Impact of socioeconomic factors and health determinants on preterm birth in Brazil: a register-based study.

BACKGROUND: More than 15 million children are born preterm annually. While preterm survival rates have increased in high-income countries. Low- and middle-income countries, like Brazil, continue to battle high neonatal mortality rates due to a lack of adequate postnatal care. Globally, neonatal mortality is higher for preterm infants compared to those born at term. Our study aims to map and analyze the spatial, socioeconomic, and health coverage determinants related to preterm birth in Brazil in order to understand how spatial variations in demographics and access to primary care may affect preterm birth occurrences.  METHODS: Using publicly available national-level data from the Brazilian health system for 2008-2017, we conducted an ecological study to visualize the spatial distributions of preterm birth along with socioeconomic status, the structure of health services, and primary care work process, each consisting of multiple variables reduced via principal component analysis. Regression models were created to determine predictive effects of numeric and spatial variation of these scores on preterm birth rates. RESULTS: In Brazil, preterm birth rates increased from 2008-2017, with small and rural municipalities frequently exhibiting higher rates than urban areas. Scores in socioeconomic status and work process were significant predictors of preterm birth rates, without taking into account spatial adjustment, with more positive scores in socioeconomic status predicting higher preterm birth rates (coefficient 0.001145) and higher scores in work process predicting lower preterm birth rates (coefficient -0.002416). Geographically weighted regression showed socioeconomic status to be a more significant predictor in the North, with the work process indicators being most significant in the Northeast. CONCLUSIONS: Results support that primary care work process indicators are more significant in estimating preterm birth rates than physical structures available for care. These results emphasize the importance of ensuring the presence of the minimum human resources needed, especially in the most deprived areas of Brazil. The association between social determinants of health and preterm birth rates raises questions regarding the importance of policies dedicated to foster equity in the accessibility of healthcare services, and improve income as protective proxies for preterm birth.

[Factors associated with hospitalizations for primary care-sensitive conditions in Brazil: an ecological studyFactores asociados a las hospitalizaciones infantiles por afecciones que podrían tratarse en la atención primaria en Brasil: estudio ecológico]. / Fatores associados às internações infantis por condições sensíveis à atenção primária no Brasil: estudo ecológico.

Objective: To investigate whether structural aspects of primary care units (PCUs) and the work processes of primary care teams are associated with the rate of hospitalizations for primary care-sensitive conditions (HPCSC) in children younger than 5 years of age in Brazil. Method: For this longitudinal ecological study, secondary data were obtained from the Brazilian Hospital Information System and from three cycles of the National Program for Access and Quality Improvement in Primary Care (PMAQ-AB) (2012, 2014, 2017/2018). The analysis included 42 916 PCUs. A multilevel random intercept model with fixed slope was used. In the first level, the outcome (HPCSC rates) and explanatory variables (structure and process indicators) aggregated by PCU were analyzed. Social determinants (represented by a stratification criterion combining municipality population and health care management indicators) were entered in the second level. The t test with Bonferroni correction was used to compare indicator means between regions, and multilevel linear regression was used to estimate the correlation coefficients. Results: The HPCSC rate in children younger than 5 years was 62.78/100 thousand population per estimated PCU coverage area. A direct association with the outcome was observed for: participation in one or more PMAQ-AB cycles; team planning; special hours; dedicated pediatric care area; and availability of vaccines. Equipment, materials, supplies, and being a small or medium-size municipality were inversely associated with HPCSC. Conclusions: HPCSC rates in children below 5 years of age may potentially be reduced through improvements in PCU structure and process indicators and in municipal social determinants.

Objetivo: Determinar la asociación de la estructura de las unidades básicas de salud (UBS) y del proceso de trabajo de los equipos de atención primaria con los determinantes sociales y las tasas de hospitalización por afecciones que podrían tratarse en la atención primaria en menores de 5 años en Brasil. Métodos: Estudio longitudinal ecológico, con datos secundarios del Sistema de Informaciones Hospitalarias y los tres ciclos del Programa Nacional de Mejora del Acceso y de la Calidad de la Atención Básica (PMAQ-AB) (2012, 2014, 2017-2018). Se analizaron 42.916 UBS. Se aplicó un modelo multinivel con pendiente fija e intercepción aleatoria. En el primer nivel, se analizaron el desenlace (tasas de hospitalización por afecciones que podrían tratarse en los servicios de atención primaria) y las variables explicativas (indicadores estructurales y procedimentales) consolidados por UBS. En el segundo nivel, se incluyeron determinantes sociales municipales (representados por un criterio de estratificación que combina el tamaño del municipio con indicadores que influyen en la gestión de salud). Se utilizó la prueba de la t con la corrección de Bonferroni para comparar las medias de los indicadores entre las regiones y la regresión lineal multinivel para estimar los coeficientes de correlación. Resultados: La tasa de hospitalización por afecciones que podrían tratarse en los servicios de atención primaria en menores de 5 años fue de 62,78/100 mil habitantes por área estimada de cobertura de UBS. Los siguientes factores presentaron una asociación directa con el desenlace: participación en uno o más ciclos del PMAQ-AB; planificación del equipo; horario especial; dependencias de atención infantil en la unidad; y disponibilidad de vacunas. La variable relativa a equipos, materiales e insumos y la clasificación como municipio pequeño o mediano se asociaron inversamente con las hospitalizaciones por afecciones que podrían tratarse en los servicios de atención primaria. Conclusiones: Las hospitalizaciones de menores de 5 años por afecciones que podrían tratarse en los servicios de atención primaria pueden reducirse mejorando los indicadores estructurales y procedimentales de las UBS y los determinantes sociales municipales.

Is there a fair distribution of the structure of dental services in the capitals of the Brazilian Federative Units?

BACKGROUND: Brazilian Primary Care Facilities (PCF) provide primary care and must offer dental services for diagnosis, prevention, and treatment of diseases. According to a logic of promoting equity, PCF should be better structured in less developed places and with higher need for oral health services. OBJECTIVE: To analyze the structure of dental caries services in the capitals of the Brazilian Federative Units and identify whether socioeconomic factors and caries (need) are predictors of the oral health services structure. METHODS: This is an ecological study with variables retrieved from different secondary databases, clustered for the level of the federative capitals. Descriptive thematic maps were prepared, and structural equations were analyzed to identify oral health service structure's predictors (Alpha = 5%). Four models with different outcomes related to dental caries treatment were tested: 1) % of PCF with a fully equipped office; 2) % of PCF with sufficient instruments, and 3) % of PCF with sufficient supplies; 4) % of PCF with total structure. RESULTS: 21.6% of the PCF of the Brazilian capitals had a fully equipped office; 46.9% had sufficient instruments, and 30.0% had sufficient supplies for caries prevention and treatment. The four models evidenced proper fit indexes. A correlation between socioeconomic factors and the structure of oral health services was only noted in model 3. The worse the socioeconomic conditions, the lower the availability of dental supplies (standard factor loading: 0.92, P = 0.012). Estimates of total, direct and indirect effects showed that dental caries experience observed in the Brazilian population by SB-Brasil in 2010 did not affect the outcomes investigated. CONCLUSION: Material resources are not equitably distributed according to the socioeconomic conditions and oral health needs of the population of the Brazilian capitals, thus contributing to persistent oral health inequities in the country.

An evaluation of outcomes in patients with traumatic brain injury at a referral hospital in Tanzania: evidence from a survival analysis.

OBJECTIVE: The purpose of this study was to determine if patients with traumatic brain injury (TBI) in low- and middle-income countries who receive surgery have better outcomes than patients with TBI who do not receive surgery, and whether this differs with severity of injury. METHODS: The authors generated a series of Kaplan-Meier plots and performed multiple Cox proportional hazard models to assess the relationship between TBI surgery and TBI severity. The TBI severity was categorized using admission Glasgow Coma Scale scores: mild (14, 15), moderate (9-13), or severe (3-8). The authors investigated outcomes from admission to hospital day 14. The outcome considered was the Glasgow Outcome Scale-Extended, categorized as poor outcome (1-4) and good outcome (5-8). The authors used TBI registry data collected from 2013 to 2017 at a regional referral hospital in Tanzania. RESULTS: Of the final 2502 patients, 609 (24%) received surgery and 1893 (76%) did not receive surgery. There were significantly fewer road traffic injuries and more violent causes of injury in those receiving surgery. Those receiving surgery were also more likely to receive care in the ICU, to have a poor outcome, to have a moderate or severe TBI, and to stay in the hospital longer. The hazard ratio for patients with TBI who underwent operation versus those who did not was 0.17 (95% CI 0.06-0.49; p < 0.001) in patients with moderate TBI; 0.2 (95% CI 0.06-0.64; p = 0.01) for those with mild TBI, and 0.47 (95% CI 0.24-0.89; p = 0.02) for those with severe TBI. CONCLUSIONS: Those who received surgery for their TBI had a lower hazard for poor outcome than those who did not. Surgical intervention was associated with the greatest improvement in outcomes for moderate head injuries, followed by mild and severe injuries. The findings suggest a reprioritization of patients with moderate TBI-a drastic change to the traditional practice within low- and middle-income countries in which the most severely injured patients are prioritized for care.

[Proposal for a methodology to estimate the potential coverage of primary care teamsPropuesta de una metodología para estimar el área de cobertura potencial de los equipos de atención primaria]. / Proposta de metodologia para estimar a área de cobertura potencial por equipes de atenção primária.

OBJECTIVE: To present a methodology for the empirical evaluation of primary health care (PHC) through the construction of digital representations of potential PHC coverage areas. METHODS: In this methodological study, potential areas were constructed by combinatorial analysis between census tracts and the location of basic health units with working PHC teams in Brazil. Six rules were used to parameterize the algorithm for the construction of potential areas. Thus, six restrictions were applied to enable the model: the selection of census tracts near the basic health unit; contiguous sectors; mutually exclusive sectors; sectors located in the same municipality of basic health units; sum of 4 500 users per health team in each unit; and volume of population ascribed proportional to the number of PHC teams allocated to the unit. Based on 316 594 census tracts and 39 758 basic health units, a neighborhood matrix was developed. To that matrix, a graph algorithm was applied to test combinations of sectors that simultaneously met the stipulated rules. RESULTS: A total of 1 901 114 arcs were defined, connecting 30 351 census tracts, allowing the construction of 26 907 potential areas. Based on these results, intra-municipal analyses can be performed to monitor PHC indicators. Customizable algorithm parameters can be adjusted to accommodate different sets of rules which may be adapted to different countries. CONCLUSIONS: The use of geoprocessing approaches creates conditions for the assessment of PHC impact, based on secondary databases at various levels, such as intra-municipal, basic health unit, and even at the team level.

OBJETIVO: Presentar una metodología para la evaluación empírica de la atención primaria de salud (APS) a través de la construcción de representaciones digitales de las áreas de cobertura potencial de los equipos de APS. MÉTODOS: Estudio de tipo metodológico. Las áreas potenciales se construyeron mediante un análisis combinatorio entre los sectores censales y la localización de las unidades básicas de salud con equipos de APS que trabajan en Brasil. Se utilizaron seis reglas para parametrizar el algoritmo de construcción de las áreas potenciales. Así, se estipularon seis restricciones que viabilizaron el modelo utilizado: selección de sectores censales cercanos a la unidad básica de salud; sectores contiguos; sectores mutuamente excluyentes; sectores ubicados en el mismo municipio de la unidad básica de salud; suma de 4 500 usuarios por equipo de salud en cada unidad básica de salud; y volumen de población adscrita proporcional al número de equipos de APS asignados en la unidad básica de salud. A partir de 316 574 sectores censales y 39 758 unidades básicas de salud se desarrolló una matriz de vecindad sobre la cual se aplicó un algoritmo gráfico que evaluaba las combinaciones de sectores que cumplían simultáneamente las reglas estipuladas. RESULTADOS: Se definieron en total 1 901 114 arcos, que conectaron 30 351 sectores censales, lo que permitió la construcción de 26 907 áreas potenciales. Sobre la base de estos resultados, se pueden realizar análisis intramunicipales para monitorear los indicadores de APS. Los parámetros modificables del algoritmo se pueden ajustar para adaptarse a diferentes conjuntos de reglas y a diferentes países. CONCLUSIONES: El uso de enfoques basados en geoprocesamiento puede crear condiciones para la evaluación del impacto de la APS conforme a bases de datos secundarias y a nivel intramunicipal, de la unidad básica de salud e incluso a nivel de equipo.

[More Doctors recruitment program: a new approach to overcome inequalities in human resourcesPrograma Más Médicos: cómo evaluar el impacto de un enfoque innovador para superar las inequidades en recursos humanos]. / Programa Mais Médicos: como avaliar o impacto de uma abordagem inovadora para superação de iniquidades em recursos humanos.

Despite the 40 years elapsed since the Alma-Ata principles were first launched, a series of challenges still persists for the consolidation of primary health care (PHC) as the backbone of health care systems around the world. Among these challenges, especially noteworthy are the issues associated with the inequality in the allocation of human resources. The experience of the More Doctors Program (Programa Mais Médicos, PMM) in Brazil is an example of initiatives that tackle this inconclusive Alma-Ata agenda. By changing key aspects of physician training, provision, and allocation, PMM was shown to be a feasible alternative to minimize the challenge of physician shortage. Assessments of PMM, even though preliminary, have produced positive evidence showing increase in access and improvement of PHC quality in Brazil, a middle income country. Nevertheless, the generation of more robust evidence regarding the impact of PMM on PHC performance indicators is urgent. The discussion proposed in the present article emphasizes the need to prioritize quasi-experimental studies to measure the impact of PMM on population health. The article thus introduces a set of guidelines that may become a useful model to approach challenges associated with the shortage of health care professionals in low and middle income countries.

A pesar de que han transcurrido 40 años desde la proclamación de los principios de Alma-Ata, aún persisten desafíos para la consolidación de la atención primaria de salud (APS) como columna vertebral de los sistemas de atención de salud en todo el mundo. Entre estos desafíos, se destacan los problemas asociados con la desigualdad en la distribución de recursos humanos. La experiencia del Programa Más Médicos (PMM) en Brasil es un ejemplo de las iniciativas que abordan esta agenda inconclusa de Alma-Ata. Al cambiar aspectos clave de la capacitación, la provisión y la asignación de médicos, el PMM demostró ser una alternativa viable para minimizar el desafío de la escasez de profesionales. Las evaluaciones del PMM, aunque preliminares, han producido evidencias positivas que muestran un aumento en el acceso y mejora de la calidad de la APS en Brasil, un país de ingresos medios. Sin embargo, urge generar evidencia más sólida sobre el impacto del PMM en los indicadores de desempeño de la APS. La discusión propuesta en este trabajo enfatiza la necesidad de priorizar estudios cuasiexperimentales para medir el impacto del PMM en la salud de la población. El artículo propone un conjunto de directrices que pueden convertirse en un modelo útil para abordar los desafíos asociados con la escasez de profesionales de la salud en países de ingresos bajos y medios.

Oral primary care: an analysis of its impact on the incidence and mortality rates of oral cancer.

BACKGROUND: Oral cancer is a potentially fatal disease, especially when diagnosed in advanced stages. In Brazil, the primary health care (PHC) system is responsible for promoting oral health in order to prevent oral diseases. However, there is insufficient evidence to assess whether actions of the PHC system have some effect on the morbidity and mortality from oral cancer. The purpose of this study was to analyze the effect of PHC structure and work processes on the incidence and mortality rates of oral cancer after adjusting for contextual variables. METHODS: An ecological, longitudinal and analytical study was carried out. Data were obtained from different secondary data sources, including three surveys that were nationally representative of Brazilian PHC and carried out over the course of 10 years (2002-2012). Data were aggregated at the state level at different times. Oral cancer incidence and mortality rates, standardized by age and gender, served as the dependent variables. Covariables (sociodemographic, structure of basic health units, and work process in oral health) were entered in the regression models using a hierarchical approach based on a theoretical model. Analysis of mixed effects with random intercept model was also conducted (alpha = 5%). RESULTS: The oral cancer incidence rate was positively association with the proportion of of adults over 60 years (ß = 0.59; p = 0.010) and adult smokers (ß = 0.29; p = 0.010). The oral cancer related mortality rate was positively associated with the proportion of of adults over 60 years (ß = 0.24; p < 0.001) and the performance of preventative and diagnostic actions for oral cancer (ß = 0.02; p = 0.002). Mortality was inversely associated with the coverage of primary care teams (ß = -0.01; p < 0.006) and PHC financing (ß = -0.52-9; p = 0.014). CONCLUSIONS: In Brazil, the PHC structure and work processes have been shown to help reduce the mortality rate of oral cancer, but not the incidence rate of the disease. We recommend expanding investments in PHC in order to prevent oral cancer related deaths.

Family health strategy and equity in prenatal care: a population based cross-sectional study in Minas Gerais, Brazil.

BACKGROUND: Prenatal care coverage is still not universal or adequately provided in many low and middle income countries. One of the main barriers regards the presence of socioeconomic inequalities in prenatal care utilization. In Brazil, prenatal care is supplied for the entire population at the community level as part of the Family Health Strategy (FHS), which is the main source of primary care provided by the public health system. Brazil has some of the greatest income inequalities in the world, and little research has been conducted to investigate prenatal care utilization of FHS across socioeconomic groups. This paper addresses this gap investigating the socioeconomic and regional differences in the utilization of prenatal care supplied by the FHS in the state of Minas Gerais, Brazil. METHODS: Data comes from a probabilistic household survey carried out in 2012 representative of the population living in urban areas in the state of Minas Gerais. The sample size comprises 1,420 women aged between 13 and 45 years old who had completed a pregnancy with a live born in the last five years prior to the survey. The outcome variables are received prenatal care, number of antenatal visits, late prenatal care, antenatal tests, tetanus immunization and low birthweight. A descriptive analysis and logistic models were estimated for the outcome variables. RESULTS: The coverage of prenatal care is almost universal in catchment urban areas of FHT of Minas Gerais state including both antenatal visits and diagnostic procedures. Due to this high level of coverage, socioeconomic inequalities were not observed. FHS supplied care for around 80% of the women without private insurance and 90% for women belonging to lower socioeconomic classes. Women belonging to lower socioeconomic classes were at least five times more likely to receive antenatal visits and any of the antenatal tests by the FHS compared to those belonging to the highest classes. Moreover, FHS was effective in reducing low birthweight. Women who had prenatal care through FHS were 40% less likely to have a child with low birthweight. CONCLUSION: This paper presents strong evidence that FHS promotes equity in antenatal care in Minas Gerais, Brazil.

Addressing geographic access barriers to emergency care services: a national ecologic study of hospitals in Brazil.

BACKGROUND: Unequal distribution of emergency care services is a critical barrier to be overcome to assure access to emergency and surgical care. Considering this context it was objective of the present work analyze geographic access barriers to emergency care services in Brazil. A secondary aim of the study is to define possible roles to be assumed by small hospitals in the Brazilian healthcare network to overcome geographic access challenges. METHODS: The present work can be classified as a cross-sectional ecological study. To carry out the present study, data of all 5843 Brazilian hospitals were categorized among high complexity centers and small hospitals. The geographical access barriers were identified through the use of two-step floating catchment area method. Once concluded the previous step an evaluation using the Getis-Ord-Gi method was performed to identify spatial clusters of municipalities with limited access to high complexity centers but well covered by well-equipped small hospitals. RESULTS: The analysis of accessibility index of high complexity centers highlighted large portions of the country with nearly zero hospital beds by inhabitant. In contrast, it was possible observe a group of 1595 municipalities with high accessibility to small hospitals, simultaneously with a low coverage of high complexity centers. Among the 1595 municipalities with good accessibility to small hospitals, 74% (1183) were covered by small hospitals with at least 60% of minimum emergency service requirements. The spatial clusters analysis aggregated 589 municipalities with high values related to minimum emergency service requirements. Small hospitals in these 589 cities could promote the equity in access to emergency services benefiting more than eight million people. CONCLUSIONS: There is a spatial disequilibrium within the country with prominent gaps in the health care network for emergency services. Taking this challenge into consideration, small hospitals could be a possible solution and foster equity in access to emergency and surgical care. However more investments in are necessary to improve small hospitals capabilities to fill this gap.

Oral health care for people with disabilities in Brazil: Transition from the specialized dental services between 2014 and 2018.

OBJECTIVE: To identify changes in the dental service provision to people with disabilities (PD) in the Dental Specialties Centers (acronym CEO in Portuguese-Centro de Especialidades Odontológicas) between the first and second cycles of the Program for the Improvement of Access and Quality of CEO and analyse factors associated with any changes. METHODS: This nationwide ecological time series study adopted the CEO as the analysis unit. The 827 CEO who participated in the two program's cycles (2014 and 2018) were included. Data on the structure and the work process were considered to identify features of providing services to PD in both cycles. Latent transition analysis (LTA) was performed to identify latent status (LS) with similar features and model the transition between LS over time. Models with five variables and with two to five LS were tested, considered best conceptual interpretability and best model fit parameters: human resources structure (dentist working exclusively with PD) and work process that identified guarantee of PD treatment at the CEO, the CEO's interface with primary care, and the interface with tertiary care. Spatial analysis was performed to identify spatial patterns of LS in the Brazilian territory with choropleth maps. A multinomial logistic regression model was performed to identify factors associated with changes in the provision of CEO (improved, remained or worsened). FINDINGS: The best-fit model identified four LS: 'Better', 'Medium better', 'Medium worse' and 'Worse'. CEO remained in the LS 'Better' (94%), LS 'Medium' (5.3%) and LS 'Worse' (78.4%). It is noteworthy that the highest proportion of CEO, in both cycles, was in the LS 'Better', featured by the CEO, characterized by all the CEO guaranteeing treatment to users with PD, high proportions of professionals working exclusively with PD, and most CEO articulated with primary care and with tertiary care. However, there is a decrease in the number of postgraduate professionals specializing in this service profile (1.3%). The higher the population growth, the greater the likelihood of the CEO achieving 'improved' in the LS. Moreover, the higher the number of goals, the lower the likelihood of the CEO getting 'worse' in the LS. CONCLUSION: Advances in dental service provision were observed, with more significant transitions to the 'Better' class, with improvements mainly in the interface with primary and tertiary care. Disability will be an even more significant concern as the population ages. Initiatives that can remove barriers and empower PD are potent in the provision of oral health services.

Advances and weaknesses of the work process of the oral cancer care network in Brazil: A latent class transition analysis.

OBJECTIVE: To analyse the provision of oral cancer (OC) care services in the Dental Specialties Centers (Centros de Especialidades Odontológicas-CEO) in Brazil and identify changes over two cycles of external evaluation of the Program for the Improvement of Access and Quality-PMAQ, in 2014 and 2018. METHOD: This is a nationwide panel ecological study, including 916 CEO. Data from interviews with managers and dentists of the CEO were used, including variables related to training on OC, clinical protocols, biopsies, referral for diagnosis and treatment, and registration of users with OC. We carried out Latent Transition Analysis (LTA) to identify patterns (latent status LS) of service adequacy and work processes' changes between the two assessment cycles. We tested models with three, four, and five LS, selecting the one with the best conceptual interpretability and good model fit parameters. Data from the LS were plotted on choropleth and hotspots maps in Brazil allowing us to identify areas with the better or worse provision of specialized OC services. RESULTS: The model with four LS was chosen. The four LS were named: 1.'Most indicators inadequate for OC care' (the worst); 2. 'Most indicators suitable for OC care' (the best); 3. 'CEO with a poor relation with Primary Health Care (PHC) services'; and 4. 'CEO with a poor relation with tertiary hospital services'. The comparison of the LS transition between the two cycles revealed that 419 (45.7%) CEO remained in the same LS (1→1, 3→4, 2→2); 228 (24.9%) switched to a worse status (2→1, 2→4, 3→1) and 269 (29.4%) switched to a better LS (1→2, 1→4, 3→2). While the majority of the CEO improved, we identified a decline of 17.8% in those who reported performing biopsies and 18.3% in the number of CEO that had hospitals for referring confirmed OC cases. Almost all Brazilian states had CEO that improved the work process. The Southeast and South regions had the highest percentage of CEO with the better work process in both cycles. Hotspots showed areas concentrating improvements in the work process in the Northeast region. However, some hotspots in the North revealed some CEO where the work process deteriorated or remained unsatisfactory. CONCLUSIONS: There are regional inequities in the provision of OC care in CEO. Most services improved their work process or remained stable. However, the biopsies and the referral to hospital care for confirmed cases declined, indicating that CEO need to improve planning and care provision to reduce OC morbimortality.

Structure and work process regarding child care in Primary Health Care in Brazil: an ecological study with data from the Program for Primary Health Care Access and Quality Improvement 2012-2018. / Estrutura e processo de trabalho referente ao cuidado à criança na Atenção Primária à Saúde no Brasil: estudo ecológico com dados do Programa de Melhoria do Acesso e Qualidade da Atenção Básica 2012-2018.

OBJECTIVE: To assess the structure of primary health care centers (PHCCs) and the work process of primary care teams in child care in Brazil. METHODS: This was an ecological study with data from the three cycles of the Program for Primary Health Care Access and Quality Improvement 2012-2018, by states and regions. Seven structural and thirteen procedural indicators were analyzed. Student's t-test was used to compare indicator averages between regions. RESULTS: 85,845 teams participated in the three cycles of the program, grouped into 68,320 PHCCs. In the last evaluation cycle (2017-2018), mean percentage adequacy rates were higher among the structure indicators: health center operation (99%), equipment/materials (82%), vaccine availability (74%) and medication dispensing (70%). Population without coverage (68%) and making appointments with specialists (52%) corresponded to the lowest percentages of adequacy of process indicators. CONCLUSION: Process indicators had higher levels of adequacy than structure indicators.

National COVID-19 vaccination plan: using artificial spatial intelligence to overcome challenges in Brazil. / Plano nacional de vacinação contra a COVID-19: uso de inteligência artificial espacial para superação de desafios.

This article explores the use of spatial artificial intelligence to estimate the resources needed to implement Brazil's COVID-19 immu nization campaign. Using secondary data, we conducted a cross-sectional ecological study adop ting a time-series design. The unit of analysis was Brazil's primary care centers (PCCs). A four-step analysis was performed to estimate the popula tion in PCC catchment areas using artificial in telligence algorithms and satellite imagery. We also assessed internet access in each PCC and con ducted a space-time cluster analysis of trends in cases of SARS linked to COVID-19 at municipal level. Around 18% of Brazil's elderly population live more than 4 kilometer from a vaccination point. A total of 4,790 municipalities showed an upward trend in SARS cases. The number of PCCs located more than 5 kilometer from cell towers was largest in the North and Northeast regions. Innovative stra tegies are needed to address the challenges posed by the implementation of the country's National COVID-19 Vaccination Plan. The use of spatial artificial intelligence-based methodologies can help improve the country's COVID-19 response.

O objetivo deste artigo é analisar o uso da inteligência artificial espacial no contexto da imunização contra COVID-19 para a seleção adequada dos recursos necessários. Trata-se de estudo ecológico de caráter transversal baseado em uma abordagem espaço-temporal utilizando dados secundários, em Unidades Básicas de Saúde do Brasil. Foram adotados quatro passos analíticos para atribuir um volume de população por unidade básica, aplicando algoritmos de inteligência artificial a imagens de satélite. Em paralelo, as condições de acesso à internet móvel e o mapeamento de tendências espaço-temporais de casos graves de COVID-19 foram utilizados para caracterizar cada município do país. Cerca de 18% da população idosa brasileira está a mais de 4 quilômetros de distância de uma sala de vacina. No total, 4.790 municípios apresentaram tendência de agudização de casos de Síndrome Respiratória Aguda Grave. As regiões Norte e Nordeste apresentaram o maior número de Unidades Básicas de Saúde com mais de 5 quilômetros de distância de antenas de celular. O Plano nacional de vacinação requer o uso de estratégias inovadoras para contornar os desafios do país. O uso de metodologias baseadas em inteligência artificial espacial pode contribuir para melhoria do planejamento das ações de resposta à COVID-19.

Vaccination services and incomplete vaccine coverage for children: a comparative spatial analysis of the BRISA cohorts, São Luís (Maranhão State) and Ribeirão Preto (São Paulo State), Brazil.

We analyzed the spatial relation between incomplete vaccine coverage for children and the distance from vaccination services. This was a cross-sectional study of children from 13 to 35 months of age from the cities of São Luís (Maranhão State) and Ribeirão Preto (São Paulo State), Brazil, and from basic health units (UBS, in Portuguese). The sample consisted of 2,744 children from São Luís and 3,325 from Ribeirão Preto. Data about incomplete vaccine coverage for children were obtained from the BRISA birth cohorts. Data about the quality of UBS vaccination services were obtained from the first cycle of the Brazilian National Program for Improvement of Access and Quality of Basic Care (PMAQ-AB, in Portuguese). For the spatial analysis, we determined the distance between the residence of the children (with and without a complete vaccine calendar) and the vaccination services of the UBS (classified according to number of structural items). Incomplete vaccine coverage was more pronounced in São Luís, with greater percentages for human rotavirus and triple viral vaccines, with the latter being the least available. In Ribeirão Preto, incomplete BCG vaccine coverage was more pronounced, with the tetravalent vaccine being the least available. Children from the two cities showed similarities: most of them had adult mothers with 9 to 11 years of schooling and did not reside with siblings in the household. They also showed differences: in São Luís, most mothers belonged to the economic class C, while in Ribeirão Preto they belong to the A and B classes. In the two cities with different socioeconomic conditions, complete vaccine coverage seemed not to depend on the location or quality of the vaccination service. Although São Luís showed a better structure of the services, incomplete vaccine coverage was higher compared to Ribeirão Preto.

[Spatial analysis of the quality of Primary Health Care services in reducing child mortality]. / Análise espacial da qualidade dos serviços de Atenção Primária à Saúde na redução da mortalidade infantil.

This study sought to analyze the correlation of the quality of Primary Health Care services in reducing child mortality, via geoprocessing. It involved an ecological study, with a cross-sectional approach, in which secondary data from all 5,565 Brazilian municipalities were used to analyze the infant mortality rate (IMR) and cause of infant death. The data related to IMR was obtained from the Mortality Information System. For the spatial analysis, 5,011 municipalities were included. The clustering analyses were performed using GEODA software and the spatial regression analyses were performed using ARCGIS 10.5 software. In Brazil, there was a 45.07% reduction in IMR between the years 2000 and 2015. The greatest reduction occurred in the northeastern region of the country, although it is still the region with the highest IMR. Of the 749 municipalities analyzed in the differential cluster for infant death, 153 had high IMR. The areas with the greatest increase in IMR were found in the North and Northeast regions. In Brazil, IMR proved to be inversely associated with the accessibility to high complexity services, health management strata and population size, reference for childbirth, live birth rate, per capita income and unemployment rate. A progressive reduction in IMR was recorded between 2000 and 2015.

Objetivou-se analisar a correlação da qualidade dos serviços da Atenção Primária na redução da mortalidade infantil, através do geoprocessamento. Um estudo ecológico, de abordagem transversal, em que foram utilizados dados secundários de todos os 5.565 municípios brasileiros para análise da taxa de mortalidade infantil (TMI) e causa de óbito infantil. Os dados da TMI foram obtidos no Sistema de Informação de Mortalidade. Para a análise espacial, incluímos 5.011 municípios. As análises de clusterização ocorreram no software GEODA e as análises de regressão espacial no ARCGIS 10.5. No Brasil houve uma redução de 45,07% da TMI entre os anos 2000 e 2015. A maior redução ocorreu na região nordeste do país, apesar de ainda ser a região com maior número na TMI. Dos 749 municípios analisados no cluster diferencial para óbito infantil, 153 apresentaram alta TMI. As áreas com maior expansão de alta TMI foram encontradas nas regiões Norte e Nordeste. No Brasil, a TMI mostrou-se inversamente associada à acessibilidade aos serviços de alta complexidade, ao estrato da gestão em saúde e porte populacional, à referência para o parto, à taxa de nascidos vivos, à renda per capita e à taxa de desemprego. Verificou-se uma crescente redução da TMI entre o período de 2000 a 2015.

Progress and challenges in potential access to oral health primary care services in Brazil: A population-based panel study with latent transition analysis.

OBJECTIVE: Compared indicators of potential access to oral health services sought in two cycles of the Program for Improvement of Access and Quality of Primary Care (PMAQ-AB), verifying whether the program generated changes in access to oral health services. METHODS: Transitional analysis of latent classes was used to analyze two cross-sections of the external evaluation of the PMAQ-AB (Cycle I: 2011-2012 and Cycle II: 2013-2014), identifying completeness classes for a structure and work process related to oral health. Consider three indicators of structure (presence of a dental surgeon, existence of a dental office and operating at minimum hours) and five of the work process (scheduling every day of the week, home visits, basic dental procedures, scheduling for spontaneous demand and continuation of treatment). Choropleth maps and hotspots were made. RESULTS: The proportion of elements that had one or more dentist (CD), dental office and operated at minimum hours varied from 65.56% to 67.13 between the two cycles of the PMAQ-AB. The number of teams that made appointments every day of the week increased 8.7% and those that made home visits varied from 44.51% to 52.88%. The reduction in the number of teams that reported guaranteeing the agenda for accommodating spontaneous demand, varying from 62.41% to 60.11% and in the continuity of treatment, varying from 63.41% to 61.11%. For the structure of health requirements, the predominant completeness profile was "Best completeness" in both cycles, comprising 71.0% of the sets at time 1 and 67.0% at time 2. The proportion of teams with "Best completeness" increased by 89.1%, the one with "Worst completeness" increased by 20%, while those with "Average completeness" decreased by 66.3%. CONCLUSION: We identified positive changes in the indicators of potential access to oral health services, expanding the users' ability to use them. However, some access attributes remain unsatisfactory, with organizational barriers persisting.

Data-driven risk stratification for preterm birth in Brazil: a population-based study to develop of a machine learning risk assessment approach.

Background: Preterm birth (PTB) is a growing health issue worldwide, currently considered the leading cause of newborn deaths. To address this challenge, the present work aims to develop an algorithm capable of accurately predicting the week of delivery supporting the identification of a PTB in Brazil. Methods: This a population-based study analyzing data from 3,876,666 mothers with live births distributed across the 3,929 Brazilian municipalities. Using indicators comprising delivery characteristics, primary care work processes, and physical infrastructure, and sociodemographic data we applied a machine learning-based approach to estimate the week of delivery at the point of care level. We tested six algorithms: eXtreme Gradient Boosting, Elastic Net, Quantile Ordinal Regression - LASSO, Linear Regression, Ridge Regression and Decision Tree. We used the root-mean-square error (RMSE) as a precision. Findings: All models obtained RMSE indexes close to each other. The lower levels of RMSE were obtained using the eXtreme Gradient Boosting approach which was able to estimate the week of delivery within a 2.09 window 95%IC (2.090-2.097). The five most important variables to predict the week of delivery were: number of previous deliveries through Cesarean-Section, number of prenatal consultations, age of the mother, existence of ultrasound exam available in the care network, and proportion of primary care teams in the municipality registering the oral care consultation. Interpretation: Using simple data describing the prenatal care offered, as well as minimal characteristics of the pregnant, our approach was capable of achieving a relevant predictive performance regarding the week of delivery. Funding: Bill and Melinda Gates Foundation, and National Council for Scientific and Technological Development - Brazil, (Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPQ acronym in portuguese) Support of the research project named: Data-Driven Risk Stratification for Preterm Birth in Brazil: Development of a Machine Learning-Based Innovation for Health Care- Grant: OPP1202186.

Characteristics of primary care and rates of pediatric hospitalizations in Brazil.

OBJECTIVE: To evaluate the association among characteristics of primary health care center (PHCC) with hospitalizations for primary care sensitive conditions (PCSC) in Brazil. METHOD: In this study, a cross-sectional ecological study was performed. This study analyzed the 27 capitals of Brazil's federative units. Data were aggregated from the following open access databases: National Program for Access and Quality Improvement in Primary Care, the Hospital Information System of Brazilian Unified Health System and Annual Population Census conducted by the Brazilian Institute of Geography and Statistics. Associations were estimated among characteristics of primary care with the number of three PCSC as the leading causes of hospitalization in children under-5 population in Brazil: asthma, diarrhea, and pneumonia. RESULTS: In general, PHCC showed limited structural adequacy (37.3%) for pediatric care in Brazil. The capitals in South and Southeast regions had the best structure whereas the North and Northeast had the worst. Fewer PCSC hospitalizations were significantly associated with PHCC which presented appropriate equipment (RR: 0.98; 95%CI: 0.97-0.99), structural conditions (RR: 0.98; 95%CI: 0.97-0.99), and signage/identification of professionals and facilities (RR: 0.98; 95%CI: 0.97-0.99). Higher PCSC hospitalizations were significantly associated with PHCC with more physicians (RR: 1.23, 95%CI: 1.02-1.48), it forms (RR: 1.01, 95%CI: 1.01-1.02), and more medications (RR: 1.02, 95%CI: 1.01-1.03). CONCLUSION: Infrastructural adequacy of PHCC was associated with less PCSC hospitalizations, while availability medical professional and medications were associated with higher PCSC hospitalizations.

Geospatial modeling of microcephaly and zika virus spread patterns in Brazil.

Microcephaly and Zika Virus infection (ZIKV) were declared Public Health Emergencies of International Concern by the World Health Organization in 2016. Brazil was considered the epicenter of the outbreak. However, the occurrence of both ZIKV and microcephaly in Brazil was not evenly distributed across the country. To better understand this phenomenon, we investigate regional characteristics at the municipal level that can be associated with the incidence of microcephaly, our response variable, and its relationship with ZIKV and other predictors. All epidemiological data in this study was provided by the Ministry of Health official database (DATASUS). Microcephaly was only confirmed after birth and the diagnostic was made regardless of the mother's ZIKV status. Using exploratory spatial data analysis and spatial autoregressive Tobit models, our results show that microcephaly incidence is significantly, at 95% confidence level, related not only to ZIKV, but also to access to primary care, population size, gross national product, mobility and environmental attributes of the municipalities. There is also a significant spatial autocorrelation of the dependent variable. The results indicate that municipalities that show a high incidence of microcephaly tend to be clustered in space and that incidence of microcephaly varies considerably across regions when correlated only with ZIKV, i.e. that ZIKV alone cannot explain the differences in microcephaly across regions and their correlation is mediated by regional attributes.

Disparities in surgical care for children across Brazil: Use of geospatial analysis.

BACKGROUND: Health systems for surgical care for children in low- and middle-income countries remain poorly understood. Our goal was to characterize the delivery of surgical care for children across Brazil and to identify associations between surgical resources and childhood mortality. METHODS: We performed a cross-sectional, ecological study to analyze surgical care for children in the public health system (Sistema Único de Saúde) across Brazil from 2010 to 2015. We collected data from several national databases, and used geospatial analysis (two-step floating catchment, Getis-Ord-Gi analysis, and geographically weighted regression) to explore relationships between infrastructure, workforce, access, procedure rate, under-5 mortality rate (U5MR), and perioperative mortality rate (POMR). RESULTS: A total of 246,769 surgical procedures were performed in 6,007 first level/ district hospitals and 491 referral hospitals across Brazil over the study period. The surgical workforce is distributed unevenly across the country, with 0.13-0.26 pediatric surgeons per 100,000 children in the poorer North, Northeast and Midwest regions, and 0.6-0.68 pediatric surgeons per 100,000 children in the wealthier South and Southeast regions. Hospital infrastructure, procedure rate, and access to care is also unequally distributed across the country, with increased resources in the South and Southeast compared to the Northeast, North, and Midwest. The U5MR varies widely across the country, although procedure-specific POMR is consistent across regions. Increased access to care is associated with lower U5MR across Brazil, and access to surgical care differs by geographic region independent of socioeconomic status. CONCLUSIONS: There are wide disparities in surgical care for children across Brazil, with infrastructure, manpower, and resources distributed unevenly across the country. Access to surgical care is associated with improved U5MR independent of socioeconomic status. To address these disparities, policy should direct the allocation of surgical resources commensurate with local population needs.