Prevalence of concomitant hypertension and diabetes among adults and elderly living in rural riverside areas in the Amazon.

INTRODUCTION: Considering the scarcity of information on the assessment of chronic diseases in traditional Amazonian populations, as well as public health policies focused on their specificities, this study aimed to estimate the prevalence of at least one of the chronic diseases (systemic arterial hypertension (SAH) or diabetes mellitus (DM)) and their concomitant occurrence in a rural riverside population of the Amazon, and determine the associated factors. METHODS: A household-based cross-sectional survey was conducted with a sample of adults and elderly people living in rural riverside locations along the left bank of the Negro River, in the municipality of Manaus, Amazonas, Brazil. The outcomes evaluated were the presence of at least one of the evaluated chronic diseases and the concomitant occurrence, based on the self-reported medical diagnosis of SAH and DM. Analysis of associated factors (sociodemographic, behavioral, and access to health services variables) was performed by Poisson regression with robust variance. RESULTS: The sample consisted of 495 individuals (young adults (n=257; 51.9%), middle-aged (n=132; 26.7%), and elderly (n=106; 21.4%)), of whom 51.5% were women (n=255), mean age 43.3±17.1 years. The monthly household income was on average R$1100±902 (A$345±283). The diagnosis of any chronic disease was reported by 18.8% of the sample, with a preponderance of SAH (17.4%). The occurrence of at least one of the chronic diseases was associated with higher average age and worse health self-assessment. Regarding concomitant occurrence of SAH and DM, prevalent in 4.4% of the sample, the same associations were observed. CONCLUSION: The data for the occurrence of chronic diseases in the studied Amazon rural riverside populations are worrying, because these people live in areas of socioeconomic vulnerability, with a lack of basic sanitation infrastructure, difficult geographic access, and limited access to health care. Health policies fail to recognize the specificities of these populations, which implies deficiencies in the provision of necessary regular care. The findings also reinforce the need to strengthen health promotion and chronic disease prevention strategies in the context of primary care.

Innovative shortcuts and initiatives in primary health care for rural/remote localities: a scoping review on how to overcome the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has emerged as one of the greatest challenges to societies, world health systems and science in the past century, making it imperative to restructure care networks. Therefore, it is essential to discuss the role and initiatives of primary health care (PHC) to deal with it. However, regarding the response to the pandemic, including the current global effort against COVID-19, the nuances of the rural/remote PHC context in the pandemic is barely visible. Rural and remote communities have differentiated health risks, such as socioeconomic disadvantages, difficulties in mobility and access to health services, in addition to linguistic and cultural barriers. This scoping review aimed to analyze the set of individual and collective initiatives and innovations developed to face the COVID-19 pandemic, within the PHC scope, in rural and remote areas. METHODS: A scoping review methodology was applied to peer-reviewed articles. Eight databases were searched to identify scientific articles published in English, Spanish and Portuguese, initially from January 2020 to July 2021, complemented by a rapid review of articles published from January 2022 to April 2023. The main focus sought in the literature was the set of initiatives and innovations carried out within the PHC scope in rural and remote locations during the pandemic, as well as the comparison with pre-pandemic situations and between different countries. The bibliographic information of each search result was imported into Rayyan (Intelligent Systematic Review), followed by the screening and eligibility stages, performed independently by two reviewers, with a third reviewer being accessed in case of conflicts. RESULTS: This review included 54 studies, with publications mostly from Australia, Canada, the US and India. The main PHC initiatives were related to access; to the roles of community health workers and health surveillance; and to the importance of placing, retaining and valuing human resources in health. Cultural, equity and vulnerability issues occupy a major place among the initiatives. Regarding the innovations, telehealth and customized communication are highlighted. From an organizational point of view, rural and remote locations showed enormous flexibility to deal with the pandemic and to improve intersectoral activities at the local level. The description of rurality and remoteness is practically coincident with that of the specific populations, present in geographic areas of difficult sociospatial and cultural access. Rarely, there is an index to measure rurality, or its description deals with the need to overcome distances and obstacles. CONCLUSION: The findings highlight and summarize knowledge about initiatives and innovations developed to face the COVID-19 pandemic, within the PHC scope in rural and remote areas in the world. This review has identified collective, clinical, intersectoral and, mainly, organizational health initiatives. An articulation between different government levels would be paramount in evaluating the implementation of policies and protocols in rural and remote locations for future sanitary crises. Innovations and lessons learned are equally relevant in strengthening health services and systems. This issue calls for considerable further exploration by new reviews and empirical research that seek evidence to assess the sustainability and effectiveness of the implemented measures to face post-pandemic difficulties and other adversities.

Invisibilidade das singularidades amazônicas na organização e oferta de serviços de Atenção Primária à Saúde (APS): Estudo de caso na área rural ribeirinha de Manaus (AM) / The invisibility of Amazonian singularities in the design and delivery of Primary Health Care (PHC) services: A case study in the rural riverside area of Manaus (AM)

Resumo A região amazônica abrange um território heterogêneo com características geográficas específicas, abrigando diversas populações vulnerabilizadas, o que exige dos serviços de saúde o desenvolvimento de habilidades e inovações. Entretanto, as respostas a esses desafios se tornam ainda mais distantes diante de uma lógica mercadológica, que tende a invisibilizar diferenças e privilegiar determinados territórios. Nesse cenário, este estudo analisou a implementação de uma Unidade Básica de Saúde Fluvial, buscando compreender como estão incluídas as necessidades e singularidades do meio rural ribeirinho no planejamento e execução dos serviços de saúde. Para isso, foram realizadas entrevistas com gestores e profissionais, além da observação do cotidiano dos serviços de saúde. Os resultados demonstram que a previsão de serviços, com formatos e recursos específicos para as áreas fluviais amazônicas, foi uma oportunidade para que as particularidades da região fossem evidenciadas e que mais recursos, inclusive financeiros, fossem previstos para essas localidades. No entanto, evidenciou-se também que os serviços ofertados continuam sendo planejados de forma hierárquica, além de serem organizados e executados visando realidades urbanas, o que aponta a necessidade de adaptações.

Abstract The Amazon region encompasses a heterogenous territory with singular geographic features, that harbous different vulnerable populations, which require the development of abilities and innovations by health services. However, answers to this challenge become even more distant in the face of a marketing logic that tends to make differences invisible and privilege certain territories. In this scenario, our study analyzed the implementation of a Basic River Health Unit (UBSF), seeking to understand how the needs and singularities of riverside rural areas are included in the planning and execution of health services. To that end, interviews with health services managers and professionals and observations of health care professionals during daily activities were carried out. The results showed the forecast of services, with specific formats and resources for the Amazonian fluvial areas, was an opportunity for the specificities of the region to be evidenced and for more resources, including financial ones, being considered for these localities. However, they also showed that the services offered are still planned in a hierarchical way and organized and executed for urban areas, which points to the need for adaptations.

Different remote realities: health and the use of territory in Brazilian rural municipalities.

OBJECTIVE: To characterize remote rural Brazilian municipalities according to their logic of insertion into socio-spatial dynamics, discussing the implications of these characteristics for health policies. METHODS: Starting from the category of analysis - the use of the territory - a typology was elaborated, with the delimitation of six clusters. The clusters were compared using socioeconomic data and the distance in minutes to the metropolis, regional capital, and sub-regional center. Mean, standard error and standard deviation of the quantitative variables were calculated, and tests on mean differences were performed. RESULTS: The six clusters identified bring together 97.2% of remote rural municipalities and were called: "Matopiba," "Norte de Minas," "Vetor Centro-Oeste," "Semiárido," "Norte Águas," and "Norte Estradas." Differences are observed between the clusters in the analyzed variables, indicating the existence of different realities. Remote rural municipalities of "Norte Águas" and "Norte Estradas" clusters are the most populous, the most extensive and are thousands of kilometers away from urban centers, while those in "Norte de Minas" and "Semiárido" clusters have smaller areas with a distance of about 200 km away from urban centers. The remote rural municipalities of the "Vetor Centro-Oeste" cluster, in turn, are distinguished by a dynamic economy, inserted into the world economic circuit due to the agribusiness. The Family Health Strategy is the predominant model in the organization of primary health care. CONCLUSION: Remote rural municipalities are distinguished by their socio-spatial characteristics and insertion into the economic logic, demanding customized health policies. The strategy of building health regions, offering specialized regional services, tends to be more effective in remote rural municipalities closer to urban centers, as long as it is articulated with the health transportation policy. The use of information technology and expansion of the scope of telehealth activities is mandatory to face distances in such scenarios. Comprehensive primary health care with a strong cultural component is key to guaranteeing the right to health for citizens residing in such regions.

Primary health care in the Amazon and its potential impact on health inequities: a scoping review.

INTRODUCTION: Health studies of the Amazon often focus on diseases and infections prevalent in the region, and few studies address health organizations and services. In this sense, this study fills a gap by reviewing the studies aimed at primary healthcare (PHC) implementation in the nine Amazonian countries. This review addresses a need to explore the forms in which PHC is implemented in the Amazon areas outside the urban centers and its potential to reduce health inequities. This study contributes to improvements in the practices of managers and health professionals and research on the topic. METHODS: Scoping review methodology was applied to peer-reviewed articles. The databases searched were PubMed, Scopus, Lilacs, Embase and Web of Science. Selected studies included peer-reviewed publications, published between January 2000 and November 2019, that focused on PHC or one of its components in the Amazon, and were published in English, Spanish and Portuguese. The study used Arksey and O'Malley's scoping review guidelines, supported by Levac, and included five steps: (i) identification phase, where search queries were applied to the databases followed by the removal of duplicates; (ii) screening phase, where titles and abstracts of articles were screened to exclude irrelevant articles; (iii) eligibility phase, where the full texts of articles were read to assess their relevancy to this study; (iv) data extraction, using a spreadsheet designed to capture relevant information required in this review, using an iterative process; (v) summarizing and classification of each article according to content. The second and third phases were conducted independently by two reviewers. If a disagreement arose between the reviewers, a third reviewer was consulted to help decide whether to include or exclude a study. RESULTS: This review included 25 studies. Of these, 11 presented promising results regarding PHC functioning in the Amazon region, and 14 presented challenges and difficulties in its functioning. Some PHC strategies implemented in the Amazon showed the potential to reduce inequities, mostly when they involved actions that increased access to PHC in the region when they developed a culturally adapted role and engaged community members in the decision-making and in the collaborative construction of health services. Actions that exposed challenges and difficulties were related to ill-prepared healthcare professionals, inadequate service approach and the inability to adapt to cultural issues. CONCLUSION: The findings reveal information about PHC implementations that have had promising results in the Amazon region and, at the same time, show the challenges and difficulties of the PHC actions. The findings also highlight and synthesize knowledge about the potential that PHC strategies have to affect existing inequities in the Amazon region and gaps in the studies that have been undertaken, or at least published, including a lack of studies of PHC implementation and examination of strategies aimed at health determinants.

Different remote realities: health and the use of territory in Brazilian rural municipalities / Remoto ou remotos: a saúde e o uso do território nos municípios rurais brasileiros

ABSTRACT OBJECTIVE To characterize remote rural Brazilian municipalities according to their logic of insertion into socio-spatial dynamics, discussing the implications of these characteristics for health policies. METHODS Starting from the category of analysis - the use of the territory - a typology was elaborated, with the delimitation of six clusters. The clusters were compared using socioeconomic data and the distance in minutes to the metropolis, regional capital, and sub-regional center. Mean, standard error and standard deviation of the quantitative variables were calculated, and tests on mean differences were performed. RESULTS The six clusters identified bring together 97.2% of remote rural municipalities and were called: "Matopiba," "Norte de Minas," "Vetor Centro-Oeste," "Semiárido," "Norte Águas," and "Norte Estradas." Differences are observed between the clusters in the analyzed variables, indicating the existence of different realities. Remote rural municipalities of "Norte Águas" and "Norte Estradas" clusters are the most populous, the most extensive and are thousands of kilometers away from urban centers, while those in "Norte de Minas" and "Semiárido" clusters have smaller areas with a distance of about 200 km away from urban centers. The remote rural municipalities of the "Vetor Centro-Oeste" cluster, in turn, are distinguished by a dynamic economy, inserted into the world economic circuit due to the agribusiness. The Family Health Strategy is the predominant model in the organization of primary health care. CONCLUSION Remote rural municipalities are distinguished by their socio-spatial characteristics and insertion into the economic logic, demanding customized health policies. The strategy of building health regions, offering specialized regional services, tends to be more effective in remote rural municipalities closer to urban centers, as long as it is articulated with the health transportation policy. The use of information technology and expansion of the scope of telehealth activities is mandatory to face distances in such scenarios. Comprehensive primary health care with a strong cultural component is key to guaranteeing the right to health for citizens residing in such regions.

RESUMO OBJETIVO Caracterizar os municípios rurais remotos brasileiros segundo suas lógicas de inserção na dinâmica socioespacial, discutindo as implicações dessas características para as políticas de saúde. MÉTODOS Partindo da categoria de análise - o uso do território - elaborou-se uma tipologia, com delimitação de seis clusters . Os clusters foram comparados a partir de dados socioeconômicos e da distância em minutos para a metrópole, capital regional e centro sub-regional. Foram calculados a média, o erro padrão e o desvio padrão das variáveis quantitativas e realizados testes de diferenças de média. RESULTADOS Os seis clusters identificados aglutinam 97,2% dos municípios rurais remotos e foram denominados de: Matopiba; Norte de Minas; vetor Centro-Oeste; Semiárido; Norte Águas; e Norte Estradas. Observam-se diferenças entre os clusters nas variáveis analisadas, indicando a existência de distintas realidades. Os municípios rurais remotos dos clusters Norte Água e Norte Estrada são os mais populosos, mais extensos e distam milhares de quilômetros de centros urbanos, enquanto os do Norte de Minas e do Semiárido tem áreas menores com distância de cerca de 200 km. Por outro lado, os municípios rurais remotos do vetor Centro-Oeste se diferem por uma economia dinâmica, inserida no circuito econômico mundial devido à presença do agronegócio. A Estratégia de Saúde da Família é o modelo predominante na organização da atenção primária à saúde. CONCLUSÃO Os municípios rurais remotos distinguem-se em suas características socioespaciais e de inserção na lógica econômica, demandando políticas de saúde customizadas. A estratégia de construção das regiões de saúde, com oferta de serviços regionais especializados, tende a ser mais efetiva nos municípios rurais remotos mais próximos de centros urbanos, desde que articulada à política de transporte sanitário. O uso de tecnologia de informação e ampliação do escopo das atividades de telessaúde é mandatório para enfrentamento das distâncias em cenários como esse. A atenção primária à saúde integral com forte componente cultural é peça-chave para garantir o direito à saúde para os cidadãos que aí residem.

Pessoas idosas tentam suicídio para chamar atenção? / Do older adults attempt suicide for attention?

Resumo Este estudo analisa parte dos resultados de pesquisa nacional multicêntrica que investigou ideações e tentativas de suicídio em idosos. O texto tem como objetivo problematizar a expressão "chamar atenção", usualmente empregada por profissionais de saúde e famílias que acompanham esses idosos para referir-se à sua motivação para o comportamento autodestrutivo. Trata-se de pesquisa qualitativa com emprego de entrevista semiestruturada, em que se buscou compreender profundamente o fenômeno. Foram analisados 12 casos de idosos com ideação e/ou tentativas de suicídio e relatos de quatro profissionais que se manifestaram sobre o comportamento de "chamar atenção" atribuído a esses idosos. O material coletado foi submetido à análise hermenêutica dialética. A pesquisa se ateve aos fatores articulados às situações na vida do idoso, buscando relacionar os sentimentos dos que idealizaram ou tentaram se matar e o comportamento do atribuído "chamar atenção". Como resultado, emergiram duas grandes categorias analíticas: o chamar atenção segundo a percepção dos idosos; e o chamar atenção para os profissionais de saúde. O estudo mostrou que a ligação que, em geral, familiares ou profissionais de saúde estabelecem entre "chamar atenção" e intenção de cometer suicídio é muito tênue, caracterizando-se mais propriamente como manifestação de que algo não corre bem na vida do idoso. Constatou-se o predomínio de compreensões derivadas do senso comum sobre esses fatos que não apresentam relação direta com o desejo ou a intenção de morte autoinfligida, mas uma dificuldade de compreensão dos sentimentos de isolamento e solidão.

Abstract This study analyzes part of the results of a multicentric national research that investigated suicidal ideation and suicide attempts in older adults. The text aims to question the so-called "attention seeking" behavior, used by health professionals and families of older patients when referring to their motivation for self-destructive behavior. This qualitative research used semi-structured interviews to thoroughly understand this phenomenon. We analyzed 12 cases of older adults with suicidal ideation and/or suicide attempts and reports from four professionals who expressed their opinion on the "attention seeking" behavior attributed to these patients. The data collected underwent dialectical hermeneutic analysis. The research focused on factors associated with situations faced by older adults, aiming to relate the feelings of those who idealized or tried to commit suicide and the "attention seeking" behavior. As a result, two major analytical categories emerged: attention seeking according to older adults; and attention seeking according to health professionals. The study showed that the connection family members or health professionals establish between "attention seeking" and intent to commit suicide is, in general, very tenuous; rather, it characterizes a proper manifestation that something is unwell in the older adult's life. We found a predominance of common-sense understandings about these facts that have no direct relationship with the desire or intention of self-inflicted death, but represent a difficulty in understanding feelings of isolation and loneliness.

Health regionalization in Amazonas: progress and challenges. / Regionalização em Saúde no Amazonas: avanços e desafios.

This paper analyses the health services regionalization process in the State of Amazonas through a case study covering the health sub-region Manaus Surroundings. This is a qualitative, descriptive and analytical research, which data were collected using interviews, documents and Internet reviews, oriented by the guiding concept of health regionalization. Study findings revealed a social setting dominated by asymmetry, verticality, competitiveness and fragile multilateral relations among municipalities, associated to a bureaucratic profile of local institutions operating in the region under study. The political agents have limited acknowledgement of the sociopolitical and institutional conditions in which they operate. They usually impute healthcare networks' management and operational issues to the natural and geographical characteristics of the Amazon region, but their financing, governance and technical capacity are insufficient to overcome them.

Regionalização em Saúde no Amazonas: avanços e desafios / Health regionalization in Amazonas: progress and challenges

Resumo O artigo analisa o processo de regionalização em saúde no estado do Amazonas por meio de estudo de caso da regional em Saúde Entorno de Manaus. Pesquisa qualitativa, descritivo-analítica, cujos dados foram coletados através de entrevistas, revisão de documentos e de páginas de internet, tomando como conceito guia a regionalização em saúde. Os achados do estudo mostram uma cena social onde predominam a assimetria, a verticalidade, a competitividade e a fragilidade das relações multilaterais entre municípios, associados a um perfil cartorial das instituições que atuam na região de saúde sob estudo. Os agentes políticos envolvidos no processo têm limitado reconhecimento das condições sociopolíticas e institucionais em que atuam. Tendem a atribuir os problemas de gestão e operacionalização das redes de assistência à configuração dos espaços naturais-geográficos amazônicos, mas seu financiamento, governança e capacidade técnica são insuficientes para superá-los.

Abstract This paper analyses the health services regionalization process in the State of Amazonas through a case study covering the health sub-region Manaus Surroundings. This is a qualitative, descriptive and analytical research, which data were collected using interviews, documents and Internet reviews, oriented by the guiding concept of health regionalization. Study findings revealed a social setting dominated by asymmetry, verticality, competitiveness and fragile multilateral relations among municipalities, associated to a bureaucratic profile of local institutions operating in the region under study. The political agents have limited acknowledgement of the sociopolitical and institutional conditions in which they operate. They usually impute healthcare networks' management and operational issues to the natural and geographical characteristics of the Amazon region, but their financing, governance and technical capacity are insufficient to overcome them.

Regional health network in the Amazonian context: the case in Manaus, Entorno and Alto Rio Negro / Rede regional de saúde no contexto Amazônico: o caso de Manaus, Entorno e Alto Rio Negro

Abstract Objectives: to analyze the dimensions of policy, structure and organization in the construction of Redes de Atenção à Saúde (RAS) (healthcare networks) in the health region of Manaus, Entorno and Alto Rio Negro, focusing on Atenção Primária à Saúde (APS) (primary healthcare) and Rede de Urgência e Emergência (RUE) (urgency and emergency network). Methods: a case study with multidimensional analysis using quantitative and qualitative approach carried out in the first semester of 2016. Results: 37 interviewed key informants, such as managers (States, Cities and Regionals), providers and civil society. The reality was marked by the difficulties in the implementation of RAS's with centralized decision-making powers of State level. Perception of insufficient human resources of limited installed capacity, particularly in the APS, with insufficient priority given to this level of care. Concentration of services in Manaus, priority for urgency and emergency actions expressed in the greatest investment in human resources and mate-rials allocated at this level of care, lack of proposals for promoting equity. Conclusions: the Region was unable to implement RAS to respond to the health demands in the region. The necessity to overcome the dependency relation with the cities and the State and to strengthen its protagonism and fulfillits roles in management network, instituting a plan capable of strengthening APS to be committed in reducing iniquities and with adequate responses in health needs.

Resumo Objetivos: analisar as dimensões da política, estrutura e organização na construção das redes de atenção à saúde (RAS) na região de saúde de Manaus, Entorno e Alto Rio Negro, enfocando a atenção primária à saúde (APS) e rede de urgência e emergência (RUE). Métodos: estudo de caso com análise multidimensional, utilizando abordagem quantitativa e qualitativa, realizado no primeiro semestre de 2016. Resultados: entrevistados 37 informantes-chaves, sendo gestores (estaduais, municipais e regionais), prestadores e sociedade civil. Realidade marcada por dificuldades na implantação das RAS, com poderes decisórios centralizados no nível estadual. Percepção de insuficiência de recursos humanos de limitação na capacidade instalada, em particular na APS, com insuficiente prioridade dada a este nível de cuidado. Concentração de serviços em Manaus, prioridade para ações de urgência e emergência, expressas em maior investimento de recursos humanos e materiais alocados nesse nível de atenção, ausência de propostas para promoção da equidade. Conclusões: região não conseguiu implantar funcionamento das RAS para responder às demandas em saúde na região. Necessidade de superar relação de dependência entre municípios e estado e de potencializar seu protagonismo e o cumprimento dos seus papéis na gestão das redes, instituindo um planejamento capaz de fortalecer a APS comprometida com a redução das iniquidades e com respostas adequadas às necessidades de saúde.

Suicidal ideation and attempted suicide in elderly people - subjective experiences.

We discuss the subjective experiences of elderly people who show suicidal ideation and/or attempts at suicide, based on their own reports. We understand the concept of 'subjective' as referring to intra-psychic experience resulting from social, economic, relationship or biographical conditions. Although the subject is sparsely covered in the literature, it is important, because it is in the field of subjectivity that ideations of, and attempts at, suicide develop and occur until they become a concrete act. Empirical data were collected through semi-structured interviews focusing on: social characterization, portrayal and mode of life, previous mental state, atmosphere of the attempt, effects on the health of the elderly person and family. Based on the analysis of the meanings that emerge, five empirical categories were generated: (1) subject's feeling of being in a non-place; (2) absence of acceptance of losses; (3) suffering due to ingratitude of family members; (4) feeling of uselessness of, and in, life; (5) re-signification of the situations that generate suicide-related conduct. The results point to a fundamental need to incorporate knowledge about the subjective processes into programs for prevention of suicide among the elderly who have ideation of, or attempts at, suicide.

Vivências subjetivas de idosos com ideação e tentativa de suicídio / Suicidal ideation and attempted suicide in elderly people – subjective experiences

Discutimos as vivências subjetivas de idosos que apresentam ideação e tentativa de suicídio a partir dos seus relatos. Entendemos a subjetividade como vivência intrapsíquica resultante da condição social, econômica, relacional e biográfica. Embora exíguo na literatura, o tema é importante, pois é no campo da subjetividade que as ideações e as tentativas de suicídio vão se configurando até que se concretizem no ato. Dados empíricos foram coletados por meio de entrevista semiestruturada focalizando: caracterização social, retrato e modo de vida, estado mental prévio, atmosfera da tentativa, impactos na saúde do idoso e família. A partir da análise dos sentidos emergentes foram geradas cinco categorias empíricas: (1) não lugar do sujeito; (2) falta de aceitação das perdas; (3) sofrimento pela ingratidão dos familiares; (4) sentimento de inutilidade da e na vida; (5) ressignificação das situações que geram condutas suicidas. Os resultados apontam a necessidade fundamental de incorporar conhecimento sobre os processos subjetivos aos programas de prevenção do suicídio do idoso com ideação e tentativa de suicídio.

We discuss the subjective experiences of elderly people who show suicidal ideation and/or attempts at suicide, based on their own reports. We understand the concept of ‘subjective’ as referring to intra-psychic experience resulting from social, economic, relationship or biographical conditions. Although the subject is sparsely covered in the literature, it is important, because it is in the field of subjectivity that ideations of, and attempts at, suicide develop and occur until they become a concrete act. Empirical data were collected through semi-structured interviews focusing on: social characterization, portrayal and mode of life, previous mental state, atmosphere of the attempt, effects on the health of the elderly person and family. Based on the analysis of the meanings that emerge, five empirical categories were generated: (1) subject's feeling of being in a non-place; (2) absence of acceptance of losses; (3) suffering due to ingratitude of family members; (4) feeling of uselessness of, and in, life; (5) re-signification of the situations that generate suicide-related conduct. The results point to a fundamental need to incorporate knowledge about the subjective processes into programs for prevention of suicide among the elderly who have ideation of, or attempts at, suicide.

"O Sesp nunca trabalhou com indios": a (in)visibilidade dos indigenas na atuacao da Fundacao Servicos de Saude Publica no estado do Amazonas / "SESP never worked with Indians": the (in)visibility of indigenes in the activities of the Fundacao de Servicos de Saude Publica in the state of Amazonas

A Fundação de Serviços de Saúde Pública, entre 1960 e 1990, foi responsável por uma rede de serviços de saúde em todo o país, em continuidade às ações do Serviço Especial de Saúde Pública. O artigo trata de pesquisa realizada no estado do Amazonas, em 2010, que investigou a atuação dessa Fundação junto às populações indígenas, com base em entrevistas com ex-profissionais da Fundação e análise de documentação a ela pertencente. Os resultados mostraram que, embora não tivesse política formal para as populações indígenas, na prática teve que atendê-las, pois eram maioria nos municípios do interior do estado.

From 1960 to 1990, the Fundação de Serviços de Saúde Pública (Public Health Services Foundation) was in charge of a network of health services across Brazil, in continuation of work previously done by the Serviço Especial de Saúde Pública (Special Public Health Service). The article presents a 2010 research conducted in the state of Amazonas regarding the Foundation's activities among indigenous populations based on interviews with the Foundation's personnel and the analysis of its documentation. The findings indicate that while the Foundation had no formal policy for indigenous populations, in practice its staff did serve indigenes since in most municipalities in the interior of Amazonas they comprised a significant number of the inhabitants.

["SESP never worked with Indians": the (in)visibility of indigenes in the activities of the Fundação de Serviços de Saúde Pública in the state of Amazonas]. / "O Sesp nunca trabalhou com índios": a (in)visibilidade dos indígenas na atuação da Fundação Serviços de Saúde Pública no estado do Amazonas.

From 1960 to 1990, the Fundação de Serviços de Saúde Pública (Public Health Services Foundation) was in charge of a network of health services across Brazil, in continuation of work previously done by the Serviço Especial de Saúde Pública (Special Public Health Service). The article presents a 2010 research conducted in the state of Amazonas regarding the Foundation's activities among indigenous populations based on interviews with the Foundation's personnel and the analysis of its documentation. The findings indicate that while the Foundation had no formal policy for indigenous populations, in practice its staff did serve indigenes since in most municipalities in the interior of Amazonas they comprised a significant number of the inhabitants.