Analysis of the Main Groups Victimized by Familiar Violence and by Violence by a Known Person in Brazil.

ABSTRACT: This study aims to evaluate the ratio of the number of cases of family violence and violence by a known person, over the four surveys that took place in 2006, 2007, 2009, and 2011, within the population treated in the Brazilian health services, according to demographic and socioeconomic characteristics. Data from the Vigilância de Violências e Acidentes survey was used. The variables age, victim sex, aggressor sex, race, and schooling level were considered in the analysis. This study pointed out decreasing trend in the number of violence-related care within the older age group. The number of familial violence-related care per victim sex was higher for male victims when the aggressor was female, and conversely, it was higher for female victims when the aggressor was male. The number of violence-related care was mostly higher in non-White people than in White. People with low schooling levels showed the highest ratio of the number of violence-related care.

Cancer care in Brazil: structure and geographical distribution.

BACKGROUND: The organisation and systematisation of health actions and services are essential to ensure patient safety and the effectiveness and efficiency of cancer care. The objective of this study was to analyse the structure of cancer care envisaged in Brazilian norms, describe the types of accreditations of cancer services and their geographic distribution, and determine the planning and evaluation parameters used to qualify the health units that provide cancer care in Brazil. METHODS: This observational study identified the current organisation of cancer care and other health services that are accredited by Brazil's national health system (SUS) for cancer treatment as of February 2017. The following information was collected from the current norms and the National Registry of Health Establishments: geographic location, type of accreditation, type of care, and hospital classification according to annual data of the number of cancer surgeries. The adequacy of the number of licensed units relative to population size was assessed. The analysis considered the facilitative or restrictive nature of policies based on the available rules and resources. RESULTS: The analysis of the norms indicated that these documents serve as structuring rules and resources for developing and implementing cancer care policies in Brazil. A total of 299 high-complexity oncology services were identified in facilities located in 173 (3.1%) municipalities. In some states, there were no authorised services in radiotherapy, paediatric oncology and/or haematology-oncology. There was a significant deficit in accredited oncology services. CONCLUSIONS: The parameters that have been used to assess the need for accredited cancer services in Brazil are widely questioned because the best basis of calculation is the incidence of cancer or disease burden rather than population size. The results indicate that the availability of cancer services is insufficient and the organisation of the cancer care network needs to be improved in Brazil.

The current scenario of emergency care policies in Brazil.

BACKGROUND: The regulation of emergency care has featured prominently in Brazil's federal health agenda since the 2000s. The aim of this study was to review up to the present day the implementation of the National Emergency Care Policy. METHODS: The methods employed were documental review, analysis of official data and 11 interviews conducted with federal, state and local managers. The results were analyzed using Giddens' Structuration Theory, relating the cognitive abilities of the agents to their action strategies, in view of the structural dimensions, rules and resources provided by the federal administration. RESULTS: Federal policy for emergency care in Brazil can be divided into three stages: from 1998 to 2003, the initial regulation; from 2004 to 2008, the expansion of the Mobile Emergency Medical Services (SAMU, in Brazil); and from 2009 onwards, the implementation of stationary pre-hospital care facilities, known as Emergency Care Units (UPA). The structuration elements identified for the emergency care policy were the public health system guidelines, legislation, standards and federal financing. Significant restrictions were found such as lack of hospital beds and intensive care treatment, gaps in the information system for producing evidence for management, ineffective Management Committees, as well as a low degree of commitment among physicians to the services. CONCLUSION: Considering the financial constraints imposed on the SUS (Brazilian Unified Health System), emergency care was identified as a political priority with financial support. The individual actions by emergency care workers and governmental agents typified the first period of the policy, structuring the basis and producing changes in the circumstances of action. Federal strategies can be equated to the rules and resources provided to support the implementation process of the policy.

An analysis of actions to promote health in underprivileged urban areas: a case in Brazil.

BACKGROUND: Two policies stood out in the 2000s geared towards changing the care model adopted in Brazil: The National Policy on Primary Health Care, based on a family health care model, and the National Policy on Health Promotion.The aim of this study was to analyze health promotion actions developed by family health care teams in the municipality of Belford Roxo. This town was chosen by virtue of its "below average" level of primary health care services offered in relation to other municipalities in Rio de Janeiro state. METHODS: The following methodological strategies were employed: analysis of health systems, document analysis (2010 Annual Health Schedule and 2010 Annual Management Report), participant observation and interviews with nine health care professionals in the region of study, namely: the manager of the Regional Health Polyclinic (responsible for health care actions in the region), and nurses belonging to the eight family health teams. Giddens' Theory of Structuration was used for analysis of the results. RESULTS: Varying levels of health care activity were found, indicating that the managers have been either unable or lacked the commitment to perform the proposed actions. From a structural point of view, 87.5% of the teams were incomplete. Also of particular note was the lack of any physicians in the teams, which, despite its detrimental effect, was regarded by the interviewees as "natural".Strong political party influence in the area hindered relations between the team and the local population. Health education, especially through lectures was the main health promotion activity picked up in this study.No cross-sectorial or public participation actions were identified. Connections between the teams for sharing responsibilities were found to be very weak. CONCLUSION: In addition to political factors, there are also structural limitations such as a lack of human resources that overburdens the teams' daily activities. From this point of view, the political context and lack of professionals were restrictive factors for health promotion.Belford Roxo is not necessarily representative of other experiences in Brazil. However, problems such as patronage, political manipulation, poverty and incipient cross-sectorial actions are common to other Brazilian towns and cities.

Oral cancer care in the "Metropolitan I" health region in the state of Rio de Janeiro, Brazil: enabling and constraining factors. / Atenção ao câncer bucal na região de saúde Metropolitana I do Rio de Janeiro, Brasil: fatores facilitadores e coercitivos.

The aim was to identify constraining and enabling factors related to the organization of health care networks that influence access to oral cancer diagnosis and treatment. A case study in the "Metropolitan I" health region using data collected from health information systems and 26 semi-structured interviews with health managers and professionals. The data were analyzed using descriptive statistics and strategic conduct analysis, drawing on the theory of structuration proposed by Giddens. The findings reveal that coverage of oral health care in primary care services is generally low and prioritizes specific groups and urgent cases, hampering access to oral cancer diagnosis. While the presence of a network of secondary care services in the municipalities that make up the health region facilitates diagnosis, there are major barriers to treatment. Informal partnerships established with dental schools play an important role in diagnosis, but do not receive funding. The regulation of appointments for diagnosis was not restrictive. In contrast, the regulation of referrals for treatment lacked transparency, was subject to long delays, and shortage of places. Despite advances, constraining factors related to structure and the actions of agents involved in the care process persist, hampering the timely diagnosis and treatment of oral cancer.

O objetivo foi identificar os fatores facilitadores e coercitivos da organização da rede de atenção à saúde que intervêm sobre o acesso ao diagnóstico e tratamento do câncer bucal. Um estudo de caso da região de saúde Metropolitana I do estado do Rio de Janeiro, com coleta de dados em sistemas de informação e 26 entrevistas com gestores e profissionais. A análise dos dados foi realizada por meio das técnicas de estatística descritiva e análise temática, à luz da Teoria da Estruturação de Giddens. Identificou-se baixa cobertura de saúde bucal na atenção básica, com priorização do acesso a grupos prioritários e urgências, dificultando o acesso ao diagnóstico do câncer bucal neste nível de atenção. A presença da rede secundária em todos os municípios da região facilita o diagnóstico, porém há limites para o acesso ao tratamento. Faculdades de odontologia atuam no diagnóstico como rede informal, ação importante, mas não financiada. A regulação para o diagnóstico não foi restritiva, mas para o tratamento a regulação foi considerada pouco transparente e demorada, com falta de vagas. Apesar dos avanços, persistem fatores coercitivos estruturais e nas ações dos agentes que restringem diagnóstico e tratamento oportuno do câncer bucal.

[Performance of the mobile emergency care service from the perspective of managers and professionals: case study in a region of the state of São Paulo, Brazil]. / Desempenho do serviço de atendimento móvel de urgência na perspectiva de gestores e profissionais: estudo de caso em região do estado de São Paulo, Brasil.

This article aims to analyze the perspective of managers and professionals about the performance of the Mobile Emergency Care Service (SAMU) in the Grande ABC region. This is a qualitative case study based on the formulation of a theoretical-logical model of intervention and semi-structured interviews. The Theoretical-Logical Model translated the dimensions of SAMU analysis: regulation, care and management. The regulation process was understood as a strategic space where the judgment of the patient's need and the ambulance dispatch time have the potential to influence the outcomes of the cases transported. In health care, the main themes that emerged were investment in the qualification of the team and in telemedicine with the perspective of improving the quality of care and making the diagnosis more accurate. In management, challenges such as integrating SAMU with tertiary centers, improving the information system, and monitoring and evaluation were highlighted aiming to qualify the regulatory processes by aligning them with the objectives proposed in the health policy. The set of data analyzed reinforces the capacity of the SAMU in emergency care in the region; however, the intervention needs to overcome important challenges in order to improve the prognosis of the cases transported.

Este artigo tem como objetivo analisar a perspectiva de gestores e profissionais sobre o desempenho do SAMU na região do Grande ABC. Trata-se de estudo de caso, de abordagem qualitativa, baseado na formulação de modelo teórico-lógico da intervenção e entrevistas semiestruturadas. O Modelo teórico-lógico traduziu as dimensões de análise do SAMU: regulação, assistência e gestão. O processo de regulação foi entendido como espaço estratégico onde o julgamento da necessidade do paciente e o tempo de despacho da ambulância tem potencial de influenciar nos desfechos dos casos transportados. Na assistência os principais temas que emergiram foram investimento na qualificação da equipe e em telemedicina com a perspectiva de melhorar a qualidade do cuidado e tornar o diagnóstico mais preciso. No âmbito da gestão desafios como integração do SAMU com centros terciários, aperfeiçoamento do sistema de informação e monitoramento e avaliação foram destacados visando qualificar os processos regulatórios alinhando-os aos objetivos propostos na política de saúde. O conjunto de dados analisados reforça a capacidade do SAMU na atenção de urgência na região, no entanto a intervenção precisa superar importantes desafios em busca de melhor prognóstico entre os casos transportados.

Mortality by colon, lung, esophagus, prostate, cervix and breast cancers in Brazilian capitals, 2000-2015: a multilevel analysis.

This study aimed to analyze the role of period, geographic and socio demographic factors in cancer-related mortality by prostate, breast, cervix, colon, lung and esophagus cancer in Brazilians capitals (2000-2015). Ecological study using data of Brazilian Mortality Information. Multilevel Poisson models were used to estimate the adjusted risk of cancer mortality. Mortality rate levels were higher in males for colon, lung and esophageal cancers. Mortality rates were highest in the older. Our results showed an increased risk of colon cancer mortality in both sexes from 2000 to 2015, which was also evidenced for breast and lung cancers in women. In both genders, the highest mortality risk for lung and esophageal cancers was observed in Southern capitals. Midwestern, Southern and Southeastern capitals showed the highest mortality risk for colon cancer both for males and females. Colon cancer mortality rate increased for both genders, while breast and lung cancers mortality increased only for women. The North region showed the lowest mortality rate for breast, cervical, colon and esophageal cancers. The Midwest and Northeast regions showed the highest mortality rates for prostate cancer.

[Evaluative Matrix of the Longitudinal Bond in primary healthcare: statistical validation in a health territory in the city of Rio de Janeiro, Brazil]. / Matriz Avaliativa do Vínculo Longitudinal na atenção primária em saúde: validação estatística em um território de saúde do Município do Rio de Janeiro, Brasil.

In keeping with the process of institutionalization of evaluation of primary healthcare in Brazil, we developed the Evaluative Matrix of the Longitudinal Bond (MAVIL in Portuguese), a simple and concise evaluative tool. MAVIL is structured according to three dimensions in the concept of longitudinal bond: Dimension 1 - recognition of the basic health unit (UBS in Portuguese) as a regular source of care, Dimension 2 - healthcare worker/patient interpersonal relationship, and Dimension 3 - continuity of information. The instrument consists of a structured set of 12 criteria, 20 indicators and respective questions, and verification items submitted to various validation stages. The current article presents the statistical validation of the MAVIL application in two UBS in a health territory in order to support future applications and also verify the instrument's capacity to capture differences in the longitudinal bond profile between UBS. The method included the following definitions: sample design, choice of the metric, descriptive data analysis, and comparative test of means, through application of the test of normality and nonparametric statistic. As results, the sample by strata, together with option of totaling the points from the MAVIL items as the metric, allowed describing the longitudinal bond profile for three cross-sections: territory and UBS A and B. To verify the capacity of MAVIL to capture differences in the longitudinal bond profile, we tested the hypothesis of the data's normality with the Kolmogorov-Smirnov test. Having rejected the hypothesis of normality, we opted for the Wilcoxon nonparametric test to compare the UBS. Dimension 1 and Dimension 2 showed similar profiles, but there was a significant difference for Dimension 3, attesting to the sensitivity of MAVIL.

Consonante com o processo de institucionalização da avaliação da atenção primária no Brasil, foi desenvolvida a Matriz Avaliativa do Vínculo Longitudinal (MAVIL), instrumental avaliativo simples e conciso. A MAVIL estrutura-se a partir das três dimensões do conceito de vínculo longitudinal: Dimensão 1 - reconhecimento da unidade básica de saúde (UBS) como fonte regular de cuidados, Dimensão 2 - relação interpessoal profissional/paciente e Dimensão 3 - continuidade da Informação. Consiste em um conjunto estruturado de 12 critérios, 20 indicadores e respectivas questões e itens de verificação, submetido a várias etapas de validação. O presente artigo apresenta a validação estatística da aplicação MAVIL em duas UBS de um território de saúde a fim de respaldar as futuras aplicações e averiguar também a capacidade do instrumento para captar diferenças no perfil do vínculo longitudinal entre UBS. O método consistiu nas seguintes definições: desenho da amostra, escolha da métrica, análise descritiva dos dados e teste comparativo de médias, por meio da aplicação do teste de normalidade e de estatística não paramétrica. Como resultados: a amostra por estrato, junto à opção da soma dos pontos dos itens da MAVIL como métrica, possibilitou descrever o perfil do vínculo longitudinal para os três recortes: território e UBS A e B. Para verificar a capacidade da MAVIL em captar diferença no perfil de vínculo longitudinal, testou-se a hipótese da normalidade dos dados a partir do teste de Kolmogorov-Smirnov. Rejeitada a hipótese da normalidade, optou-se pelo teste não paramétrico de Wilcoxon para comparar as UBS. Para Dimensão 1 e Dimensão 2, constatou-se a semelhança de perfil, contudo, para Dimensão 3, houve diferença significativa, atestando a sensibilidade da MAVIL.

En consonancia con el proceso de institucionalización de la evaluación de la atención primaria en Brasil, se desarrolló la Matriz Evaluativa del Vínculo Longitudinal (MAVIL), un instrumento evaluativo simple y conciso. MAVIL se estructura a partir de las tres dimensiones del concepto de vínculo longitudinal: Dimensión 1 - reconocimiento de la unidad básica de salud (UBS) como fuente regular de cuidados, Dimensión 2 - relación interpersonal profesional/paciente y Dimensión 3 - continuidad de la información. Consiste en un conjunto estructurado de 12 criterios, 20 indicadores y sus respectivas cuestiones e ítems de verificación, sometido a varias etapas de validación. Este artículo presenta la validación estadística de la aplicación MAVIL en dos UBS de una zona con servicios de salud, con el fin de respaldar sus futuras aplicaciones y también averiguar la capacidad de la herramienta para captar diferencias en el perfil del vínculo longitudinal entre UBS. El método consistió en las siguientes definiciones: diseño de la muestra, elección del sistema de medición, análisis descriptivo de los datos y test comparativo de medias, a través de la aplicación del test de normalidad y de estadística no paramétrica. Como resultados: muestra por estrato, junto a la opción de suma de los puntos de los ítems de la MAVIL como sistema de medición, posibilitó describir el perfil del vínculo longitudinal para las tres secciones elegidas: territorio, UBS A y B. Para verificar la capacidad de la MAVIL en captar la diferencia en el perfil de vínculo longitudinal se probó la hipótesis de la normalidad de los datos, a partir del test de Kolmogorov-Smirnov. Rechazada la hipótesis de la normalidad, se optó por la prueba no paramétrica de Wilcoxon para comparar las UBS. En Dimensión 1 y Dimensión 2 se constató la semejanza de perfil, sin embargo, en la Dimensión 3 hubo una diferencia significativa, constatando la sensibilidad de la MAVIL.

The Effect of Continuous Low-Intensity Exposure to Electromagnetic Fields from Radio Base Stations to Cancer Mortality in Brazil.

BACKGROUND: this study aims to estimate the rate of death by cancer as a result of Radio Base Station (RBS) radiofrequency exposure, especially for breast, cervix, lung, and esophagus cancers. METHODS: we collected information on the number of deaths by cancer, gender, age group, gross domestic product per capita, death year, and the amount of exposure over a lifetime. We investigated all cancer types and some specific types (breast, cervix, lung, and esophagus cancers). RESULTS: in capitals where RBS radiofrequency exposure was higher than 2000/antennas-year, the average mortality rate was 112/100,000 for all cancers. The adjusted analysis showed that, the higher the exposure to RBS radiofrequency, the higher cancer mortality was. The highest adjusted risk was observed for cervix cancer (rate ratio = 2.18). The spatial analysis showed that the highest RBS radiofrequency exposure was observed in a city in southern Brazil that also showed the highest mortality rate for all types of cancer and specifically for lung and breast cancer. CONCLUSION: the balance of our results indicates that exposure to radiofrequency electromagnetic fields from RBS increases the rate of death for all types of cancer.

Policies for Prevention and Control of Oral Cancer in the light of Giddens' Structuration Theory. / Políticas de Prevenção e Controle do Câncer Bucal à luz da Teoria da Estruturação de Giddens.

Challenges remain to ensure access to diagnosis and treatment ten years into continuous cancer prevention, control, and oral health policies. This study aims to analyze the oncology and oral health policies in force regarding the process of implanting oral cancer-related care components. Ten policies were analyzed under the lenses of the Structuration Theory, besides data on the supply of services between 2002 and 2017. Low coverage and inadequate regional distribution were highlighted in primary and secondary health care levels, despite increased funding and number of services. Unequal distribution of performed surgeries was identified in tertiary care. The limitation of home care services has hindered users' access to palliative care. A convergence was identified between the analyzed policies and concern with the regulation of authoritative resources and the increase of allocative resources, which stirred the expansion of services. Investments should be made in the expansion, regionalization, and universalization of services. A possible setback in these policies could aggravate the situation and contribute to the increase in health inequalities.

Passados mais de dez anos de continuidade das políticas de prevenção e controle do câncer e de saúde bucal, persistem desafios para garantia do acesso ao diagnóstico e tratamento. O objetivo do estudo é analisar as políticas de oncologia e de saúde bucal em vigor, no que se refere ao processo de implantação dos componentes assistenciais relacionados ao câncer bucal. Foram analisadas dez normativas que estruturam essas políticas, sob a ótica da Teoria da Estruturação, além de dados de oferta de serviços entre 2002 e 2017. Nas atenções básica e secundária, destacou-se a baixa cobertura assistencial e a distribuição regional inadequada, apesar do aumento do financiamento e do número de serviços. Na atenção terciária foi identificada a distribuição desigual da realização de cirurgias. Por sua vez, a limitação de serviços da atenção domiciliar tem dificultado o acesso dos usuários aos cuidados paliativos. Houve convergência entre as políticas analisadas e uma preocupação com a regulação dos recursos autoritativos e com o aumento de recursos alocativos, o que estimulou a expansão dos serviços. Deve-se investir na ampliação, regionalização e universalização dos serviços. Um possível retrocesso nessas políticas poderá agravar a situação e contribuir para o aumento das desigualdades em saúde.

[Competing ideas on the State's roles in the prevention and control of childhood obesity in Brazil]. / Ideias em disputa sobre as atribuições do Estado na prevenção e controle da obesidade infantil no Brasil.

The study analyzed competing ideas on the State's roles in the prevention and control of childhood obesity in Brazil, with cognitive analysis of public policies as the frame of reference. The study included document analysis and semi-structured interviews with 20 individuals from government, organized civil society, and the commercial private sector. The State was viewed as the main party responsible for dealing with childhood obesity, but the definitions of its roles varied according to the narratives on the factors that condition obesity and the proposed solutions. Members of the commercial private sector criticized the regulatory State in the name of parents' freedom of choice. Civil society representatives and part of the government defended regulatory measures, which they considered essential. They contended that agreements between government and the food industry to reduce unhealthy ingredients are ineffective. However, some government representatives defended such agreements. These tensions and contradictions were also expressed in the policy documents acknowledging that practices by the commercial private sector favor obesity, even while considering the private sector a partner in this process. The arguments against the regulatory State were based on individual factors conditioning obesity, but the object of regulation is institutional practices by the commercial private sector, not individual behaviors. However, this kind of argument is part of corporate policy activity, since it overlooks the conflicts of interests that have contributed to delaying the reduction in obesity prevalence.

O estudo analisou as ideias em disputa em torno das atribuições do Estado na prevenção e controle da obesidade infantil no Brasil com base no referencial de análise cognitiva de políticas públicas. Realizou-se análise documental e entrevista semiestruturada com 20 depoentes referenciados às esferas do Estado/Governo, sociedade civil organizada e do setor privado comercial. O Estado foi considerado o principal responsável pelo enfrentamento da obesidade infantil, mas as concepções sobre suas atribuições variaram de acordo com as narrativas sobre os condicionantes da obesidade e as soluções apresentadas. O setor privado comercial critica o Estado regulador em nome da liberdade de decisão dos pais. Representantes da sociedade civil e de parte do governo valorizam ações regulatórias e reconhecem que são fundamentais. Consideram que os acordos para a redução de ingredientes, realizados entre o governo e a indústria alimentícia, não são efetivos. Porém, alguns representantes do governo os defendem. Essas tensões e contradições também se expressam nos documentos de políticas que reconhecem que as práticas do setor privado comercial favorecem a obesidade, mas o consideram parceiro. Os argumentos contrários ao Estado regulador são pautados nos condicionantes individuais da obesidade, contudo, as práticas institucionais do setor privado comercial é que são objeto de regulação e não o comportamento dos indivíduos. No entanto, esse tipo de argumento é parte da ação política corporativa, pois omite os conflitos de interesses que vêm contribuindo para retardar a redução da prevalência da obesidade.

El estudio analizó las ideas en disputa en torno a las atribuciones del Estado en cuanto a la prevención y control de la obesidad infantil en Brasil, basándose en el marco referencial del análisis cognitivo de políticas públicas. Se realizó un análisis documental, al igual que una entrevista semiestructurada con 20 participantes, relacionados con diferentes esferas del Estado/Gobierno, sociedad civil organizada, así como del sector privado comercial. El Estado fue considerado el principal responsable del combate a la obesidad infantil, pero las concepciones sobre sus atribuciones variaron de acuerdo con las narraciones sobre los condicionantes de la obesidad y las soluciones presentadas. El sector privado comercial critica al Estado regulador, en nombre de la libertad de decisión de los padres. Los representantes de la sociedad civil y del gobierno valoran las acciones regulatorias y reconocen que son fundamentales. Consideran que los acuerdos para la reducción de ingredientes, realizados entre el gobierno y la industria alimentaria, no son efectivos. Sin embargo, algunos representantes del gobierno los defienden. Estas tensiones y contradicciones también se expresan en los documentos de políticas que reconocen que las prácticas del sector privado comercial favorecen la obesidad, pero lo consideran como un aliado. Los argumentos contrarios al Estado regulador se encuentran pautados en los condicionantes individuales de la obesidad, no obstante, las prácticas institucionales del sector privado comercial son las que son objeto de regulación, y no el comportamiento de los individuos. Sin embargo, este tipo de argumento forma parte de la acción política corporativa, puesto que omite los conflictos de intereses que han contribuido a retrasar la reducción de la prevalencia de la obesidad.

Interventions in overcrowding of emergency departments: an overview of systematic reviews.

OBJECTIVE To present an overview of systematic reviews on throughput interventions to solve the overcrowding of emergency departments. METHODS Electronic searches for reviews published between 2007 and 2018 were made on PubMed, Cochrane Library, EMBASE, Health Systems Evidence, CINAHL, SciELO, LILACS, Google Scholar and the CAPES periodicals portal. Data of the included studies was extracted into a pre-formatted sheet and their methodological quality was assessed using AMSTAR 2 tool. Eventually, 15 systematic reviews were included for the narrative synthesis. RESULTS The interventions were grouped into four categories: (1) strengthening of the triage service; (2) strengthening of the ED's team; (3) creation of new care zones; (4) change in ED's work processes. All studies observed positive effect on patient's length of stay, expect for one, which had positive effect on other indicators. According to AMSTAR 2 criteria, eight revisions were considered of high or moderate methodological quality and seven, low or critically low quality. There was a clear improvement in the quality of the studies, with an improvement in focus and methodology after two decades of systematic studies on the subject. CONCLUSIONS Despite some limitations, the evidence presented on this overview can be considered the cutting edge of current scientific knowledge on the topic.

Financial crisis and healthcare: the case of the municipality of Rio de Janeiro, Brazil. / A crise financeira e a saúde: o caso do município do Rio de Janeiro, Brasil.

This study aimed to portray the effects of the Brazilian financial crisis, and especially in Rio de Janeiro in the 2013-18 period. We analyzed revenues, expenditure, service provision, and health performance indicators from free access and restricted data. We adopted the Giddens' Structuration Theory. Revenues and expenditures shrunk, and this reduction was higher for investments and unlinked revenues. The provision of services declined, resulting in decreased primary care coverage, outpatient production, total hospital admissions, number of beds, doctors, community health workers, surgeries performed, and hospital occupancy rate. An increase was observed in waiting times for ambulances, exams and outpatient visits, as well as the number of pending requests in regulation. Health and performance indicators remained mostly unchanged, within previous parameters, corroborating the care capacity of PHC, despite financial and structural contingencies imposed by austerity. The current situation threatens the right to health, and governmental response, such as unlinking revenues, point to an increased risk of this occurrence.

Este estudo explorou os efeitos da crise financeira nas receitas e despesas, na produção de serviços e indicadores de saúde e de desempenho no município do Rio de Janeiro no período de 2013 a 2018. Analisou-se receitas, despesas, parâmetros de provisão de serviços e indicadores de desempenho e de saúde, a partir de dados de acesso livre e restrito. Utilizou-se a análise institucional de Giddens. As receitas e despesas sofreram redução, sendo maiores nos investimentos e receitas não vinculadas. A provisão de serviços encolheu, com queda da cobertura na Atenção Primária, produção ambulatorial, internações totais, número de leitos, médicos e agentes comunitários de saúde, cirurgias realizadas e taxa de ocupação de hospitais. Os tempos de espera para ambulâncias, exames e consultas ambulatoriais, bem como o número de solicitações pendentes na regulação aumentaram. Indicadores de saúde e desempenho persistiram, em sua maioria, dentro dos parâmetros anteriores, corroborando a potência assistencial da Atenção Primária, apesar do impacto financeiro e estrutural da austeridade. A conjuntura atual ameaça o direito à saúde e as respostas governamentais, como a desvinculação de receitas, sinalizam uma ampliação desse risco.

Health and Food and Nutritional Security Policies: challenges in controlling childhood obesity. / Políticas de Saúde e de Segurança Alimentar e Nutricional: desafios para o controle da obesidade infantil.

The study analyzed the initiatives of prevention and control of childhood obesity, especially those of Adequate and Healthy Food Promotion (PAAS) which have been part of the policies of the Brazilian federal government for the last 15 years. All documents that feature PAAS initiatives in the food and nutrition security, as well as public health policy fields, were evaluated according to the following criteria: (1) the approach to PAAS initiatives; (2) the aspects of obesitythat they intend to affect and (3) potential interest disputes. The main PAAS initiatives identified are intended to encourage: food and nutrition education; agroecological production systems; family agriculture; food accessibility; healthy environments and regulatory measures. These initiatives alter different aspects of childhood obesityand highlight different conceptions about the problem and affect different interests. We highlight the disputes between the interests of the processed foods and agribusiness corporations, and the governmental and corporate sectors guided by PAAS objectives. Measures aimed at regulating purchases and publicizing unhealthy products for children, are those that best express the interests involved.

O estudo analisou as ações de prevenção e controle da obesidade infantil, especialmente as de Promoção da Alimentação Adequada e Saudável (PAAS), que integram Políticas do governo federal brasileiro nos últimos 15 anos. Foram analisados todos os documentos que apresentam ações de PAAS no âmbito das políticas de saúde e segurança alimentar e nutricional a partir das seguintes dimensões: (1) a abordagem das ações de PAAS; (2) os condicionantes da obesidade que pretendem afetar e (3) as potenciais disputas de interesses. As principais ações de PAAS identificadas visam fomentar: a educação alimentar e nutricional; os sistemas produtivos de base agroecológica; a agricultura familiar; a acessibilidade alimentar; os ambientes saudáveis e as ações regulatórias. Essas ações interferem em diferentes condicionantes da obesidade infantil, apresentam distintas concepções sobre o problema e afetam distintos interesses. Destacam-se as disputas entre os interesses das corporações comerciais de alimentos processados e do agronegócio e os setores governamentais e societários norteados pelos objetivos de PAAS. As ações voltadas para a regulamentação das compras e espaços públicos, além da publicidade de produtos não saudáveis para crianças, são as que melhor expressam os interesses em disputa.

Risk factors for the ill-defined causes of death in the Brazilian states: a multilevel analysis.

This study describes the spatial-temporal changes of the proportion of ill-defined causes of death in Brazil (1998-2012) and investigates which demographic and socioeconomic factors affect this proportion. We collected information of the proportion of ill-defined causes of death by age (15-59 years), sex, period, locality, and socioeconomic data. We used a multilevel Poisson model to investigate which factors affect the risk of ill-defined causes of death. Unlike states located in the South and Midwest, we detected clusters with high proportional levels of these deaths in states in the North and Northeast regions. A greater proportion occurred in 1998-2002 (0.09), in the North and Northeast (0.14 and 0.12, respectively), in older age groups (0.09), and in places with poor socioeconomic conditions. The adjusted analysis showed differences in proportion according to the region, age, period, schooling, social inequality, and income. The results indicate that the lower the age group and the better the socioeconomic situation, the lower the risk to register the cause of death as ill-defined. Although over the past years, the quality of Brazil's mortality data has gradually increased, investments towards improving mortality registries cannot be discontinued.

[Implementation of the Mobile Emergency Medical Service in Brazil: action strategies and structural dimension]. / O processo de implantação do Serviço de Atendimento Móvel de Urgência no Brasil: estratégias de ação e dimensões estruturais.

The Mobile Emergency Medical Service (SAMU) was the first component of the National Policy for Emergency Care implemented in Brazil in the early 2000. The article analyzed the implementation of mobile pre-hospital emergency care in Brazil. The methods included document analysis, interviews with state emergency care coordinators, and an expert panel. The theoretical reference was the strategic conduct analysis from Giddens' Structuration Theory. The results showed uneven implementation of the SAMU between states and regions of Brazil, identifying six patterns of implementation, considering the states' capacity to expand the population coverage and regionalize the service. Structural difficulties included physician retention, poorly equipped dispatch centers, and shortage of ambulances. The North and Northeast were the country's most heavily affected regions. SAMU is formatted as a structuring strategy in the emergency care network, but its performance suffered the impact of limited participation by primary care in the emergency network and especially the lack of hospital beds.

The increase in domestic violence in Brazil from 2009-2014.

In recent decades, the rise violent phenomena in Brazil has reached epidemic proportions. However, the prevalence of domestic violence (DV) across different states in the country is not well established. The objective of this study was to describe the distribution of DV across Brazilian states from 2009 to 2014. An ecological study based on spatial analysis techniques was performed using Brazilian states as geographical units of analysis. A multilevel Poisson model was used to explain the risk of DV in Brazil according to age, sex, period (fixed effects), the Human Developing Index, and the victim's residence state (random effects). The overall average rate of DV almost tripled from 2009-2010 to 2013-2014. The rate of DV in Brazil in the 2013-2014 period was 3.52 times greater than the 2009-2010 period. The risk of DV in men was 74% lower than in women. The increase of DV against women during period under study occurred mainly in the Southeast, South, and Midwest. DV was more frequent in adolescence and adulthood. DV is gradually increasing in recent years in Brazil. More legislation and government programs are needed to combat the growth of violence in society.

The process of implementation of emergency care units in Brazil.

OBJECTIVE: To analyze the process of implementation of emergency care units in Brazil. METHODS: We have carried out a documentary analysis, with interviews with twenty-four state urgency coordinators and a panel of experts. We have analyzed issues related to policy background and trajectory, players involved in the implementation, expansion process, advances, limits, and implementation difficulties, and state coordination capacity. We have used the theoretical framework of the analysis of the strategic conduct of the Giddens theory of structuration. RESULTS: Emergency care units have been implemented after 2007, initially in the Southeast region, and 446 emergency care units were present in all Brazilian regions in 2016. Currently, 620 emergency care units are under construction, which indicates expectation of expansion. Federal funding was a strong driver for the implementation. The states have planned their emergency care units, but the existence of direct negotiation between municipalities and the Union has contributed with the significant number of emergency care units that have been built but that do not work. In relation to the urgency network, there is tension with the hospital because of the lack of beds in the country, which generates hospitalizations in the emergency care unit. The management of emergency care units is predominantly municipal, and most of the emergency care units are located outside the capitals and classified as Size III. The main challenges identified were: under-funding and difficulty in recruiting physicians. CONCLUSIONS: The emergency care unit has the merit of having technological resources and being architecturally differentiated, but it will only succeed within an urgency network. Federal induction has generated contradictory responses, since not all states consider the emergency care unit a priority. The strengthening of the state management has been identified as a challenge for the implementation of the urgency network.

Distribution of pulmonary tuberculosis in Rio de Janeiro (Brazil): a spatial analysis.

The aim of this study was to analyze the spatial distribution of the tuberculosis endemic in Rio de Janeiro State from 2002 to 2011. A retrospective study was conducted in the state of Rio de Janeiro from 2002 to 2011. Spatial analysis techniques were used to describe the distribution of tuberculosis incidence in the state. Multilevel Poisson regression model was used to access the relationship of tuberculosis and the following factors: "sex", "age-group" and "diagnostic year" (individual-level factors). Demographic density and municipality were also included in the model as contextual-level factors. A reduction in endemic tuberculosis was observed over the years. The highest incidence rates were concentrated on the south coast of the state, covering Rio de Janeiro City (capital) and neighboring cities. We detected a significant clustering of high TB incidence rates on the south coast of the state and a cluster of low incidence in the northeastern region of state. The risk of tuberculosis was higher in early 2000s, in males and in 40-59 age group. Metropolitan regions are important risk areas for the spread of tuberculosis. These findings could be used to plan control measures according to the characteristics of each region.

Mobile prehospital emergency care: an analysis of implementation in the State of Rio de Janeiro, Brazil. / Atenção pré-hospitalar móvel às urgências: análise de implantação no estado do Rio de Janeiro, Brasil.

Mobile prehospital care is a key component of emergency care. The aim of this study was to analyze the implementation of the State of Rio de Janeiro's Mobile Emergency Medical Service (SAMU, acronym in Portuguese). The methodology employed included document analysis, visits to six SAMU emergency call centers, and semistructured interviews conducted with 12 local and state emergency care coordinators. The study's conceptual framework was based on Giddens' theory of structuration. Intergovernmental conflicts were observed between the state and municipal governments, and between municipal governments. Despite the shortage of hospital beds, the SAMUs in periphery regions were better integrated with the emergency care network than the metropolitan SAMUs. The steering committees were not very active and weaknesses were observed relating to the limited role played by the state government in funding, management, and monitoring. It was concluded that the SAMU implementation process in the state was marked by political tensions and management and coordination weaknesses. As a result, serious drawbacks remain in the coordination of the SAMU with the other health services and the regionalization of emergency care in the state.