Migration process of Venezuelan women to Brazil: living conditions and use of health services in Manaus and Boa Vista, 2018-2021.

BACKGROUND: The last decade saw the emergence of a new significant migration corridor due to the mass migration of Venezuelans to neighboring countries in South America. Since 2018, Brazil became the third host country of Venezuelan displaced populations. Little is known about how migratory processes affect needs, access to social programs, and public health services of migrant women. The goal of this study is to shed light on the socio-economic profile, living conditions, and use of health services of Venezuelan migrant women in two main reception cities in Brazil. METHODS: A survey was conducted using respondent-driven sampling (RDS) in the cities of Boa Vista (Roraima), and Manaus (Amazonas). The study included 2012 Venezuelan migrant women aged between 15 and 49 years old who migrated from Venezuela to Brazil between 2018 and 2021. Relative prevalence was calculated, and the χ2 test was used to analyse the homogeneity of proportions. All analyses considered the complex sampling. RESULTS: The main reasons for migrating relate to difficulties obtaining food (54%) and accessing health services (37.8%) in their country of origin. They were young and mixed race (65.7%) and had high school education (69.9%). In Manaus, 3.7% of the interviewees declared that they had no family income in the last month, while in Boa Vista, it was higher (66.2%) (p-value < 0.001). Almost one-third of them sought health care in the last 15 days, and 95% of them received care. The residents of Boa Vista arrived more recently and family income and access to paid work improved with time of residence in Brazil. CONCLUSIONS: Given the increasing flow of Venezuelan migrants crossing to Brazil, a reception system was established for the provision of food, shelter, access to health services, and income transfer programs to migrants. This was the case despite high unemployment and poverty levels and income inequality, particularly in the city of Boa Vista. However, the majority had legal migrant status and had access to the public and universal healthcare system in Brazil (SUS). The use of the SUS was similar in both cities, acting as a buffer for the differences in opportunities offered.

Prevalence of trachoma in indigenous and non-indigenous areas, Northeastern Brazil, 2019-2021.

Objective: To estimate the prevalence of trachoma in indigenous and non-indigenous populations in selected areas of the state of Maranhão, in northeastern Brazil. Methods: This was a population-based survey with probabilistic sampling. For the diagnosis of trachoma, external ocular examination was performed using head magnifying loupes, at 2.5X magnification. The prevalence of trachomatous inflammation - follicular (TF) in children aged 1-9 years and the prevalence of trachomatous trichiasis (TT) in the population aged ≥15 years were estimated. Relative frequencies of sociodemographic and environmental characteristics were obtained. Results: The study included 7 971 individuals, 3 429 from non-indigenous populations and 4 542 from indigenous populations. The prevalence of TF in non-indigenous and indigenous populations was 0.1% and 2.9%, respectively, and the prevalence of TT among indigenous populations was 0.1%. Conclusions: The prevalence of TF and TT in the two evaluation units in the state of Maranhão were within the limits recommended for the elimination of trachoma as a public health problem. However, the prevalence of TF was higher in the indigenous evaluation unit, indicating a greater vulnerability of this population to the disease. The prevalence of TF of below 5.0% implies a reduction in transmission, which may have resulted from improved socioeconomic conditions and/or the implementation of the World Health Organization SAFE strategy.

Sexual behavior and self-declaration of sexual orientation among people 18-64 years in Brazil: results from the Knowledge, Attitudes, and Practices survey, 2013 and the National Health Survey, 2019.

BACKGROUND: Population surveys involving the monitoring of high-risk sexual behavior have been recognized as important public health tools to control the HIV epidemic and other sexually transmitted infections (STIs). METHODS: Using data from the Knowledge, Attitudes, and Practices survey (PCAP-2013) and from the National Health Survey (PNS-2019), indicators of sexual behavior were compared according to sociodemographic characteristics among individuals aged 18-64 years, including size (%) estimates of men who have sex with men (MSM) and women who have sex with women (WSW). Specifically, the PNS-2019 prevalence estimates of homosexual, bisexual, heterosexual males and females were compared with those from the PCAP-2013. To compare PCAP and PNS proportional distributions, the Pearson's chi-square test, adjusted by the Rao-Scott's correction, was applied. RESULTS: Size (%) estimates of MSM and WSW obtained by direct questions from the PCAP-2013, showed higher homosexuality prevalence estimates than those resulting from the PNS-2019 self-declared sexual orientation. Significant differences were found between the MSM proportions according to the PCAP-2013 (3.7%; 95% CI 3.1-4.4%) and to the PNS-2019 (2.2%; 95% CI 1.9-2.5), and between the WSW proportions (4.6%; 95% CI 4.0-5.4%) and (2.1%; 95% CI 1.8-2.4), respectively. Results from both surveys showed MSM and WSW prevalence estimates increase with educational level, decrease with age, and is larger among people who do not live with partner, live in urban areas and in state capitals. Regarding condom use at last sexual intercourse, no differences between the PCAP-2013 and the PNS-2019 estimates were found at the national level, but significant improvements were found for MSM, people aged 18-24 and 25-34 years, and individuals not living with a partner. CONCLUSIONS: The underestimation of MSM and WSW prevalence by self-declared sexual orientation suggests that sexual minorities face many difficulties related to disclosing their sexuality and reinforces the importance of developing public health interventions for changing population attitudes and promoting sexual orientation disclosure. Moreover, the low use of condoms in both surveys (PCAP-2013 and PNS-2019) carried out 6 years apart highlights the need of public policies to expand prevention strategies for HIV infection and other STIs.

Sexual Violence and Low Rates of HIV Post-exposure Prophylaxis Access Among Female Sex Workers in Brazil.

Female sex workers (FSW) are disproportionately affected by sexual violence (SV) and HIV. Social and structural barriers limit their access to post-exposure prophylaxis (PEP). Respondent-driven sampling survey in 12 Brazilian cities among 4188 FSW aimed to estimate the rates of SV and factors associated with access to PEP use among FSW who experienced SV. The prevalence of SV was 26.3% (1199). Of the 1199, 7.5% sought out healthcare and used PEP, 19% sought out healthcare, but did not use PEP, and 73.5% did not seek out healthcare after SV. Factors associated with PEP use included PEP awareness, participation in HIV/STI prevention workshops, and disclosure of FSW status in healthcare services. Although Brazil has a PEP program free of charge, it is not readily accessible, even for FSW who seek out healthcare. The development of effective strategies to link FSW to HIV preventive services is urgently needed.

RESUMEN: Mujeres trabajadoras sexuales (MTS) se ven afectadas de manera desproporcionada por la violencia sexual (VS) y el VIH. Las barreras sociales y estructurales limitan su acceso a la profilaxis posexposición (PEP). Encuesta de muestreo dirigida por encuestados en 12 ciudades brasileñas con 4188 MTS para estimar la prevalencia de VS y los factores asociados al uso de PEP entre MTS que experimentaron VS. La prevalencia de VS fue del 26.3% (1199). De essas, el 7.5% buscó atención médica y usó PEP, el 19% buscó atención médica pero no usó PEP y el 73.5% no buscó atención después del SV. Factores asociados con el uso de PEP: conciencia de PEP; participación en talleres educativos y divulgación del trabajo en los servicios de salud. Aunque Brasil tiene un programa de PEP gratuito, no es de fácil acceso. Es urgente el desarrollo de estrategias efectivas para vincular las MTS con servicios de prevención.

Association of public physical activity facilities and participation in community programs with leisure-time physical activity: does the association differ according to educational level and income?

BACKGROUND: Our aim was to analyze the association of the presence of public physical activity (PA) facilities and participation in public PA programs with leisure-time PA, with an emphasis on the moderating role of educational level and income. METHODS: We used data of 88,531 adults (46,869 women), with a mean age of 47.2 ± 17.1y, from the 2019 Brazilian National Health Survey. Leisure-time PA (dichotomized considering 150 min/week), the presence of a public PA facility near the household (yes or no), participation in public PA programs (yes or no), educational level (divided into quintiles) and per capita income (divided into quintiles) were all self-reported through interviews. Adjusted logistic regression models were used for the analyses. RESULTS: The presence of public PA facilities near the household and the participation in public PA programs were associated with higher leisure-time PA among all quintiles of income and educational level. However, multiplicative interactions revealed that participating in PA programs [Quintile (Q)1: OR: 13.99; 95%CI: 6.89-28.38 vs. Q5: OR: 3.48; 95%CI: 2.41-5.01] and the presence of public PA facilities near the household (Q1: OR: 3.07; 95%CI: 2.35-4.01 vs. Q5: OR: 1.38; 95%CI: 1.22-1.55) were more associated with higher odds of being active in the leisure-time among the lowest quintile of educational level. CONCLUSIONS: The presence of public PA facilities and participation in public PA programs are environmental correlates that may be relevant for designing effective public health interventions to reduce social inequalities in leisure-time PA among adults in low-income areas.

Body mass index trajectories and noncommunicable diseases in women: The role of leisure time physical activity.

OBJECTIVE: To analyze the association between body mass index trajectories and non-communicable diseases (NCDs) in women, and the interaction effects of leisure time physical activity on this relationship. METHODS: Sample was composed by 15 628 women (≥30 years old) who performed objective measurement of body mass, height, and blood pressure in the 2013 Brazilian Health Survey (2013). Information regarding the body mass at 20 years old, current type 2 diabetes (T2DM), dyslipidemia diagnosis, and leisure time physical activity were self-reported by the participants. Socio-demographic and behavioral covariates were considered. Logistic regression models were used for the statistical analysis. RESULTS: Those who were obese in both moments and women who become obese showed similar high risk, however, the prevalence of NCDs among women who were no longer obese was similar to the consistently non-obese. Leisure time physical activity attenuated the general deleterious effect of obesity, especially among the consistently obese women for dyslipidemia (inactive: OR: 2.02 [95%CI: 1.69-2.43] vs active: OR: 1.05 [95%CI: 0.55-1.99]), T2DM (inactive: OR: 3.84 [95%CI: 2.72-5.43] vs active: OR: 4.38 [95%CI: 1.49-12.86]) and high blood pressure (inactive: OR: 2.00 [95%CI: 1.56-2.57] vs active: OR: 1.15 [95%CI: 0.57-2.52]). CONCLUSIONS: Changes in body mass index appear to be sensitive to detecting the risk of NCDs over lifespan. In addition, leisure time physical activity attenuates the negative effects of obesity on NCDs, but this appears more important for the consistently non-obese women.

Associations of sedentary behaviours and incidence of unhealthy diet during the COVID-19 quarantine in Brazil.

OBJECTIVE: Our aim was to analyse the association of change patterns on TV-viewing and computer/tablet use and incidence of elevated consumption of ultra-processed food consumption and lower consumption of fruits and vegetables during the COVID-19 pandemic. DESIGN: Data of 39 208 Brazilian adults from a Behaviour Web Survey were used. Unhealthy nutrition habits were eating fruits or vegetables for <5 d/week and ultra-processed food (sugary foods, snacks, ready-to-eat frozen foods and embedded foods) for ≥5 d/week. For incidence indicators, we only considered participants without unhealthy behaviour before the quarantine. We created four categories of change in TV-viewing and computer/tablet use, considering a cut-off point of 4 h/d for each behaviour (1 - consistently low, 2 - become low during the quarantine, 3 - become high during the quarantine or 4 - consistently high). Analyses were adjusted for sex, age group, highest academic achievement, per capita income, working status during the quarantine, skin colour and adherence to the quarantine. SETTING: Brazil. PARTICIPANTS: Brazilian adults (nationally representative). RESULTS: Logistic regression models revealed that high TV-viewing and computer/tablet use incidence were associated with higher odds for elevated frequency of ultra-processed food consumption (TV-viewing: OR 1·70; 95 % CI 1·37, 2·12; computer/tablet: OR 1·73; 95 % CI 1·31, 2·27) and low consumption of fruit and vegetables (TV-viewing: OR 1·70; 95 % CI 1·29, 2·23; computer/tablet: OR 1·53; 95 % CI 1·08, 2·17) incidence. Consistent high computer/tablet use also presented higher odds for incidence of elevated frequency of ultra-processed food consumption. CONCLUSIONS: Participants with incidence of sedentary behaviours were also more likely to present incidence of unhealthy diet during the COVID-19 pandemic quarantine.

Physical activity can attenuate, but not eliminate, the negative relationships of high TV viewing with some chronic diseases: findings from a cohort of 60 202 Brazilian adults.

BACKGROUND: This study examined the joint associations of leisure time physical activity and television (TV) viewing time with the prevalence of chronic diseases among Brazilian adults. METHODS: Data from the Brazilian Health Survey, a nationally representative survey conducted in 2013 (n = 60 202; ≥18 years), were used. Time spent in TV viewing and leisure physical activity, physician diagnoses of diabetes, hypertension and heart disease and information on co-variables (chronological age, education, ethnicity, candies/sweets consumption, sodium intake and tobacco smoking) were collected via interview. Descriptive statistics (mean and 95% confidence interval) and logistic regression models were used for etiological analyses. RESULTS: Physical activity attenuated but did not eliminate the risk associated with high TV viewing for at least one chronic disease in the general population [odds ratio [OR]: 1.29 (1.11-1.50)] and among women [OR: 1.31 (1.09-1.60)], adults [OR: 1.24 (1.05-1.46)] and older adults [OR: 1.63 (1.05-2.53)]. On the other hand, physical activity eliminated the risk associated with high TV viewing for at least one chronic disease among men [OR: 1.24 (0.98-1.58)]. CONCLUSIONS: We conclude that physical activity can attenuate but not eliminate the negative effects of high TV viewing on chronic disease among subgroups of Brazilian adults.

Correlates of screen-based behaviors among adults from the 2019 Brazilian National Health Survey.

We aimed to investigate correlates of TV viewing and other types of screen-based behaviors in a nationally representative sample of Brazilian adults. In the 2019 Brazilian National Health Survey (including 88,509 adults), TV viewing time and other types of screen behaviors (computer, tablet, and cellphone use) were self-reported and different geographical, sociodemographic, behavioral, and health status factors were investigated as potential correlates. Multinomial logistic regression models were used for the main analyses. Living in capital cities, urban areas, being unemployed, high consumption of soft drinks, obesity, and elevated depressive symptoms were each associated with more TV viewing and more time using other types of screens. There were differential associations between TV viewing and the use of other types of screen across age and socioeconomic variables. For instance, younger adults have a more diverse portfolio of screen time than older adults. To conclude, levels of screen-based behaviors vary by geographical, sociodemographic, behavioral, and health status characteristics. Interventions should focus on high-risk population groups and may benefit from targeting specific sedentary behaviors of interest.

Macroeconomic, demographic and human developmental correlates of physical activity and sitting time among South American adults.

BACKGROUND: Our aim was to investigate the association of macroeconomic, human development, and demographic factors with different domains of physical activity and sitting time among South American adults. METHODS: We used data from nationally representative samples in Argentina (n = 26,932), Brazil (n = 52,490), Chile (n = 3866), Colombia (n = 14,208), Ecuador (n = 19,883), Peru (n = 8820), and Uruguay (n = 2403). Our outcomes included leisure time (≥150 min/week), transport (≥10 min/week), occupational (≥10 min/week), and total (≥150 min/week) physical activity, as well as sitting time (≥4 h/day), which were collected through self-reported questionnaires. As exposures, gross domestic product, total population, population density, and human development index indicators from the most updated national census of each country were used. Age and education were used as covariates. Multilevel logistic regressions with harmonized random effect meta-analyses were conducted, comparing highest vs. lowest (reference) tertiles. RESULTS: Higher odds for transport physical activity were observed among the highest tertiles of total population (ORmen: 1.41; 95% CI: 1.23-1.62), ORwomen: 1.51; 95% CI:1.32-1.73), population density (ORmen: 1.36; 95% CI: 1.18-1.57, ORwomen: 1.49; 95% CI: 1.30-1.70), and gross domestic product (ORmen: 1.16; 95% CI: 1.00-1.35, ORwomen: 1.39; 95% CI: 1.20-1.61). For leisure physical activity, women living in departments with higher human development index presented 18% higher odds for being active, and for total physical activity a similar estimate in both sexes was observed among those who live in more populated areas. No consistent associations were found for occupational physical activity and sitting time. CONCLUSION: Macroeconomic, demographic and human development indicators are associated with different domains of physical activity in the South American context, which can in turn guide policies to promote physical activity in the region.

Inequalities in infant mortality in Brazil at subnational levels in Brazil, 1990 to 2015.

BACKGROUND: In this study, infant mortality rate (IMR) inequalities are analyzed from 1990 to 2015 in different geographic scales. METHODS: The Ministry of Health (MoH) IMR estimates by Federative Units (FU) were compared to those obtained by the Global Burden of Disease (GBD) group. In order to measure the inequalities of the IMR by FU, the ratios from highest to lowest from 1990 to 2015 were calculated. Maps were elaborated in 2000, 2010, and 2015 at the municipality level. To analyze the effect of income, IMR inequalities by GDP per capita were analyzed, comparing Brazil and the FU to other same-income level countries in 2015, and the IMR municipal estimates were analyzed by income deciles, in 2000 and 2010. RESULTS: IMR decreased from 47.1 to 13.4 per 1000 live births (LB) from 1990 to 2015, with an annual decrease rate of 4.9%. The decline was less pronounced for the early neonatal annual rate (3.5%). The Northeast region showed the most significant annual decline (6.2%). The IMR estimates carried out by the GBD were about 20% higher than those obtained by the MoH, but in terms of their inequalities, the ratio from the highest to the lowest IMR among the 27 FU decreased from 4 to 2, for both methods. The percentage of municipalities with IMR higher than 40 per 1000 LB decreased from 23% to 2%, between 2000 and 2015. Comparing the IMR distribution by income deciles, all inequality measures of the IMR decreased markedly from 2000 to 2010. CONCLUSION: The results showed a marked decrease in the IMR inequalities in Brazil, regardless of the geographic breakdown and the calculation method. Despite clear signs of progress in curbing infant mortality, there are still challenges in reducing its level, such as the concentration of deaths in the early neonatal period, and the specific increases of post neonatal mortality in 2016, after the recent cuts in social investments.

Association between physical activity and alcohol consumption: sociodemographic and behavioral patterns in Brazilian adults.

BACKGROUND: Our aim was to investigate the association between physical activity and alcohol consumption, as well as the sociodemographic and behavioral patterns of this association in a representative sample of Brazilian adults. METHODS: Data from the Brazilian Health Survey (PNS), a nationally representative survey conducted in 2013 (n = 60 202; age≥18 years), were used. Time spent in leisure physical activity, alcohol consumption as well as sociodemographic (chronological age, educational status and skin color) and associated behavioral factors (TV viewing and tobacco smoking) were collected via interview. Logistic regression models were used for the main analyses. RESULTS: Prevalence of weekly and almost daily alcohol consumption were 29.5% and 6.7% for men and 12.0% and 1.0% for women respectively. Adults with weekly alcohol consumption were more likely to be classified as physically active [young: men=OR:1.20 (CI 95%:1.02-1.39), women= OR:2.33 (CI 95%:1.92-2.82); middle-aged: men= OR:1.46 (CI 95%: 1.17-1.82), women= OR:1.75 (CI 95%:1.38-2.22); older: men= OR:1.83 (CI 95%:1.27-2.66), women= OR:2.11 (CI 95%: s1.26-3.52)], when compared to adults with no alcohol consumption. Almost daily alcohol consumption was associated with lower physical activity among young and middle-aged adults but with higher physical activity among older adults of both sexes and young women. CONCLUSIONS: Weekly alcohol consumption was associated with a higher level of physical activity among young, middle aged and older adults.

Sex work stigma and non-disclosure to health care providers: data from a large RDS study among FSW in Brazil.

BACKGROUND: Stigma in health services may be detrimental to health seeking attitudes and practices. This study investigates non-disclosure of sex work to health care providers among female sex workers (FSW) in Brazil and its association with the utilization of health care services. METHODS: This study used cross-sectional respondent-driven sampling, carried out in 12 Brazilian cities to identify HIV risk behaviors among FSW. We first assessed statistical associations of sociodemographic, human right violations, health service access and utilization, and discrimination variables with non-disclosure of FSW status to health care providers as outcome. Secondly, we investigated the association of non-disclosure of FSW status with selected preventive health care outcomes: HIV testing, PAP smear exam, and post-exposure prophylaxis (PEP). Adjusted odds ratio with 95% confidence intervals were calculated by multivariable logistic regressions. RESULTS: Among 4245 recruited FSW, a high percentage received free condoms (82%) but only 24.4% were counseled on STI. Most FSW used non-specialized public healthcare routinely (62.6%), but only 51.5% had a Pap smear exam in the last two years and less than 40% were tested for HIV in the last 12 months. Among FSW who engaged in risky behavior (49.6%), only 8.3% used PEP. Regarding human rights violations, approximately 15% were required to give part of their earnings to owners of workplace establishments, 38% started sex work under 18 years old and 6% were required to periodically present their HIV test results. 21.3% reported having faced discrimination in health services, and 24.3% always disclosed their FSW status. Multivariable logistic models indicated significant associations of non-disclosure on the four healthcare outcomes, with lower odds of using preventive health services among women who did not disclose their sex work status, even after controlling for age, educational level, NGO affiliation, and type of health care routinely used. CONCLUSIONS: Our results indicate that sex work stigmatization within health services may be one of the main barriers to STI control and HIV response among FSW. It is essential to combat stigmatization and discrimination against FSW in health services to guarantee the appropriate uptake of preventive services available in the public health system in Brazil.

HIV Testing among men in Curitiba, Brazil.

In 2015, a community-wide intervention was launched in the city of Curitiba to evaluate the uptake of multiple HIV testing. A three-stage cluster sampling of 4800 men aged 15-64 years was selected in Curitiba. Logistic regression models were used to establish driving factors of HIV testing over the past 12 months. In the total sample, 49.5% have tested for HIV once in lifetime and 18.7% in the last 12 months. Among MSM, the proportions were much higher: 75.9% and 47.8% respectively. In the multivariate analysis, a significantly higher likelihood of HIV testing was found for young men (15-24 years), men with better educational level, those with more than 6 casual partners, and MSM compared to heterosexual men. The results indicate that the intervention to increase HIV diagnosis has substantially expanded MSM access to HIV testing.

Age at menarche and cancer risk at adulthood.

AIM: The aim was to evaluate the association between age at menarche and cancer using a nationally representative sample of Brazilian women. METHODS: Data from the Brazilian Health Survey (PNS), a nationally representative survey conducted in 2013 (n = 33,715 women; ≥18 years), were used. Information on cancer diagnosis, age at menarche and other co-variables (chronological age, educational status, skin colour, menopause, leisure-time physical activity and tobacco smoking) were collected via interview. Logistic regression models were used for aetiological analyses. RESULTS: The prevalence of cancer diagnosis was greater among women with early age at menarche [2.6% (2.0-3.5%)] compared to on-time [1.6% (1.4-1.9%)] and late women [2.0% (1.1-3.4%)]. The onset of menarche ≤11 years was significantly associated with cancer risk, regardless of co-variables [OR =2.45 (1.34-4.48)], compared to the late group. CONCLUSION: Early age at menarche was associated with cancer risk in adulthood, regardless of race, educational status, chronological age, obesity, menopause onset, tobacco smoking or physical activity.

Social inequalities in the prevalence of self-reported chronic non-communicable diseases in Brazil: national health survey 2013.

BACKGROUND: Considering the high socioeconomic inequalities in Brazil related to occurrence of morbidity and premature mortality, the objective of this study was to analyze inequalities in self-reported prevalence of Non-Communicable Diseases (NCD) and in the physical limitations caused by these diseases, among the Brazilian adult population, according to sociodemographic variables. METHODS: This was a population-based cross-sectional study that analyzed information on 60,202 individuals who formed a representative sample of Brazilian adults interviewed for the National Health Survey 2013. Disparities by schooling levels and possession of private health insurance were assessed by calculating the prevalence (P) and prevalence ratio (PR) of each of the 13 NCDs and any associated limitations, while controlling for other socioeconomic and demographic variables. RESULTS: 45 % of the Brazilian adult population reported having at least one NCD. The prevalence ratio was greater among women (1.24 CI 1.21-1.28), individuals over 55 years of age, individuals with low schooling levels (illiterate and incomplete elementary education) (1.08 CI 1.02-1.14) and people living in the Southeast (1.10 CI 1.04-1.16), South (1.26 CI 1.19-1.34) and Central-West (1.11 CI 1.05-1.18) regions of the country. Diseases such as diabetes (1.42 CI 1.13-1.47), hypertension (1.17 CI 1.06-1.28), stroke (2.52 CI 1.74-3.66), arthritis (1.4 CI 1.11-1.77), spinal problems (1.39 CI .1.25-1.56), and chronic renal failure (1.65 CI 1.10.2.46), were more prevalent among adults with low education. For most NCDs, greater reports of limitations were associated with lower schooling levels and lack of private health insurance. CONCLUSION: Populations with lower schooling levels and lack of private health insurance present higher prevalence of various NCD and greater degrees of limitation due to these diseases. Results reveal the extent of social inequalities that persist with regard to occurrence and the impact of NCDs in Brazil.

Inequalities in healthy life expectancy by Brazilian geographic regions: findings from the National Health Survey, 2013.

BACKGROUND: The demographic shift and epidemiologic transition in Brazil have drawn attention to ways of measuring population health that complement studies of mortality. In this paper, we investigate regional differences in healthy life expectancy based on information from the National Health Survey (PNS), 2013. METHODS: In the survey, a three-stage cluster sampling (census tracts, households and individuals) with stratification of the primary sampling units and random selection in all stages was used to select 60,202 Brazilian adults (18 years and over). Healthy life expectancies (HLE) were estimated by Sullivan's method according to sex, age and geographic region, using poor self-rated health for defining unhealthy status. Logistic regression models were used to investigate socioeconomic and regional inequalities in poor self-rated health, after controlling by sex and age. RESULTS: Wide disparities by geographic region were found with the worst indicators in the North and Northeast regions, whether considering educational attainment, material deprivation, or health care utilization. Life expectancy at birth for women and men living in the richest regions was 5 years longer than for those living in the less wealthy regions. Modeling the variation across regions for poor self-rated health, statistically significant effects (p < 0.001) were found for the North and Northeast when compared to the Southeast, even after controlling for age, sex, diagnosis of at least one non-communicable chronic disease, and schooling or socioeconomic class. Marked regional inequalities in HLE were found, with the loss of healthy life much higher among residents of the poorest regions, especially among the elderly. CONCLUSIONS: By combining data on self-rated health status and mortality in a single indicator, Healthy Life Expectancy, this study demonstrated the excess burden of poor health experienced by populations in the less wealthy regions of Brazil. To mitigate the effects of social exclusion, the development of strategies at the regional level is essential to provide health care to all persons in need, reduce risk exposures, support prevention policies for adoption of healthy behaviors. Such strategies should prioritize population groups that will experience the greatest impact from such interventions.

Social inequalities in health behaviors among Brazilian adults: National Health Survey, 2013.

BACKGROUND: Considering the high socioeconomic inequalities prevailing in Brazil and lifestyle as a strong determinant of morbidity and premature mortality, our purpose was to evaluate the degree of socioeconomic disparities in the prevalence of health behaviors among Brazilian adult population using data from the 2013 Brazilian National Health Survey. METHOD: Based on a sample of 49,025 individuals aged 20 to 59 years, we estimated the prevalence of several health behaviors and a score of unhealthy behaviors according to gender, education, race/color and possession of private health insurance. The prevalence ratios adjusted by age and gender were estimated by means of multiple Poisson regression and the analyses took into account the sampling design. RESULTS: Significant social inequalities were identified in the Brazilian adults. Higher prevalence of current smoking, leisure-time physical inactivity, sedentary lifestyle, whole milk consumption and low ingestion of greens, vegetables, and fruits were observed among the less educated, in the non-white population, and among those without private health insurance. Higher prevalence of heavy episodic drinking was found in the non-white population, but no difference in the consumption of fatty meat was found according to skin color. Score of unhealthy behavior higher than 6 was more frequent in lower educational strata (PR = 3.74) in the non-white population (PR = 1.39) and among those without private health insurance (PR = 1.78). Compared to women, men had higher prevalence rates of smoking, hazardous alcohol consumption, and fatty meat consumption and lower consumption of greens, vegetables and fruits. CONCLUSION: The results of the study emphasize the importance of monitoring social inequalities in health as part of national health policies and the urgent need to prioritize actions to promote healthy behaviors, especially among the most socially vulnerable segments of society.

Prenatal testing and prevalence of HIV infection during pregnancy: data from the "Birth in Brazil" study, a national hospital-based study.

BACKGROUND: The rate of vertical HIV transmission has decreased in Brazil, but regional inequalities suggest problems in implementing control measures during pregnancy and delivery. The aims of this study were to ascertain the coverage of HIV testing during prenatal care and estimate the prevalence of HIV infection during pregnancy in Brazil. METHODS: This was a national hospital-based study of 23,894 women that was conducted in 2011-2012. The data came from interviews with mothers during postpartum hospitalization, from hospital medical files and from prenatal cards. All the pregnant women with reactive serological results for HIV infection marked on their cards or with diagnoses of HIV infection during the hospital stay for delivery were considered cases of HIV infection. Univariate and multivariable logistic regression were performed to investigate factors associated with the prevalence of HIV infection and with performing at least one HIV test during pregnancy. RESULTS: Among participating women, the coverage of testing for HIV infection was 81.7% among those who presented with prenatal card and the prevalence of HIV infection among pregnant women was 0.4% (95% CI: 0.32-0.51%). In the adjusted analysis, there was higher coverage of testing among women living in the South and Southeast regions; of women aged 35 years and over; with greater schooling levels; who self-reported as white; with prenatal care provided in private services; with an early start to prenatal care; and with an adequate number of consultations, defined as a minimum of six for a term pregnancy. In the adjusted analyses there was a greater odds ratio of HIV infection among women living in the South region, aged 35 years and over, with schooling of less than 8 years, who self-reported race as black, without a partner, with syphilis coinfection and who were attended by public services. CONCLUSIONS: The prevalence of HIV infection among pregnant women in Brazil remains below 1% and the coverage of testing for HIV infection is over 80%. However, the regional and social inequalities in access to healthcare services and the missed opportunities for diagnoses of HIV infection indicate the importance of strengthening HIV infection control programs during pregnancy.

Correction of vital statistics based on a proactive search of deaths and live births: evidence from a study of the North and Northeast regions of Brazil.

BACKGROUND: In the last 20 years, Brazil has undergone dramatic changes in terms of socioeconomic development and health care. In the first decade of the 2000s, the Ministry of Health (MoH) developed a series of programs focused on reducing infant mortality, including the Family Health Program as a national policy for primary care. In this paper, we propose a method to correct underreporting of deaths and live births. After vital statistics are corrected, infant mortality trends are analyzed for the period 2000-2010 by macro-geographical region. METHODS: A proactive search of live births and deaths was carried out in the Amazon and Northeast regions in 2010 to find vital events that occurred in 2008 and were not reported to the Ministry of Health. The probabilistic sample of 133 municipalities was stratified by adequacy of vital information reporting. For each municipality, the adequacy analysis was based on the reported age-standardized mortality rate per 1,000 population and the ratio between reported and estimated live births. Correction factors were estimated by strata based on additional vital events found in the proactive search. The procedure was generalized to correct municipal vital statistics for the period 2000-2010. RESULTS: In the proactive search, 35% of non-reported deaths were found within the health system (hospitals and other health establishments), but 28% were found in non-official sources, like illegal cemeteries. In areas of extreme poverty and unreliable vital information, the estimated completeness of infant death reporting was only 33%. After correction of vital information, the estimated infant mortality rate decreased from 26.1 in 2000 to 16.0 in 2010, with an annual rate of decrease of 4.7%, greater than the required rate to achieve the Millennium Development Goal. Among Brazilian regions, the Northeast showed the largest decrease, from 38.4 to 20.1 per 1,000 live births. CONCLUSIONS: The proactive search for vital events was shown to be a good strategy both in terms of understanding local irregularities and for correcting vital statistics. The methodology could be applied in other countries to routinely assess the pattern and extent of birth and death under-registration in order to improve the utility of these data to inform health policies.