson regression models with robust variance to evaluate crude and adjusted associations between parental physical activity and offspring's nutritional status. All analyses were stratified according to the sex of the parent. PARTICIPANTS: A total of 874 members from the 1993 Pelotas (Brazil) birth cohort followed-up at 22 years of age with their first-born child were analysed. RESULTS: Children were, on average, 3·1 years old. Crude analyses showed that the mother's cumulative physical activity measure had an indirect association with the prevalence of children's obesity. The most recent maternal physical activity measure before the birth of the child was associated with 41 % lower prevalence of obesity in children, even after adjustment for confounders. CONCLUSIONS: The most recent maternal physical activity measure was indirectly associated with the prevalence of obesity in children. No associations were found for fathers, reinforcing the hypothesis of a biological effect of maternal physical activity on offspring's nutritional status.

Effects of parenting interventions on child and caregiver cortisol levels: systematic review and meta-analysis.

BACKGROUND: Nurturing care, in which children are raised in engaging and safe environments, may reduce child stress and shape hypothalamic-pituitary-adrenal axis functioning. Hence, parent-training programs may impact child cortisol levels, as well as behavioral, social and health outcomes. We conducted a systematic review of the impact of parent-training interventions on children's and caregivers' cortisol levels, and meta-analyzed the results. METHODS: In January 2020, searches in PubMed, LILACS, ERIC, Web of Science, Scielo, Scopus, PsycNET and POPLINE databases were conducted, and two independent researchers screened the results for eligible studies - randomized trials that assessed the impact of parent-training interventions on child or caregiver cortisol levels. Random effects were used to pool the estimates, separately for children and caregivers, and for children's morning and evening cortisol levels, as well as change across the day. RESULTS: A total of 27 eligible studies were found. Data from 19 studies were extracted and included in the meta-analyses, with 18 estimates of child cortisol levels and 5 estimates for caregiver cortisol levels. The pooled effect size (standardized mean difference) for the effects of parent training programs on morning child cortisol was 0.01 (95%CI: - 0.14 to 0.16; I2: 47.5%), and for caregivers it was 0.04 (95%CI: - 0.22 to 0.30; I2: 0.0%). Similar null results were observed for child evening cortisol and for the slope between morning and evening child cortisol. No evidence of publication bias was found. CONCLUSION: Existing evidence shows no effect of parent-training interventions on child or caregiver post-intervention cortisol. Researchers are encouraged to adopt standardized protocols to improve evaluation standards, to test for intervention effects on psychosocial outcomes that are theorized to mediate the effects on biomarkers, and to use additional biomarkers for chronic stress.

Parental attendance in two early-childhood training programmes to improve nurturing care: A randomized controlled trial.

Parent training programmes have significant potential to improve the quality of children's early environments and thereby their development and life-course outcomes. The aim of this study was to identify and explain the extent to which parents engaged in two group-based training programmes, offered to high-risk families enrolled in a randomized controlled trial study called PIÁ in Southern Brazil. The programmes were: (1) ACT: Raising Safe Kids, a 9-week programme aiming to reduce harsh parenting and maltreatment and improve positive parenting practices; (2) Dialogic book-sharing (DBS), an 8-week programme aiming to promote parental sensitivity and improve child cognitive development and social understanding. Of the 123 mothers randomly allocated to the ACT programme, 64.2% (n = 79) completed the course, and of 124 mothers allocated to DBS, 76.6% (n = 95) completed the course. After the interventions, mothers were very positive about the experience of both programmes but highlighted practical difficulties in attending. In adjusted regression analyses, only two variables significantly predicted ACT course completion (maternal age and distance between the intervention site and household); no significant predictor was found for DBS attendance. We conclude that although high completion rates are possible, there are important challenges to engaging parents of young children in training programmes, and practical difficulties occurring during training courses may be more important for attendance than baseline participant characteristics.

Gender Division of Housework and Intimate Partner Violence Among Mothers of Toddlers During the COVID-19 Pandemic: Findings from the 2019 Rio Grande (Brazil) Birth Cohort.

During the COVID-19 pandemic, we evaluated the association between gender division of housework and intimate partner violence (IPV) victimization in a population-based cohort of mothers. We collected data on psychological, physical, and sexual IPV using an adapted version of the World Health Organization Violence Against Women instrument and division of housework using a validated questionnaire. We used logistic regression to calculate adjusted odds ratios. We found that in mothers who reported an unequal gender division of housework (higher load), the odds of suffering psychological, physical, or sexual IPV were higher during the first and second years of the pandemic.

Adverse childhood experiences and crime outcomes in early adulthood: A multi-method approach in a Brazilian birth cohort.

This study aimed to investigate alternative approaches to a cumulative risk score in the relationship between adverse childhood experiences (ACEs) and crime. Using data from the 1993 Pelotas (Brazil) Birth Cohort (n = 3236), we measured 12 ACEs up to 15 years, and past-year violent and non-violent crime at 22 years. We used four analytical approaches: single adversities, cumulative risk, latent class analysis, and network analysis. When examined individually, physical abuse, emotional abuse, and domestic violence were associated with both crime outcomes, whereas maternal mental illness and discrimination were associated with violent crime only, and parental divorce and poverty with non-violent crime only. There was a cumulative effect of ACEs on crime. The class with child maltreatment and household challenges was associated with both crime outcomes; exposure to household challenges and social risks was associated with violent crime only. In network models, crime showed conditional associations with physical abuse, maternal mental illness, and parental divorce. Although cumulative ACEs did associate with crime, some individual and combinations of ACEs showed particularly strong and robust effects, which were not captured by the cumulative score. Many ACEs are closely connected and/or cluster together, and the usefulness of the ACE score needs to be further evaluated.

Agreement between measured weight, height and BMI and Web-based self-reported data in participants of the 1993 Pelotas Birth Cohort, Brazil: a cross-sectional validation study.

OBJECTIVE: to evaluate the agreement between measured height, weight, and body mass index (BMI) during the 22-year follow-up of the 1993 Pelotas Birth Cohort, state of Rio Grande do Sul, Brazil, and self-reported data during the online follow-up of the coortesnaweb. METHODS: this was a cross-sectional validation study; agreement was assessed by means of Lin's concordance correlation coefficient for continuous measures and weighted Kappa for nutritional status; Spearman's rank correlation coefficient was used to estimate the correlation between measurements. RESULTS: a total of 783 participants were included; it could be seen high correlation and high agreement between the measured height (r = 0.966; ρ = 0.966), weight (r = 0.934; ρ = 0.928), and BMI (r = 0.903; ρ = 0.910) and Web-based self-reported data; there was no correlation between mean difference and the time interval between measurements. CONCLUSION: using the Internet to collect self-reported anthropometric measurements is as valid as the traditional method.

Physical Activity and Chronic Stress in Early Life: Findings From the 2015 Pelotas (Brazil) Birth Cohort.

BACKGROUND: The association of physical activity through early childhood on children's chronic stress still is unclear. Therefore, the aim of the present study is to test the association of physical activity through early childhood (1-4 y) with chronic stress, measured by hair cortisol at age 4. METHODS: Longitudinal study including children from the 2015 Pelotas (Brazil) Birth Cohort. Cortisol at age 4 was measured using a hair sample, which provided cortisol concentration from the past months. Physical activity was measured using accelerometers at 1, 2, and 4 years. Linear regression models were used to assess the association between physical activity and chronic stress. Trajectory models were also applied to examine chronic stress in relation to physical activity patterns throughout early childhood. RESULTS: Children with valid physical activity and hair cortisol data were included in the analyses (N = 1475). Three groups of physical activity trajectories between 1 and 4 years were identified: low, medium, and high. No association between physical activity at 1, 2, and 4 years and chronic stress at age 4 was observed. However, children in the "high" physical activity trajectory presented low cortisol concentration; the magnitude of the regression coefficient was slightly larger in girls (ß = -0.125; 95% confidence interval, -0.326 to 0.074) than boys (ß = -0.051; 95% confidence interval, -0.196 to 0.09). CONCLUSION: There was no clear association between physical activity and chronic stress in early childhood. Trajectories models suggest that higher activity throughout early childhood may positively impact chronic stress; however, more studies are needed to confirm that hypothesis.

Child and Maternal Mental Health Before and During the COVID-19 Pandemic: Longitudinal Social Inequalities in a Brazilian Birth Cohort.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has caused major stress for families and children, particularly in the context of prolonged school closures. Few longitudinal studies are available on young children's mental health, including data both before and during the pandemic. This study examined experiences that might increase risk for mental health problems among caregivers and young children during the COVID-19 pandemic and inequalities driven by pre-pandemic disadvantage. METHOD: This prospective, population-based birth cohort study in Pelotas, Brazil, analyzed 2,083 children and caregivers with data from before the pandemic in 2019, when children were 4 years old, and again in 2020, when schools were closed for a long period during the pandemic. Child conduct problems, emotional problems, and hyperactivity-inattention problems were assessed using the Strengths and Difficulties Questionnaire. Family financial hardship, relationship difficulties, caregiver mental health, parenting practices, and child fears and isolation were considered as potential risk factors. RESULTS: Across the whole population, the only significant increase in mental health problems from before to during the pandemic was found for maternal depression. However, poorer families were at far greater risk of experiencing serious financial problems, food shortages, increased conflict in adult relationships, parenting problems, and child worries about food availability during the pandemic. In turn, these difficulties were associated with increases in multiple mental health problems for both caregivers and children. Increased child mental health problems were most strongly associated with concurrent maternal anxiety (ß > 0.20, p < .001, for each of child conduct, emotional, and hyperactivity problems), maternal depression (ß = 0.26, p < .001, for child emotional problems), partner criticism (ß = 0.21, p < .001, for child conduct problems), and harsh parenting (ß > 0.20, p < .001, for both child conduct and hyperactivity problems). Child worry about COVID-19 was associated with increased emotional problems (ß = 0.14, p < .001), but children's isolation was not associated with their mental health. CONCLUSION: Overall, the impact of the COVID-19 pandemic on mental health is a mixed picture, but for families in poverty, marked material and interpersonal difficulties were associated with increases in mental health problems among children and caregivers.

Determinants of hair cortisol in preschool children and their mothers: A Brazilian birth cohort study.

OBJECTIVE: Few large-scale studies have provided population-based estimates of hair cortisol levels and its determinants. Hair cortisol and potential determinants were measured in children and their mothers in a population-based sample in a Brazilian city with large variations in socioeconomic conditions. METHODS: We used data from the 4-year follow-up of the 2015 Pelotas (Brazil) Birth Cohort Study. Hair samples were collected by trained fieldworkers to analyze average levels of cortisol over a 3-month period. Four groups of variables were tested as potential determinants: hair characteristics (natural color, treatment, type, and frequency of wash), use of corticosteroids and oral contraceptives, sociodemographic factors (sex, age, skin color, socioeconomic level, maternal relationship, pregnancy, daycare enrollment), maternal perceived stress, and substance exposure (smoking and illicit drug use). Linear regression with log transformation was used to test associations. RESULTS: 3235 children and 3102 mothers were analyzed (80.7% and 77.4% of those interviewed when children were 4 years of age, respectively), for whom sufficient hair was collected for cortisol analysis. The median of hair cortisol concentration was 7.8 pg/mg (IQR = 5.6 - 11.0) for children, and 5.6 pg/mg (IQR = 4.2 - 7.8) for mothers. In adjusted models, sex and socioeconomic level were associated with child cortisol levels. For mothers, hair cortisol levels were associated with socioeconomic level, skin color, age, hair treatment and hair natural color. CONCLUSION: This study provides estimates of hair cortisol levels in a diverse population in a upper-middle income country. Although just a few predictors were associated with maternal/child cortisol levels, socioeconomic level was the key variable that should be incorporated in studies using hair cortisol to measure biological manifestations of stress, but other variables, such as some hair and sociodemographic characteristics are important to consider when using hair cortisol.

Physical Activity During Adolescence and Mental Health in Early Adulthood: Findings From the 1993 Pelotas Birth Cohort Study.

BACKGROUND: Low prevalence of physical activity (PA) and a high prevalence of mental health problems are common among youth. The aim of this study was to evaluate the association between PA during adolescence and depression and anxiety disorders in young adulthood. METHODS: Data from the 1993 Pelotas (Brazil) Birth Cohort Study were analyzed. Leisure-time PA and total PA (leisure plus commuting) were evaluated at 11, 15, and 18 years using self-reported data. PA was evaluated at each age separately and during adolescence, considering the number of times participants reached PA recommendations. Depression and anxiety were assessed through Mini International Neuropsychiatric Interview at 22 years. Crude and adjusted association analyses were performed using Poisson regression with robust error variance, providing prevalence ratios and 95% confidence intervals. RESULTS: Three thousand two hundred and forty-seven participants were included in the study. In the adjusted analyses, active participants in leisure-time PA (≥300 min/wk) and total PA at 11 years were less likely to be depressed at age 22 (prevalence ratios: 0.54; 95% confidence interval, 0.33-0.89; prevalence ratios: 0.63; 95% confidence interval, 0.41-0.97). For leisure-time PA, the more PA recommendations were met during adolescence, the lower the prevalence of depression. There was no association when PA variables were evaluated separately at 15 and 18 years and between PA and anxiety after controlling for potential confounders. CONCLUSIONS: Early adolescence appears to be a sensitive period for PA benefits on depression in early adulthood. The more timepoints reaching PA recommendations during adolescence, the lower the risk of depression. On the other hand, PA during adolescence was not associated with anxiety in young adults.

The association between maternal fears about their infant/ toddler during the COVID-19 pandemic and depression and anxiety: a birth cohort study.

OBJECTIVE: To assess the association between maternal fears about their infant/toddler and depression and anxiety during the COVID-19 pandemic. METHODS: In 2019, all mothers who gave birth in hospitals in Rio Grande, RS, Brazil were asked to respond to a standardized questionnaire (baseline). We followed them between May-June 2020 (first follow-up point), August-December 2020 (second follow-up point), and from October 2021 to March 2022 (third follow-up point), and asked them if they were: (1) afraid that their infant/toddler would become infected with COVID or get sick (yes/no), (2) afraid that they would contaminate their own child with COVID, and/or (3) worried about the pandemic's effects on their child's future. At baseline and at all follow-up points, we assessed depressive symptoms using the Edinburgh Postnatal Depression Scale and anxiety symptoms using the Generalized Anxiety Disorder Scale, creating symptom trajectories using group-based trajectory modelling. We used multinomial logistic regression to calculate adjusted relative risk ratios (RRR). RESULTS: A total of 1,296 mothers participated. Worrying about the pandemic's effects on their child's future and the fear of contaminating their own child with COVID-19 increased the risk of raising depressive symptoms to a clinical level (RRR = 4.97, 95%CI 2.32-10.64 and RRR = 3.87, 95%CI 1.58-9.47, respectively) and anxiety to a moderate level (RRR = 2.91, 95%CI 1.69-5.01 and RRR = 1.86, 95%CI 1.03-3.35, respectively). CONCLUSION: Fear for their children increased maternal depressive and anxiety symptoms during the pandemic.

School Performance and Young Adult Crime in a Brazilian Birth Cohort.

Poor school performance may increase the risk of crime and violence via effects on self-esteem, risky behaviours, peer networks, and perceived stakes in society. Despite very high rates of violence in Latin America, no longitudinal research has addressed this issue in the region. Two aspects of educational performance (grade repetition and school completion) were examined during adolescence in a population-based Brazilian birth cohort study (n = 3584). Violent and non-violent crime were measured at age 22 years in confidential self-reports; sociodemographic, family, and individual confounders were measured between birth and age 11 years, and potential mediators were measured at age 18 years. The prevalence of violent and non-violent crimes at 22 years was 8.2% and 3.3%, respectively, referring to acts in the previous twelve months. For youth repeating school grades three times or more, the odds of violent crime were 2.4 (95%CI: 1.6-3.6) times higher than for those who had not repeated any school grade. Youth completing school had a lower risk for both violent (OR = 0.5; 95%CI: 0.4-0.7) and non-violent crime (OR = 0.3; 95%CI: 0.2-0.5), compared to those who did not finish school by the expected age. The protective effect of completing school was independent of the number of grades previously repeated. In conclusion, repeating school grades was associated with increased risk for crime; however, successfully managing to complete school by the expected age was an important protective factor against crime, even after multiple grade repetitions. Supplementary Information: The online version contains supplementary material available at 10.1007/s40865-022-00214-x.

Effects of Regular Exercise During Pregnancy on Early Childhood Neurodevelopment: The Physical Activity for Mothers Enrolled in Longitudinal Analysis Randomized Controlled Trial.

BACKGROUND: The aim of this study was to investigate the effect of exercise during pregnancy on early childhood neurodevelopment (cognitive, motor, and language domains). METHODS: A randomized controlled trial nested into the 2015 Pelotas (Brazil) Birth Cohort was conducted. Healthy pregnant women were enrolled between 16 and 20 weeks of gestation; 424 women and their children (intervention [n = 141]; control [n = 283]) were analyzed. An exercise-based intervention 3 times per week was delivered over 16 weeks. Child neurodevelopment and its domains were assessed at 1, 2, and 4 years. Standardized mean differences and 95% confidence intervals are presented. RESULTS: No effects of exercise during pregnancy on child neurodevelopment and its domains at age 1 year were observed. Compared with the control group, children from women in the exercise group had higher language score at age 2 years (standardized mean differences = 0.23; 95% confidence intervals, 0.02 to 0.44) and higher cognitive score (standardized mean differences = 0.22; 95% confidence intervals, 0.03 to 0.41) at age 4 years. No effects of exercise during pregnancy were observed in the motor domain at 1, 2, and 4 years. CONCLUSIONS: No detrimental effects of exercise during pregnancy on child neurodevelopment were observed. In addition, these findings suggest that exercise during pregnancy can result in small benefits for language and cognitive development.

[Child abuse and sexual risk behavior in adulthood: a systematic review]. / Maus-tratos infantis e comportamentos sexuais de risco na idade adulta: uma revisão sistemática.

Child abuse is a public health problem and can lead to serious consequences, such as involvement in sexual risk behavior (SRB). The scope of this article is to identify the studies that evaluated the association between different types of child maltreatment and SRB in adulthood through a systematic review. The search was conducted in the PubMed, Web of Science, PsycNET and Lilacs databases. The inclusion criteria were: cross-sectional, cohort or case-control design; assessment of individuals who have been exposed to maltreatment before the age of 18; evaluation of SRB in adulthood. The search identified 18,951 articles, 34 of which were included in this study. The selection process was performed by two researchers independently. Studies have generally shown that sexual abuse is a risk factor for the tendency of SRB in adulthood, however there is less evidence of this association for other forms of child abuse, such as domestic violence, emotional abuse and neglect. Child maltreatment negatively influences SRB in early adulthood. Further studies are needed to evaluate this relationship longitudinally, including the different types of abuse and the possible mechanisms of this relationship.

Os maus-tratos infantis são um problema de saúde pública e podem gerar graves consequências, como envolvimento em comportamentos sexuais de risco (CSR). O objetivo deste artigo é identificar os estudos que avaliaram a associação entre diferentes tipos de maus-tratos infantis e CSR na idade adulta, por meio de uma revisão sistemática da literatura. A busca foi realizada nas bases de dados PubMed, Web of Science, PsycNET e Lilacs. Os critérios de inclusão foram: delineamento transversal, coorte ou caso-controle; avaliação de indivíduos que foram expostos a maus-tratos até os 18 anos e avaliação de CSR na idade adulta. A busca identificou 18.951 artigos, sendo 34 incluídos neste estudo. O processo de seleção foi realizado por duas pesquisadoras de maneira independente. Em geral os estudos mostraram que o abuso sexual é um fator de risco para a adoção de CSR na vida adulta, no entanto há menos evidências dessa associação para as outras formas de maus-tratos, como violência doméstica, abuso emocional e negligência. Os maus-tratos infantis influenciam de maneira negativa os CSR da vida adulta. São necessários novos estudos que avaliem essa relação de maneira longitudinal, incluindo os diferentes tipos de maus-tratos e os possíveis mecanismos dessa relação.

A WhatsApp-Based Intervention to Improve Maternal Social Support and Maternal-Child Health in Southern Brazil: The Text-Message Intervention to Enhance Social Support (TIES) Feasibility Study.

Participatory learning and action cycles with women's groups have been recommended by the WHO to promote maternal and newborn health, but few studies have tested its feasibility and acceptability in mobile health (mHealth) interventions among mothers of toddlers. This was a mixed-method feasibility assessment of an 8-week WhatsApp-based maternal support group for mothers of toddlers (12-18 months of age) enrolled in a birth cohort study in Southern Brazil. Daily messages and weekly activities were sent by moderators to promote maternal-child outcomes: child nutrition, child sleep, nurturing care, and maternal psychosocial well-being (assessed pre- and post-intervention via self-reported questionnaire). The implementation and engagement of the mothers in the program were assessed by message extraction. Acceptability was evaluated through in-depth interviews (n = 5) and open-ended surveys (n = 10). 1481 messages were exchanged in 3 WhatsApp groups (n = 30 mothers). Mothers were most active on weekdays (68.6% of messages sent on Tuesdays and 72.6% on Thursdays), afternoons (2:00-4:00pm), and evenings (9:00-11:00 pm). Engagement was higher at weeks 1-4. Mothers enjoyed and considered topics relevant. Group interaction was perceived as low, which influenced their participation. The prevalence of depression symptoms decreased from pre- to post-intervention (9% to 5%; P = .04). A moderated mobile-based support group for mothers of toddlers was feasible. mHealth services to promote maternal support are a promising strategy to improve maternal-child outcomes, but engagement and use of the service remains a challenge. Program managers should work with community members to identify ways to support engagement and participation throughout the intervention.

Sources of access to medication and its use in the rural area of Pelotas, Rio Grande do Sul, Brazil, in 2016: a cross-sectional population-based study. / Fontes de acesso e utilização de medicamentos na zona rural de Pelotas, Rio Grande do Sul, em 2016: estudo transversal de base populacional.

OBJECTIVE: To analyze the prevalence of medication use, sources of access, and associated factors among rural residents in Pelotas, RS, Brazil. METHODS: This was a cross-sectional study conducted in 2016 with adults ≥18 years old. Participants reported on medication use and sources of access to medication in the month prior to the interview. Poisson regression was used. RESULTS: Among the 1,519 respondents, 54.7% (95%CI 48.7;60.5) used some form of medication and 3.3% (95%CI 2.4;4.5) stopped taking necessary medication. Higher prevalence of use occurred in: women (PR=1.23 - 95%CI 1.12;1.34), the elderly (PR=2.36 - 95%CI 2.05;2.73), people with poorer self-perceived health (PR=1.29 - 95%CI 1.14;1.46) and people with a higher number of diseases (PR=2.37 - 95%CI 2.03;2.77). A total of 14.0% (95%CI 11.2;17.4) obtained medication exclusively from the Brazilian National Health System, prevalence of which was higher among those who self-reported themselves to be non-white and from lower economic classification. CONCLUSION: A low number stopped taking medication they needed to take. Use of free-of-charge medication was greater in groups with lower income.

Simultaneity of risk factors for chronic non-communicable diseases in a rural population of a Southern Brazilian city. / Simultaneidade de fatores de risco para doenças crônicas não transmissíveis em população rural de um município no sul do Brasil.

OBJECTIVES: To describe the occurrence of simultaneous risk factors for chronic noncommunicable diseases, and factors associated with these prevalences in rural adults of a Southern Brazilian city. METHODS: The design of this study was cross-sectional with a sample of 1,445 adults from the rural area of Pelotas, RS. Four risk factors were considered: smoking, alcohol consumption, physical inactivity and inadequate consumption of vegetables. To verify the simultaneous occurrence of the outcomes, a cluster analysis was used. The association was tested by ordinal regression resulting in odds ratios. RESULTS: Among the four risk factors evaluated, three were the most prevalent among men, and only physical inactivity was greater among women. In the cluster analysis, only the combination of alcohol consumption + smoking + inadequate vegetable consumption presented an observed prevalence that was significantly higher than the expected (O/E = 2.67, 95%CI 1.30, 5.48), and higher than another study in the south of the country. This can be justified because that study included an evaluation of urban dwellers and the consumption of fruits. After adjustment, men, single individuals, non-white people, those with less schooling, those with a worse socioeconomic status, those who reported poor perception of health, and those who do not work in specifically rural activities had a greater probability of having the simultaneity of risk factors. CONCLUSION: The results show the importance of developing priority actions regarding the health of rural populations with special attention to the subgroups with an identified higher risk.

Temporal Trends of Physical Activity and Sedentary Behavior Simultaneity in Brazilian Students.

OBJECTIVE: To evaluate trends in physical activity and sedentary behavior simultaneity among Brazilian students from 2009 to 2015 and its association with independent variables. METHODS: This study presents a panel of 3 cross-sectional studies carried out in 2009, 2012, and 2015 (Pesquisa Nacional de Saúde do Escolar-PeNSE). The population was comprised of ninth-grade public and private schools students from Brazilian capitals. Physical activity and sedentary behavior variables were combined to create the outcome of simultaneity of these risk factors. RESULTS: A large proportion of students were simultaneously inactive and sedentary in the 3 surveys. However, it was possible to observe a downward trend (2009: 56.4%; 95% confidence interval, 55.7-57.1; 2012: 53.7%; 95% confidence interval, 53.0-54.4; 2015: 51.9%; 95% confidence interval, 51.2-52.7). In 2015, estimates of physical inactivity and sedentary behavior simultaneity were greater than 48% for 20 out of 27 of the Brazilian states. Significant declining trends were observed among mideast residents, females, nonwhite, and those attending private schools. Only around 5%-7% of the adolescents were both active and nonsedentary in the 3 surveys. CONCLUSION: Despite of a slight decreasing trend in the proportion of Brazilian students simultaneously inactive and sedentary throughout the period, the prevalence remained elevated across the surveys.

Protocol for Objective Measurement of Infants' Physical Activity using Accelerometry.

PURPOSE: This study aimed to evaluate methods for infants' physical activity measurement based on accelerometry, including the minimum number of measurement days and placement of a wrist or ankle device. We also evaluated the acceptability of the device among infants and mothers. METHODS: A cross-sectional mixed-methods study was conducted on a convenience sample of 90 infants. Physical activity was measured using the Actigraph GT3X+ accelerometer placed on the wrist and/or ankle for 7 consecutive days (worn for 24 h), and a qualitative interview was performed to verify acceptability. The intraclass correlation coefficient (ICC) method and the Bland and Altman's dispersion diagram were used to verify the minimum number of measurement days. All analyses were stratified by walking status. RESULTS: The mean (SD) age was 12.9 (1.70) months; the mean acceleration varied between 25.8 mg (95% confidence interval (CI), 14.3-52.7) and 27.3 mg (95% CI, 17.9-44.5) using the wrist placement, and between 24.9 mg (95% CI, 10.6-48.4) and 26.2 mg (95% CI, 11.7-65.6) using the ankle placement. The ICC results showed a lower acceleration variability between days among infants incapable of walking; they achieved an ICC of 0.80 with 1 d of measurement in both placements. Among those capable of walking, the minimum number of days to achieve an ICC of 0.80 was 2 d measured at the wrist (0.85; 95% CI, 0.71-0.93) and 3 d measured at the ankle (0.92; 95% CI, 0.84-0.96). The qualitative results pointed to the wrist placement as the preferred placement among the overall sample. CONCLUSIONS: Two and three measurement days with the accelerometer placed on the wrist and ankle, respectively, seemed to adequately represent a week of measurement. The accelerometer placed on the wrist had better acceptance by the infants and mothers.