Detection of risk clusters for deaths due to tuberculosis specifically in areas of southern Brazil where the disease was supposedly a non-problem.

BACKGROUND: Tuberculosis (TB) is the infectious disease that kills the most people worldwide. The use of geoepidemiological techniques to demonstrate the dynamics of the disease in vulnerable communities is essential for its control. Thus, this study aimed to identify risk clusters for TB deaths and their variation over time. METHODS: This ecological study considered cases of TB deaths in residents of Londrina, Brazil between 2008 and 2015. We used standard, isotonic scan statistics for the detection of spatial risk clusters. The Poisson discrete model was adopted with the high and low rates option used for 10, 30 and 50% of the population at risk, with circular format windows and 999 replications considered the maximum cluster size. Getis-Ord Gi* (Gi*) statistics were used to diagnose hotspot areas for TB mortality. Kernel density was used to identify whether the clusters changed over time. RESULTS: For the standard version, spatial risk clusters for 10, 30 and 50% of the exposed population were 4.9 (95% CI 2.6-9.4), 3.2 (95% CI: 2.1-5.7) and 3.2 (95% CI: 2.1-5.7), respectively. For the isotonic spatial statistics, the risk clusters for 10, 30 and 50% of the exposed population were 2.8 (95% CI: 1.5-5.1), 2.7 (95% CI: 1.6-4.4), 2.2 (95% CI: 1.4-3.9), respectively. All risk clusters were located in the eastern and northern regions of the municipality. Additionally, through Gi*, hotspot areas were identified in the eastern and western regions. CONCLUSIONS: There were important risk areas for tuberculosis mortality in the eastern and northern regions of the municipality. Risk clusters for tuberculosis deaths were observed in areas where TB mortality was supposedly a non-problem. The isotonic and Gi* statistics were more sensitive for the detection of clusters in areas with a low number of cases; however, their applicability in public health is still restricted.

[Family Health Strategy, private health care, and inequalities in access to mammography in BrazilEstrategia de Salud Familiar, salud suplementaria y desigualdad en el acceso a la mamografía en Brasil]. / Estratégia Saúde da Família, saúde suplementar e desigualdade no acesso à mamografia no Brasil.

OBJECTIVE: To evaluate the association between access to mammography and coverage by private health insurance or by the public healthcare system through the Family Health Strategy (FHS). METHOD: An ecological study was performed with data obtained from the Unified Health System Data Processing Department (DATASUS). Time trends were analyzed using the Prais-Winsten method, having the Brazilian federal units as units of analysis. Multiple linear regression was used to investigate the relationship between the dependent variable - women aged 50 to 69 years who never had a mammogram - and the independent variables (coverage by the FHS or private health care and socioeconomic aspects). RESULTS: Acre was the only Brazilian state for which an increasing growth trend in private health care was not observed. Roraima, Tocantins, Maranhão, Piauí, Rio Grande do Norte, and Paraíba showed a stable trend for FHS coverage, whereas all other federal units had increasing coverage. A significant association was observed between never having had a mammogram at 50 to 69 years of age and the variables mean per capita income and FHS and private health care coverage (R2 = 0.77; P < 0.001). CONCLUSION: Unequal access to mammography is a reality in Brazil. Both private health care and the FHS have contributed to improve health care accessibility for Brazilian women.

OBJETIVO: Evaluar la asociación entre el acceso a la mamografía en Brasil y la cobertura prestada por la Estrategia de Salud Familiar (ESF) y por la salud suplementaria. MÉTODOS: Se realizó un estudio ecológico con datos obtenidos del Departamento de Informática del Sistema Único de Salud (DATASUS). La tendencia de la serie temporal fue analizada mediante el método de Prais-Winsten utilizando como unidades de análisis las entidades federativas brasileñas. Para investigar la relación entre la variable dependiente ­mujeres de 50 a 69 años que nunca se habían realizado una mamografía­ y las independientes, de cobertura por la ESF o salud suplementaria y las variables socioeconómicas, se realizó un análisis de regresión lineal múltiple. RESULTADOS: Acre fue el único estado que no presentó una tendencia creciente para la cobertura por la salud suplementaria. Roraima, Tocantins, Maranhão, Piauí, Rio Grande do Norte y Paraíba presentaron una tendencia estacionaria para la cobertura por la ESF, mientras que las otras entidades federativas mostraron una cobertura en ascenso. Se observó una asociación significativa entre el hecho de nunca haberse realizado una mamografía entre los 50 y los 69 años y las variables renta media per cápita, cobertura por la ESF y la salud suplementaria (R2 = 0,77; P <0,001). CONCLUSIÓN: En Brasil, la desigualdad en el acceso a la mamografía es una realidad. Tanto la salud suplementaria como la Estrategia de Salud Familiar han contribuido a mejorar el acceso de estas mujeres a la mamografía.

Validity and reliability of the tuberculosis-related stigma scale version for Brazilian Portuguese.

BACKGROUND: Stigma associated with tuberculosis (TB) has been an object of interest in several regions of the world. The behaviour presented by patients as a result of social discrimination has contributed to delays in diagnosis and the abandonment of treatment, leading to an increase in the cases of TB and drug resistance. The identification of populations affected by stigma and its measurement can be assessed with the use of valid and reliable instruments developed or adapted to the target culture. This aim of this study was to analyse the initial psychometric properties of the Tuberculosis-Related Stigma scale in Brazil, for TB patients. METHODS: The Tuberculosis-Related Stigma scale is a specific scale for measuring stigma associated with TB, originally validated in Thailand. It presents two dimensions to be assessed, namely Community perspectives toward tuberculosis and Patient perspectives toward tuberculosis. The first has 11 items regarding the behaviour of the community in relation to TB, and the second is made up of 12 items related to feelings such as fear, guilt and sorrow in coping with the disease. A pilot test was conducted with 83 TB patients, in order to obtain the initial psychometric properties of the scale in the Brazilian Portuguese version, enabling simulation of the field study. RESULTS: As regards its psychometric properties, the scale presented acceptable internal consistency for its dimensions, with values ≥0.70, the absence of floor and ceiling effects, which is favourable for the property of scale responsiveness, satisfactory converging validity for both dimensions, with values over 0.30 for initial studies, and diverging validity, with adjustment values different from 100%. CONCLUSION: The results found show that the Tuberculosis-Related Stigma scale can be a valid and reliable instrument for the Brazilian context.

Integrated health service delivery networks and tuberculosis avoidable hospitalizations: is there a relation between them in Brazil?

BACKGROUND: The early identification of the Breathing Symptoms within the scope of Primary Health Care is recommended, and is also one of the strategies of national sanitary authorities for reaching the elimination of tuberculosis. The purpose of this study is to consider which attributes and which territories have shown the most significant progress in Primary Health Care, in terms of coordination of Health Care Networks, and also check if those areas of Primary Health Care that are most critical regarding coordination, there were more or less cases of avoidable hospitalizations for tuberculosis. METHODS: This is an ecological study that uses primary and secondary data. For analysis, coropletic maps were developed through the ArcGIS software, version 10.2. There was also the calculation of gross annual and Bayesian rates for hospitalizations for tuberculosis, for each Primary Health Care territory. RESULTS: There were satisfactory results for attributes such as Population (n = 37; 80.4 %), Primary Health Care (n = 43; 93.5 %), Support System (n = 45; 97.8 %); the exceptions were Logistics System (n = 32; 76.0 %) and Governance System, with fewer units in good condition (n = 31; 67.3 %). There is no evidence of any connection between networks' coordination by Primary Health Care and tuberculosis avoidable admissions. CONCLUSION: The results show that progress has been made regarding the coordination of the Health Care Networks, and a positive trend has been shown, even though the levels are not excellent. It was found no relationship between the critical areas of Primary Health Care and tuberculosis avoidable hospitalizations, possibly because other variables necessary to comprehend the phenomena.

Assessment of the coordination of integrated health service delivery networks by the primary health care: COPAS questionnaire validation in the Brazilian context.

BACKGROUND: Health systems organized as networks and coordinated by the Primary Health Care (PHC) may contribute to the improvement of clinical care, sanitary conditions, satisfaction of patients and reduction of local budget expenditures. The aim of this study was to adapt and validate a questionnaire - COPAS - to assess the coordination of Integrated Health Service Delivery Networks by the Primary Health Care. METHODS: A cross sectional approach was used. The population was pooled from Family Health Strategy healthcare professionals, of the Alfenas region (Minas Gerais, Brazil). Data collection was performed from August to October 2013. The results were checked for the presence of floor and ceiling effects and the internal consistency measured through Cronbach alpha. Construct validity was verified through convergent and discriminant values following Multitrait-Multimethod (MTMM) analysis. RESULTS: Floor and ceiling effects were absent. The internal consistency of the instrument was satisfactory; as was the convergent validity, with a few correlations lower then 0.30. The discriminant validity values of the majority of items, with respect to their own dimension, were found to be higher or significantly higher than their correlations with the dimensions to which they did not belong. CONCLUSION: The results showed that the COPAS instrument has satisfactory initial psychometric properties and may be used by healthcare managers and workers to assess the PHC coordination performance within the Integrated Health Service Delivery Network.

[Tuberculosis and social inequity in health: an ecological study using multivariate statistical techniques, São Paulo, Brazil]. / Tuberculose e iniquidade social em saúde: uma análise ecológica utilizando técnicas estatísticas multivariadas, São Paulo, Brasil.

OBJECTIVE: To identify the patterns of São Paulo state municipalities, in Brazil, regarding the relationship between tuberculosis and indicators of health care services, health care service availability, context, and social inequality. METHODS: This ecological study covered all 645 municipalities of São Paulo and eight variables belonging to three dimensions: health care service availability, context, and social inequality. Data were analyzed using hierarchical and non-hierarchical clustering, principal components analysis, and geoprocessing. RESULTS: The analysis revealed five groups of municipalities: group 1 (117 municipalities), with similar directly observed treatment (DOT) and family health strategy (FHS) coverage, high tuberculosis incidence and death coefficients, and a low human development index (HDI); group 2 (142 municipalities), with low DOT and FHS coverage; group 3 (36 municipalities), with medium DOT and FHS coverage and high tuberculosis incidence, high demand for anti-HIV testing, and treatment dropout; group 4 (186 municipalities) with lower HDI as compared to groups 2, 3, and 5, but high FHS coverage and the lowest numbers of anti-HIV testing, tuberculosis incidence, and DOT coverage; and group 5 (164 municipalities), with better social conditions as compared to the other groups, medium FHS coverage, and higher DOT coverage. Together, the first two components selected for the study-health service availability in terms of DOT coverage indicator and social inequality indicator-explained 76.96% of the variance. In municipalities with high DOT coverage there was evidence of better organized tuberculosis control services. CONCLUSIONS: Municipalities with the highest social inequality had FHS coverage. However, without DOT, FHS seem less efficient to control tuberculosis.

[The families and directly observed treatment of tuberculosis: senses and prospects to the production of care]. / Famílias e o tratamento diretamente observado da tuberculose: sentidos e perspectivas para produção do cuidado.

The purpose was to identify the families' participation on care management of patients with tuberculosis. Also, to ascertain the contribution offered by health professionals for patients'families with ongoing treatment, and investigate the importance attributed by the families to the directly observed treatment It is a descriptive, cross-sectional study conducted in the municipality of Ribeirão Preto/SP with families of patients diagnosed with tuberculosis. For data collection, it was developed an instrument that underwent pretesting and content validation. Ninety four subjects were interviewed. According to the results, 64 (68.096) relatives participated in the care management and 81 (86.2%) reported a good relationship with the staff. Sixty three family members (67%) did not receive any guidance about drugs and 75 (80.0%) of the respondents considered the strategy as relevant. The findings indicate that the Directly Observed Treatment has limitations regarding the guidelines of clinical management of the disease, the inclusion of family in care management and understanding of its goals.

Spatial pattern and temporal trend of mortality due to tuberculosis.

OBJECTIVES: To describe the epidemiological profile of mortality due to tuberculosis (TB), to analyze the spatial pattern of these deaths and to investigate the temporal trend in mortality due to tuberculosis in Northeast Brazil. METHODS: An ecological study based on secondary mortality data. Deaths due to TB were included in the study. Descriptive statistics were calculated and gross mortality rates were estimated and smoothed by the Local Empirical Bayesian Method. Prais-Winsten's regression was used to analyze the temporal trend in the TB mortality coefficients. The Kernel density technique was used to analyze the spatial distribution of TB mortality. RESULTS: Tuberculosis was implicated in 236 deaths. The burden of tuberculosis deaths was higher amongst males, single people and people of mixed ethnicity, and the mean age at death was 51 years. TB deaths were clustered in the East, West and North health districts, and the tuberculosis mortality coefficient remained stable throughout the study period. CONCLUSIONS: Analyses of the spatial pattern and temporal trend in mortality revealed that certain areas have higher TB mortality rates, and should therefore be prioritized in public health interventions targeting the disease.

The role of Primary Healthcare in the coordination of Health Care Networks in Rio de Janeiro, Brazil, and Lisbon region, Portugal. / Atenção Primária à Saúde na coordenação das Redes de Atenção à Saúde no Rio de Janeiro, Brasil, e na região de Lisboa, Portugal.

Considering the trajectory of Rio de Janeiro e Lisboa region regarding strengths of the their health local systems to achieve health for all and equity, the study aimed to compare the organization of the Primary Healthcare from both regions, searching to identify the advancement which in terms of the Delivery Health Networks' coordination. It is a case study with qualitative approach and assessment dimensions. It was used material available online such as scientific manuscripts and gray literature. The results showed the different grades regarding Delivery Health Networks. Lisboa region present more advancement, because of its historic issues, it has implemented Primary Healthcare expanded and nowadays it achieved enough maturity related to coordination of its health local system and Rio de Janeiro suffers still influence from historic past regarding Primary Healthcare selective. The both regions has done strong bids in terms of electronic health records and telemedicine. After of the study, it is clearer the historic, cultural and politics and legal issue that determined the differences of the Primary Healthcare coordinator of the Delivery Health Network in Rio de Janeiro and Lisboa region.

Spatial risk of tuberculosis mortality and social vulnerability in Northeast Brazil.

INTRODUCTION: Tuberculosis (TB) is the most common infectious disease in the world. We aimed to analyze the spatial risk of tuberculosis mortality and to verify associations in high-risk areas with social vulnerability. METHODS: This was an ecological study. The scan statistic was used to detect areas at risk, and the Bivariate Moran Index was used to verify relationships between variables. RESULTS: High-risk areas of tuberculosis mortality were statistically significantly associated with domain 2 of the Social Vulnerability Index (I=0.010; p=0.001). CONCLUSIONS: This study provides evidence regarding areas with high risk and that vulnerability is a determinant of TB mortality.

Spatial clustering and local risk of leprosy in São Paulo, Brazil.

BACKGROUND: Although the detection rate is decreasing, the proportion of new cases with WHO grade 2 disability (G2D) is increasing, creating concern among policy makers and the Brazilian government. This study aimed to identify spatial clustering of leprosy and classify high-risk areas in a major leprosy cluster using the SatScan method. METHODS: Data were obtained including all leprosy cases diagnosed between January 2006 and December 2013. In addition to the clinical variable, information was also gathered regarding the G2D of the patient at diagnosis and after treatment. The Scan Spatial statistic test, developed by Kulldorff e Nagarwalla, was used to identify spatial clustering and to measure the local risk (Relative Risk-RR) of leprosy. Maps considering these risks and their confidence intervals were constructed. RESULTS: A total of 434 cases were identified, including 188 (43.31%) borderline leprosy and 101 (23.28%) lepromatous leprosy cases. There was a predominance of males, with ages ranging from 15 to 59 years, and 51 patients (11.75%) presented G2D. Two significant spatial clusters and three significant spatial-temporal clusters were also observed. The main spatial cluster (p = 0.000) contained 90 census tracts, a population of approximately 58,438 inhabitants, detection rate of 22.6 cases per 100,000 people and RR of approximately 3.41 (95%CI = 2.721-4.267). Regarding the spatial-temporal clusters, two clusters were observed, with RR ranging between 24.35 (95%CI = 11.133-52.984) and 15.24 (95%CI = 10.114-22.919). CONCLUSION: These findings could contribute to improvements in policies and programming, aiming for the eradication of leprosy in Brazil. The Spatial Scan statistic test was found to be an interesting resource for health managers and healthcare professionals to map the vulnerability of areas in terms of leprosy transmission risk and areas of underreporting.

Cultural adaptation of the Tuberculosis-related stigma scale to Brazil. / Adaptação cultural para o Brasil da escala Tuberculosis-related stigma.

The process of stigmatization associated with TB has been undervalued in national research as this social aspect is important in the control of the disease, especially in marginalized populations. This paper introduces the stages of the process of cultural adaptation in Brazil of the Tuberculosis-related stigma scale for TB patients. It is a methodological study in which the items of the scale were translated and back-translated with semantic validation with 15 individuals of the target population. After translation, the reconciled back-translated version was compared with the original version by the project coordinator in Southern Thailand, who approved the final version in Brazilian Portuguese. The results of the semantic validation conducted with TB patients enable the identification that, in general, the scale was well accepted and easily understood by the participants.

Pulmonary tuberculosis in São Luis, State of Maranhão, Brazil: space and space-time risk clusters for death (2008-2012).

INTRODUCTION: The objective was to identify space and space-time risk clusters for the occurrence of deaths in a priority city for the control of tuberculosis (TB) in the Brazilian Northeast. METHODS: Ecological research was undertaken in the City of São Luis/Maranhão. Cases were considered that resulted in deaths in the population living in the urban region of the city with pulmonary TB as the basic cause, between 2008 and 2012. To detect space and space-time clusters of deaths due to pulmonary TB in the census sectors, the spatial analysis scan technique was used. RESULTS: In total, 221 deaths by TB occurred, 193 of which were due to pulmonary TB. Approximately 95% of the cases (n=183) were geocoded. Two significant spatial clusters were identified, the first of which showed a mortality rate of 5.8 deaths per 100,000 inhabitants per year and a high relative risk of 3.87. The second spatial cluster showed a mortality rate of 0.4 deaths per 100,000 inhabitants per year and a low relative risk of 0.10. A significant cluster was observed in the space-time analysis between 11/01/2008 and 04/30/2011, with a mortality rate of 8.10 deaths per 100,000 inhabitants per year and a high relative risk (3.0). CONCLUSIONS: The knowledge of priority sites for the occurrence of deaths can support public management to reduce inequities in the access to health services and permit an optimization of the resources and teams in the control of pulmonary TB, providing support for specific strategies focused on the most vulnerable populations.

Factors associated with knowledge about tuberculosis and attitudes of relatives of patients with the disease in Ribeirão Preto, São Paulo, Brazil.

OBJECTIVE: To investigate the knowledge regarding tuberculosis among relatives of patients with tuberculosis and the possible factors associated with this event and also to conduct comparative analyses between groups of relatives with or with few knowledge regarding tuberculosis, considering their attitudes in both groups. METHODS: Cross-sectional study in which the sample was obtained through simple and randomized method. The data were collected by trained interviewers and validated tool. Logistic regression analyses were done using statistical software SPSS, version 22.0. RESULTS: Among the 110 subjects recruited for the study, 85 (87.5%) were women, and the mean age was 49 years. Regarding common symptoms of tuberculosis, 102 relatives (90.9%) pointed the chronic cough; regarding the knowledge about tuberculosis transmission modes, 100 (90.9%) of them pointed symptomatic respiratory as the probable infection source. The relatives also reported other tuberculosis transmission models: sharing of clothes (n = 87; 79.1%) and household utensils (n = 66; 60%); sexual relations (n = 50; 50%). Illiterate relatives (adjusted OR = 4.39; 95%CI 1.11 - 17.36), those who do not watch or watch little television (adjusted OR = 3.99; 95%CI 1.2 - 13.26), and also those who do not have the Internet access (adjusted OR = 5.01; 95%CI 1.29 - 19.38) were more likely to have low knowledge regarding tuberculosis. Regardless the group, with or without tuberculosis knowledge, the attitudes of both were satisfactory. CONCLUSION: There are evidences that social inequity is associated to the tuberculosis knowledge of patient relatives.

Spatial analysis of deaths from pulmonary tuberculosis in the city of São Luís, Brazil.

OBJECTIVE: To characterize deaths from pulmonary tuberculosis, according to sociodemographic and operational variables, in the city of São Luís, Brazil, and to describe their spatial distribution. METHODS: This was an exploratory ecological study based on secondary data from death certificates, obtained from the Brazilian Mortality Database, related to deaths from pulmonary tuberculosis. We included all deaths attributed to pulmonary tuberculosis that occurred in the urban area of São Luís between 2008 and 2012. We performed univariate and bivariate analyses of the sociodemographic and operational variables of the deaths investigated, as well as evaluating the spatial distribution of the events by kernel density estimation. RESULTS: During the study period, there were 193 deaths from pulmonary tuberculosis in São Luís. The median age of the affected individuals was 52 years. Of the 193 individuals who died, 142 (73.60%) were male, 133 (68.91%) were Mulatto, 102 (53.13%) were single, and 64 (33.16%) had completed middle school. There was a significant positive association between not having received medical care prior to death and an autopsy having been performed (p = 0.001). A thematic map by density of points showed that the spatial distribution of those deaths was heterogeneous and that the density was as high as 8.12 deaths/km2. CONCLUSIONS: The sociodemographic and operational characteristics of the deaths from pulmonary tuberculosis evaluated in this study, as well as the identification of priority areas for control and surveillance of the disease, could promote public health policies aimed at reducing health inequities, allowing the optimization of resources, as well as informing decisions regarding the selection of strategies and specific interventions targeting the most vulnerable populations.

[Primary Health Care in the coordination of health care networks: an integrative review]. / A atenção primária à saúde na coordenação das redes de atenção: uma revisão integrativa.

Health systems organized in health care networks and coordinated by Primary Health Care can contribute to an improvement in clinical quality with a positive impact on health outcomes and user satisfaction (by improving access and resolubility) and a reduction in the costs of local health systems. Thus, the scope of this paper is to analyze the scientific output about the evidence, potential, challenges and prospects of Primary Health Care in the coordination of Health Care Networks. To achieve this, the integrative review method was selected covering the period between 2000 and 2011. The databases selected were Medline (Medical Literature Analysis and Retrieval System online), Lilacs (Latin American Literature in Health Sciences) and SciELO (Scientific Electronic Library Online). Eighteen articles fulfilled the selection criteria. It was seen that the potential impacts of primary care services supersede the inherent weaknesses. However, the results revealed the need for research with a higher level of classification of the scientific evidence about the role of Primary Healh Care in the coordination of Health Care Networks.

[Social stigma and the families of patients with tuberculosis: a study based on cluster and multiple correspondence analysis]. / Estigma social e as famílias de doentes com tuberculose: um estudo a partir das análises de agrupamento e de correspondência múltipla.

The social stigma associated with TB is a challenge facing management of the area of public health care. The aim of this study was to investigate the social stigma in families of patients with TB and identify the profile of those who are affected by the event in relation to socioeconomic and demographic conditions. It is a cross-sectional study that was conducted in 2011 in the city of Ribeirão Preto, state of São Paulo, Brazil, with a sample of 110 individuals. The data were analyzed using the univariate descriptive technique and cluster and multiple correspondence assessment. The stigmatized groups tend to have lower scholarity, incipient access to the media and little understanding about TB, as opposed to those that have higher educational levels, continuous access to the media, consider themselves well informed and show proactive attitudes to deal with the disease. The identification of varied profiles highlights the need to develop health interventions to cater to the singularities of families with respect to the social stigma of the disease.

Patients' perceptions on the performance of a local health system to eliminate leprosy,Paraná State, Brazil.

BACKGROUND: In Brazil, leprosy has been listed among the health priorities since 2006, in a plan known as the "Pact for life" (Pacto pela Vida). It is the sole country on the American continent that has not reached the global goal of disease elimination. Local health systems face many challenges to achieve this global goal. The study aimed to investigate how patients perceive the local health system's performance to eliminate leprosy and whether these perceptions differ in terms of the patients' income. METHODOLOGY/PRINCIPAL FINDINGS: A cross-sectional study was conducted in Londrina, State of Paraná, Brazil. Interviews were performed with the leprosy patients. The local health system was assessed through a structured and adapted tool, considering the domains judged as good quality of health care. The authors used univariate, bivariate and multivariate analyses. One hundred and nineteen patients were recruited for the study, 50.4% (60) of them were male, 54.0% (64) were between 42 and 65 years old and 66.3% (79) had finished elementary school. The results showed that patients used the Primary Health Care service near their place of residence but did not receive the leprosy diagnosis there. Important advances of this health system were verified for the elimination of leprosy, verifying protocols for good care delivery to the leprosy patients, but these services did not develop collective health actions and did not engage the patients' family members and community. CONCLUSIONS/SIGNIFICANCE: The patients' difficulty was observed to have access to the diagnosis and treatment at health services near their homes. Leprosy care is provided at the specialized level, where the patients strongly bond with the teams. The care process is individual, with limited perspectives of integration among the health services for the purpose of case management and social mobilization of the community to the leprosy problem.

Estratégia Saúde da Família, saúde suplementar e desigualdade no acesso à mamografia no Brasil / Family Health Strategy, private health care, and inequalities in access to mammography in Brazil / Estrategia de Salud Familiar, salud suplementaria y desigualdad en el acceso a la mamografía en Brasil

RESUMO Objetivo Avaliar a associação entre o acesso à mamografia no Brasil e a cobertura pela Estratégia Saúde da Família (ESF) e pela saúde suplementar. Métodos Realizou-se um estudo ecológico com dados obtidos do Departamento de Informática do Sistema Único de Saúde (DATASUS). A tendência da série temporal foi analisada pelo método de Prais-Winsten utilizando-se como unidades de análise as unidades federativas brasileiras. Para investigar a relação entre a variável dependente - mulheres de 50 a 69 anos que nunca realizaram exame de mamografia - e as independentes, de cobertura de ESF ou saúde suplementar e socioeconômicas, realizou-se análise de regressão linear múltipla. Resultados O Acre foi o único estado que não apresentou tendência crescente da cobertura da saúde suplementar. Roraima, Tocantins, Maranhão, Piauí, Rio Grande do Norte e Paraíba apresentaram tendência estacionária para a cobertura pela ESF, enquanto as demais unidades federativas apresentaram cobertura crescente. Observou-se associação significativa entre nunca ter realizado mamografia na idade de 50 a 69 anos e as variáveis renda média per capita e cobertura pela ESF e saúde suplementar (R2 = 0,77; P < 0,001). Conclusão A desigualdade no acesso a mamografia é uma realidade no Brasil. Tanto a saúde suplementar quanto a Estratégia Saúde da Família têm contribuído para melhoria do acesso dessas mulheres.

ABSTRACT Objective To evaluate the association between access to mammography and coverage by private health insurance or by the public healthcare system through the Family Health Strategy (FHS). Method An ecological study was performed with data obtained from the Unified Health System Data Processing Department (DATASUS). Time trends were analyzed using the Prais-Winsten method, having the Brazilian federal units as units of analysis. Multiple linear regression was used to investigate the relationship between the dependent variable - women aged 50 to 69 years who never had a mammogram - and the independent variables (coverage by the FHS or private health care and socioeconomic aspects). Results Acre was the only Brazilian state for which an increasing growth trend in private health care was not observed. Roraima, Tocantins, Maranhão, Piauí, Rio Grande do Norte, and Paraíba showed a stable trend for FHS coverage, whereas all other federal units had increasing coverage. A significant association was observed between never having had a mammogram at 50 to 69 years of age and the variables mean per capita income and FHS and private health care coverage (R2 = 0.77; P < 0.001). Conclusion Unequal access to mammography is a reality in Brazil. Both private health care and the FHS have contributed to improve health care accessibility for Brazilian women.

RESUMEN Objetivo Evaluar la asociación entre el acceso a la mamografía en Brasil y la cobertura prestada por la Estrategia de Salud Familiar (ESF) y por la salud suplementaria. Métodos Se realizó un estudio ecológico con datos obtenidos del Departamento de Informática del Sistema Único de Salud (DATASUS). La tendencia de la serie temporal fue analizada mediante el método de Prais-Winsten utilizando como unidades de análisis las entidades federativas brasileñas. Para investigar la relación entre la variable dependiente —mujeres de 50 a 69 años que nunca se habían realizado una mamografía— y las independientes, de cobertura por la ESF o salud suplementaria y las variables socioeconómicas, se realizó un análisis de regresión lineal múltiple. Resultados Acre fue el único estado que no presentó una tendencia creciente para la cobertura por la salud suplementaria. Roraima, Tocantins, Maranhão, Piauí, Rio Grande do Norte y Paraíba presentaron una tendencia estacionaria para la cobertura por la ESF, mientras que las otras entidades federativas mostraron una cobertura en ascenso. Se observó una asociación significativa entre el hecho de nunca haberse realizado una mamografía entre los 50 y los 69 años y las variables renta media per cápita, cobertura por la ESF y la salud suplementaria (R2 = 0,77; P <0,001). Conclusión En Brasil, la desigualdad en el acceso a la mamografía es una realidad. Tanto la salud suplementaria como la Estrategia de Salud Familiar han contribuido a mejorar el acceso de estas mujeres a la mamografía.

Spatial pattern and temporal trend of mortality due to tuberculosis / Padrão espacial e tendência temporal da mortalidade por tuberculose / Patrón espacial y tendencia temporal de la mortalidad debido a la tuberculosis

ABSTRACT Objectives: To describe the epidemiological profile of mortality due to tuberculosis (TB), to analyze the spatial pattern of these deaths and to investigate the temporal trend in mortality due to tuberculosis in Northeast Brazil. Methods: An ecological study based on secondary mortality data. Deaths due to TB were included in the study. Descriptive statistics were calculated and gross mortality rates were estimated and smoothed by the Local Empirical Bayesian Method. Prais-Winsten's regression was used to analyze the temporal trend in the TB mortality coefficients. The Kernel density technique was used to analyze the spatial distribution of TB mortality. Results: Tuberculosis was implicated in 236 deaths. The burden of tuberculosis deaths was higher amongst males, single people and people of mixed ethnicity, and the mean age at death was 51 years. TB deaths were clustered in the East, West and North health districts, and the tuberculosis mortality coefficient remained stable throughout the study period. Conclusions: Analyses of the spatial pattern and temporal trend in mortality revealed that certain areas have higher TB mortality rates, and should therefore be prioritized in public health interventions targeting the disease.

RESUMO Objetivos: descrever o perfil epidemiológico da mortalidade por tuberculose (TB), analisar o padrão espacial dessas mortes e investigar a tendência temporal da mortalidade por tuberculose no Nordeste do Brasil. Métodos: estudo ecológico baseado em dados secundários de mortalidade. As mortes por TB foram incluídas no estudo. As estatísticas descritivas e as taxas brutas de mortalidade foram calculadas e suavizadas pelo Método Bayesiano Empírico Local. A regressão de Prais-Winsten foi utilizada para analisar a tendência temporal dos coeficientes de mortalidade por tuberculose. A técnica de densidade de Kernel foi utilizada para analisar a distribuição espacial da mortalidade por TB. Resultados: a tuberculose foi citada em 236 óbitos. A maioria das mortes por tuberculose ocorreu entre os homens, solteiros, de etnia mista e média de idade de 51 anos. As mortes por tuberculose concentraram-se nos distritos de saúde leste, oeste e norte e o coeficiente de mortalidade por tuberculose permaneceu estacionário ao longo do período de estudo. Conclusões: as análises do padrão espacial e da tendência temporal da mortalidade revelaram áreas com maiores taxas de mortalidade por TB, as quais devem ser priorizadas para intervenções de saúde pública visando o controle da doença.

RESUMEN Objetivos: describir el perfil epidemiológico de la mortalidad por tuberculosis (TB), analizar el patrón espacial de estas muertes e investigar la tendencia temporal de la mortalidad por tuberculosis en el noreste de Brasil. Métodos: estudio ecológico basado en datos secundarios de mortalidad. Las muertes por TB se incluyeron en el estudio. Se calcularon las estadísticas descriptivas y se estimaron y suavizaron las tasas de mortalidad bruta mediante el Método Bayesiano Empírico Local. La regresión de Prais-Winsten se utilizó para analizar la tendencia temporal en los coeficientes de mortalidad por TB. La técnica de densidad de Kernel se utilizó para analizar la distribución espacial de la mortalidad por TB. Resultados: la tuberculosis estuvo presente en 236 muertes. El peso de muertes por tuberculosis fue mayor en hombres, personas solteras y personas de origen étnico mixto y la edad media al momento de la muerte fue de 51 años. Las muertes por tuberculosis se agruparon en los distritos de salud del este, oeste y norte y el coeficiente de mortalidad por tuberculosis se mantuvo estable durante todo el período de estudio. Conclusiones: los análisis del patrón espacial y la tendencia temporal de la mortalidad revelaron que ciertas áreas con tasas más altas de mortalidad por TB y, por lo tanto, deberían ser priorizadas en las intervenciones de salud pública dirigidas a esta enfermedad.