Socioeconomic inequalities related to maternal perception of children's oral health at age 4: Results of a birth cohort.

OBJECTIVES: To estimate socioeconomic inequalities in the maternal perception of children's oral health from a birth cohort study in Brazil. METHODS: The data from this study were collected through perinatal interviews and at the 48-month follow-up from the 2015 Pelotas Birth Cohort Study. The main outcome was the maternal perception of children's oral health, dichotomized into positive (good/very good) and negative (fair/bad/very bad). The secondary outcome was untreated dental caries (absence and presence, according to the ICDAS index - International Caries Detection and Assessment System). For the statistical analysis, the absolute inequality index (Slope Index of Inequality - SII) and the relative concentration index (Concentration Index - CIX) were used. Analyses were stratified by maternal educational level, family income and wealth index. RESULTS: The prevalence of outcomes was 19.4% (95% CI 18.2; 20.7) for the negative maternal perception of children's oral health and 15.6% (95% CI 14.4; 16.8) for untreated dental caries. Socioeconomics inequalities were observed in negative maternal perception of children's oral health in both absolute and relative terms. A SII of -16.6 (95% CI -20.8; -12.5) was observed for family income, with higher prevalence in poor families. A higher prevalence of the negative maternal perception of children's oral health was observed in mothers without any educational level or a few years of study (CIX -21.1 [95% CI -24.5; -17.7]). CONCLUSIONS: This study demonstrates socioeconomics disparities in the maternal perception of children's oral health and in the prevalence of untreated caries in children. A higher concentration of negative maternal perception of children's oral health was identified among the most socioeconomically vulnerable individuals. The findings reinforce the presence of socioeconomic inequalities in subjective measures about children's oral health.

Child and Maternal Mental Health Before and During the COVID-19 Pandemic: Longitudinal Social Inequalities in a Brazilian Birth Cohort.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has caused major stress for families and children, particularly in the context of prolonged school closures. Few longitudinal studies are available on young children's mental health, including data both before and during the pandemic. This study examined experiences that might increase risk for mental health problems among caregivers and young children during the COVID-19 pandemic and inequalities driven by pre-pandemic disadvantage. METHOD: This prospective, population-based birth cohort study in Pelotas, Brazil, analyzed 2,083 children and caregivers with data from before the pandemic in 2019, when children were 4 years old, and again in 2020, when schools were closed for a long period during the pandemic. Child conduct problems, emotional problems, and hyperactivity-inattention problems were assessed using the Strengths and Difficulties Questionnaire. Family financial hardship, relationship difficulties, caregiver mental health, parenting practices, and child fears and isolation were considered as potential risk factors. RESULTS: Across the whole population, the only significant increase in mental health problems from before to during the pandemic was found for maternal depression. However, poorer families were at far greater risk of experiencing serious financial problems, food shortages, increased conflict in adult relationships, parenting problems, and child worries about food availability during the pandemic. In turn, these difficulties were associated with increases in multiple mental health problems for both caregivers and children. Increased child mental health problems were most strongly associated with concurrent maternal anxiety (ß > 0.20, p < .001, for each of child conduct, emotional, and hyperactivity problems), maternal depression (ß = 0.26, p < .001, for child emotional problems), partner criticism (ß = 0.21, p < .001, for child conduct problems), and harsh parenting (ß > 0.20, p < .001, for both child conduct and hyperactivity problems). Child worry about COVID-19 was associated with increased emotional problems (ß = 0.14, p < .001), but children's isolation was not associated with their mental health. CONCLUSION: Overall, the impact of the COVID-19 pandemic on mental health is a mixed picture, but for families in poverty, marked material and interpersonal difficulties were associated with increases in mental health problems among children and caregivers.

Two decades of socioeconomic inequalities in the prevalence of untreated dental caries in early childhood: Results from three birth cohorts in southern Brazil.

OBJECTIVES: To estimate the socioeconomic disparities in untreated dental caries in early childhood according to socioeconomic characteristics in three birth cohorts in Southern Brazil. METHODS: The socioeconomic data to this study were collected at the 48-month follow-up and oral health studies of 1993, 2004 and 2015 Pelotas birth cohort studies. The outcome was untreated dental caries in children aged 6 (1993 cohort), 5 (2004 cohort) and 4 years (2015 cohort), dichotomized into absence/presence. Analyses were stratified by maternal skin colour/race, maternal education and family income. For statistical purposes, the prevalence difference, relative risk and absolute and relative indices of health inequality (Slope Index of Inequality-SII and Concentration Index-CIX) were used. RESULTS: The prevalence of untreated dental caries in primary dentition was 63.4%, 45.5% and 15.6%, in 1993, 2004 and 2015 cohorts, respectively. The prevalence of untreated dental caries was concentrated in the poorest quintile and lower maternal education group in both absolute (SII) and relative (CIX) measures of inequality, being characterized as a pro-poor event. A higher risk of untreated caries was found in the poorest quintile of family income compared with the richest quintile in the 1993 cohort (RR 1.44 [95% CI 1.05; 1.98]). That risk was higher considering the 2004 Cohort (RR 1.78 [95% CI 1.42; 2.23]) and 2015 cohort (RR 4.20 [95% CI 2.97; 5.94]) data. CONCLUSIONS: Over the course of two decades, a higher prevalence of untreated dental caries is concentrated among the most socioeconomically deprived children.

Demand and unmet need for modern contraception among mothers from a Pelotas Birth Cohort

ABSTRACT OBJECTIVE To determine the total demand and unmet need for contraception with modern methods and their determinants among mothers participating in the 2015 Pelotas Birth Cohort. METHODS Data from the 48-month follow-up of mothers participating in the 2015 Pelotas Birth Cohort were analyzed. Only biological mothers (aged up to 49 years) of children belonging to the 2015 Birth Cohort and who answered the 48-month questionnaire were included in the study sample. Logistic regression and respective 95% confidence intervals were used to determine associated factors. RESULTS The study sample consisted of 3577 biological mothers. The prevalence of use of any contraceptive and of modern contraceptives was 86.0% (95%CI: 84.8-87.1) and 84.9% (95%CI: 83.7-86.1), respectively. The prevalence of unmet need for modern contraceptives was 10.7% (95%CI: 9.7-11.7), and the total demand for contraceptives was 95.6%. The factors associated with an unmet need for modern contraception were being over 34 years of age (OR = 0.6, 95%CI: 0.5-0.8), not having a husband or partner (OR = 1.9, 95%CI: 1.4-2.6), not being the head of the household (OR = 0.6, 95%CI: 0.4-0.9), having had three or more pregnancies (OR = 1.9, 95%CI: 1.3-2.6), and having had an abortion at least once after the birth of the child participating in the cohort (OR = 1.9, 95%CI: 1.0-3.6). CONCLUSIONS Despite the high prevalence of modern contraceptive use, one in ten women had an unmet need for modern contraception and was at risk of unplanned pregnancy.

Construction and validation of the Oxford Neurodevelopment Assessment (OX-NDA) in 1-year-old Brazilian children.

BACKGROUND: Over 250 million children under 5 years, globally, are at risk of developmental delay. Interventions during the first 2 years of life have enduring positive effects if children at risk are identified, using standardized assessments, within this window. However, identifying developmental delay during infancy is challenging and there are limited infant development assessments suitable for use in low- and middle-income (LMIC) settings. Here, we describe a new tool, the Oxford Neurodevelopment Assessment (OX-NDA), measuring cognition, language, motor, and behaviour, outcomes in 1-year-old children. We present the results of its evaluation against the Bayley Scales of Infant Development IIIrd edition (BSID-III) and its psychometric properties. METHODS: Sixteen international tools measuring infant development were analysed to inform the OX-NDA's construction. Its agreement with the BSID-III, for cognitive, motor and language domains, was evaluated using intra-class correlations (ICCs, for absolute agreement), Bland-Altman analyses (for bias and limits of agreement), and sensitivity and specificity analyses (for accuracy) in 104 Brazilian children, aged 12 months (SD 8.4 days), recruited from the 2015 Pelotas Birth Cohort Study. Behaviour was not evaluated, as the BSID-III's adaptive behaviour scale was not included in the cohort's protocol. Cohen's kappas and Cronbach's alphas were calculated to determine the OX-NDA's reliability and internal consistency respectively. RESULTS: Agreement was moderate for cognition and motor outcomes (ICCs 0.63 and 0.68, p < 0.001) and low for language outcomes (ICC 0.30, p < 0.04). Bland-Altman analysis showed little to no bias between measures across domains. The OX-NDA's sensitivity and specificity for predicting moderate-to-severe delay on the BSID-III was 76, 73 and 43% and 75, 80 and 33% for cognition, motor and language outcomes, respectively. Inter-rater (k = 0.80-0.96) and test-rest (k = 0.85-0.94) reliability was high for all domains. Administration time was < 20 minutes. CONCLUSION: The OX-NDA shows moderate agreement with the BSID-III for identifying infants at risk of cognitive and motor delay; agreement was low for language delay. It is a rapid, low-cost assessment constructed specifically for use in LMIC populations. Further work is needed to evaluate its use (i) across domains in populations beyond Brazil and (ii) to identify language delays in Brazilian children.

Validity assessment of a portable anthropometer to measure length in 24-month children from the 2015 Pelotas Birth Cohort.

OBJECTIVE: This study aimed to assess the validity of a portable anthropometer against the gold standard among 2-year-old infants from the 2015 Pelotas (Brazil) Birth Cohort. DESIGN: Birth cohort study. SETTING: A fixed Harpenden® infant anthropometer was considered as the gold standard for measuring infant length due to its greater precision and stability. The portable SANNY® (model ES2000) anthropometer was the instrument to be validated. The acceptable mean difference in length between the anthropometers was 0·5 cm. In order to compare length estimates, the interviewers carried out two length measures for each of the anthropometers (fixed and portable) and for each child. The mean of the two lengths was calculated for each anthropometer, and their difference was calculated. PARTICIPANTS: A subsample of 252 24-month-old members of the 2015 Pelotas (Brazil) birth cohort study. RESULTS: Children's mean age was 23·5 months. According to Bland-Altman plot, there were no differences in overall lengths between the portable and the fixed anthropometers, or in lengths according to sex. There was a high overall concordance between the length estimates of the fixed and portable anthropometers (ρ = 0·94; 95 % CI 0·92, 0·95). CONCLUSIONS: The portable anthropometer proved to be accurate to measure the length of 24-month-old infants, being applicable to studies using the same standardised protocol used in the present study.

The emergence of vaccine hesitancy among upper-class Brazilians: Results from four birth cohorts, 1982-2015.

Vaccine hesitancy has been increasingly reported in Brazil. We describe secular trends and socioeconomic disparities from 1982 to 2015, using data from four population-based birth cohorts carried out in the city of Pelotas. Full immunization coverage (FIC) was defined as having received four basic vaccines (one dose of BCG and measles, and three doses of polio and DTP) scheduled for the first year of life. Information on income was collected through standardized questionnaires, and the slope index of inequality (SII) was calculated to express the difference in percent points between the rich and poor extremes of the income distribution. Full immunization coverage was 80.9% (95% CI 79.8%; 82.0%) in 1982, 97.2% (96.1%; 98.0%) in 1993, 87.8% (86.7%; 88.8%) in 2004 and 77.2% (75.8%; 78.4%) in 2015. In 1982 there was a strong social gradient with higher coverage among children from wealthy families (SII = 25.0, P < 0.001); by 2015, the pattern was inverted with higher coverage among poor children (SII = -6.0; P = 0.01). Vertical immunization programs in the 1980s and creation of the National Health Services in 1980 eliminated the social gradient that had been present up to the 1980s, to reach near universal coverage. The recent decline in coverage is likely associated with the growing complexity of the vaccination schedule and underfunding of the health sector. In addition, the faster decline observed among children from wealthy families is probably due to vaccine hesitancy.

Income-related inequality and inequity in children's health care: A longitudinal analysis using data from Brazil.

The Brazilian Unified Health System was created in the late 1980s to ensure free universal access to health care and was funded by taxes and social contributions. The persistent inequity in access to health services in favour of richer individuals in Brazil has been observed in the literature. However, to the best of our knowledge, no measurement of inequality in medicine use or private health insurance (PHI) among children has been performed with longitudinal data. This paper uses inequality indices and their decompositions to analyse the income-related inequalities/inequities in children's health care in the city of Pelotas, Brazil, using longitudinal data following children from 12 to 72 months of age. Our sample with data in all waves has between 1877 and 2638 children (varying according to outcome). We seek to answer three questions: i) How does the inequality/inequity in health care evolve as children grow up? ii) What are the main factors associated with inequality in children's health care? iii) How much of the change in inequality/inequity is explained by mobility in children's health care and income mobility? We found that inequities in health care have their beginnings in early childhood but that there was a reduction in inequity at 72 months of age. Ownership of children's PHI was associated with greater pro-rich inequity in health care. The reduction in inequality/inequity was linked to mobility in the sense that initially poorer children had greater gains in health care (a greater increase in PHI ownership and a lower reduction in medicine use). Despite this improvement among the poorest, apparently, the Brazilian public health service seems to fail to ensure equity in health care use among children, with possible long-term consequences on inequalities in health.

Falls among older adults in the South of Brazil: prevalence and determinants.

OBJECTIVE Evaluate the prevalence and the factors associated with the occurrence of falls among older adults. METHODS A cross-sectional study with a representative sample of 1,451 elderly residents in the urban area of Pelotas, RS, in 2014. A descriptive analysis of the data was performed and the prevalence of falls in the last year was presented. The analysis of demographic, socioeconomic, behavioral and health factors associated with the outcome was performed using Poisson regression with adjustment for robust variance according to the hierarchical model. The variables were adjusted to each other within each level and for the higher level. Those with p ≤ 0.20 were maintained in the model for confounding control and those with p < 0.05 were considered to be associated with the outcome. RESULTS The prevalence of falls among older adults in the last year was 28.1% (95%CI 25.9-30.5), and most occurred in the person's own residence. Among the older adults who fell, 51.5% (95%CI 46.6-56.4) had a single fall and 12.1% (95%CI 8.9-15.3) had a fracture as a consequence, usually in the lower limbs. The prevalence of falls was higher in women, adults of advanced age, with lower income and schooling level, with functional incapacity for instrumental activities, and patients with diseases such as diabetes, heart disease, and arthritis. CONCLUSIONS The occurrence of falls reached almost a third of the older adults, and the prevalence was higher in specific segments of the population in question. About 12% of the older adults who fell fractured some bone. The factors associated with the occurrence of falls identified in this study may guide measures aimed at prevention in the older adult population.

Overall and Leisure-Time Physical Activity Among Brazilian Adults: National Survey Based on the Global Physical Activity Questionnaire.

BACKGROUND: To describe overall physical activity prevalence measured by the Global Physical Activity Questionnaire as well as inequalities in leisure-time physical activity among Brazilian adults (15 y and older). METHODS: Data from the Brazilian Survey on Medicine Access, Utilization, and Rational Use of Medicines were analyzed. The study was carried out between September 2013 and February 2014. Physical activity was measured through Global Physical Activity Questionnaire and classified according to the recommendations of the World Health Organization. Additional analysis determined the contribution of each physical activity domain to the total amount of physical activity. Inequalities in terms of sex, age, and socioeconomic position were explored. RESULTS: About one-third of the participants (37.1%; 95% confidence interval, 35.5-38.8) were physically inactive. Work-based activities were responsible for 75.7% of the overall physical activity. The prevalence of participants achieving physical activity guidelines considering only leisure-time activities was 17.8% (95% confidence interval, 16.7-19.2). Females and older participants were less active than their counterparts for both overall and leisure-time physical activity; socioeconomic status was positively associated to leisure-time physical activity. CONCLUSIONS: Major overall physical activity is attributed to work-related physical activity. Leisure-time physical activity, a key domain for public health, presents important gender and socioeconomic inequalities.

Falls among older adults in the South of Brazil: prevalence and determinants / Quedas em idosos no Sul do Brasil: prevalência e determinantes

ABSTRACT OBJECTIVE Evaluate the prevalence and the factors associated with the occurrence of falls among older adults. METHODS A cross-sectional study with a representative sample of 1,451 elderly residents in the urban area of Pelotas, RS, in 2014. A descriptive analysis of the data was performed and the prevalence of falls in the last year was presented. The analysis of demographic, socioeconomic, behavioral and health factors associated with the outcome was performed using Poisson regression with adjustment for robust variance according to the hierarchical model. The variables were adjusted to each other within each level and for the higher level. Those with p ≤ 0.20 were maintained in the model for confounding control and those with p < 0.05 were considered to be associated with the outcome. RESULTS The prevalence of falls among older adults in the last year was 28.1% (95%CI 25.9-30.5), and most occurred in the person's own residence. Among the older adults who fell, 51.5% (95%CI 46.6-56.4) had a single fall and 12.1% (95%CI 8.9-15.3) had a fracture as a consequence, usually in the lower limbs. The prevalence of falls was higher in women, adults of advanced age, with lower income and schooling level, with functional incapacity for instrumental activities, and patients with diseases such as diabetes, heart disease, and arthritis. CONCLUSIONS The occurrence of falls reached almost a third of the older adults, and the prevalence was higher in specific segments of the population in question. About 12% of the older adults who fell fractured some bone. The factors associated with the occurrence of falls identified in this study may guide measures aimed at prevention in the older adult population.

RESUMO OBJETIVO Avaliar a prevalência e os fatores associados à ocorrência de quedas em idosos. MÉTODOS Estudo transversal com amostra representativa de 1.451 idosos residentes na zona urbana de Pelotas, RS, em 2014. Foi realizada análise descritiva dos dados e apresentada a prevalência de quedas no último ano. A análise de fatores demográficos, socioeconômicos, comportamentais e de saúde associados ao desfecho foi realizada por meio de regressão de Poisson com ajuste para variância robusta conforme modelo hierárquico. As variáveis foram ajustadas entre si dentro de cada nível e para as de nível superior. Aquelas com p ≤ 0,20 foram mantidas no modelo para controle de confusão e aquelas com p < 0,05 foram consideradas associadas ao desfecho. RESULTADOS A prevalência de quedas em idosos no último ano foi de 28,1% (IC95% 25,9-30,5), e a maioria ocorreu na própria residência do idoso. Entre os idosos que sofreram queda, 51,5% (IC95% 46,6-56,4) tiveram uma única queda e 12,1% (IC95% 8,9-15,3) tiveram fratura como consequência, sendo a de membros inferiores a mais relatada. A prevalência de quedas foi maior em mulheres, idosos com idade avançada, de menor renda e escolaridade, com incapacidade funcional para atividades instrumentais e portadores de enfermidades como diabetes, doença cardíaca e artrite. CONCLUSÕES A ocorrência de quedas atingiu quase um terço dos idosos, e a prevalência foi mais elevada em segmentos específicos da população em questão. Cerca de 12% dos idosos que caíram, fraturaram algum osso. Os fatores associados à ocorrência de quedas identificados neste estudo poderão nortear medidas que visem sua prevenção na população de idosos.

[Inequality in Brazilian women's access to medicines for chronic diseases]. / Desigualdade no acesso a medicamentos para doenças crônicas em mulheres brasileiras.

This study aimed to assess the prevalence of access to continuous prescription drugs for a group of chronic diseases and to investigate the existence of socioeconomic inequalities in access. The data are from the Brazilian National Demographic and Health Survey on Women and Children (2006), with a sample of 15,575 women 15 to 49 years of age. Among these women, 7,717 were diagnosed with a chronic disease that required acquiring medicine and were considered eligible for the study. The dependent variable was defined as the diagnosis of a chronic disease and the need to obtain medication for treatment. Multivariate analysis used Poisson regression. Higher access was associated with residence in a rural area, having one or two chronic diseases, and higher socioeconomic status. Prevalence of access to medication was high, but the analysis revealed socioeconomic inequality in access to medicines in favor of the wealthy, while identifying the most vulnerable groups as the poorest and those with more chronic diseases.

[Poor dad, poor child? An investigation of intergenerational income mobility in the 1982 Birth Cohort in Pelotas, Rio Grande do Sul State, Brazil]. / Pai pobre, filho pobre? Uma análise da mobilidade intergeracional de renda na coorte de nascimentos de 1982, Pelotas, Rio Grande do Sul, Brasil.

Brazil is one of the countries with the lowest intergenerational income mobility. This article aimed to analyze intergenerational income mobility in the 1982 Birth Cohort in Pelotas, Rio Grande do Sul State. Two methods were used, intergenerational income elasticity and quantile regressions, in order to measure heterogeneity in income mobility as a function of different levels of parents' past income. The results show relatively high income mobility for Brazilian standards. The main explanation is that the data cover the children's income at a younger age (about 23 years). Quantile regressions show higher social mobility in the intermediary social stratum. The results reinforce the notion of two opposite "traps", poverty and wealth.

Desigualdade no acesso a medicamentos para doenças crônicas em mulheres brasileiras / Inequality in Brazilian women’s access to medicines for chronic diseases / Inequidad en el acceso a medicamentos para enfermedades crónicas en mujeres brasileñas

O objetivo deste trabalho foi analisar a prevalência de acesso a medicamentos para tratamento de doenças crônicas e a existência de desigualdades socioeconômicas no acesso. Os dados são da Pesquisa Nacional de Demografia e Saúde e da Mulher e da Criança de 2006, com uma amostra de 15.575 mulheres (15 a 49 anos). Dessas, 7.717 tiveram diagnóstico de doença crônica com necessidade de obtenção de medicamento e foram consideradas elegíveis para o estudo. O desfecho foi construído com base no diagnóstico de doença crônica e na necessidade de obtenção de medicamento para o tratamento. A análise ajustada foi conduzida usando-se a regressão de Poisson. Os grupos que apresentaram maior prevalência de acesso foram os domiciliados na zona rural, com uma ou duas doenças crônicas e com nível socioeconômico mais elevado. A prevalência de acesso encontrada foi alta, no entanto, as análises demonstram que existe desigualdade socioeconômica no acesso a medicamentos a favor dos mais ricos, identificando como grupo mais vulnerável aquele dos indivíduos mais pobres e com maior número de doenças crônicas.

This study aimed to assess the prevalence of access to continuous prescription drugs for a group of chronic diseases and to investigate the existence of socioeconomic inequalities in access. The data are from the Brazilian National Demographic and Health Survey on Women and Children (2006), with a sample of 15,575 women 15 to 49 years of age. Among these women, 7,717 were diagnosed with a chronic disease that required acquiring medicine and were considered eligible for the study. The dependent variable was defined as the diagnosis of a chronic disease and the need to obtain medication for treatment. Multivariate analysis used Poisson regression. Higher access was associated with residence in a rural area, having one or two chronic diseases, and higher socioeconomic status. Prevalence of access to medication was high, but the analysis revealed socioeconomic inequality in access to medicines in favor of the wealthy, while identifying the most vulnerable groups as the poorest and those with more chronic diseases.

El objetivo de este estudio fue analizar la prevalencia del acceso a los medicamentos para enfermedades crónicas y la existencia de desigualdades socioeconómicas en su acceso a los mismos. Los datos son de la Encuesta Nacional de Demografía y Salud de la Mujer y la Infancia de 2006, con una muestra de 15.575 mujeres (15-49 años). Entre éstas, 7.717 fueron diagnosticadas de enfermedad crónica con necesidad de obtener medicamentos, y fueron elegibles para este estudio. Se construyó la variable dependiente, a partir del diagnóstico de la enfermedad crónica, y de la necesidad de obtener la medicación para el tratamiento. El análisis multivariado fue realizado mediante regresión de Poisson. Los grupos que tenían mayor prevalencia de acceso estaban domiciliados en una zona rural, con una o dos enfermedades crónicas y una mejor posición socioeconómica. La prevalencia encontrada de acceso fue elevada, sin embargo, el análisis muestra que existe una desigualdad socioeconómica en el acceso a los medicamentos, en favor del grupo más rico, se identificó el grupo más pobre como más vulnerable y con mayor número de enfermedades crónicas.

Determinants of out-of-pocket health expenditure on children: an analysis of the 2004 Pelotas Birth Cohort.

BACKGROUND: The present study aimed to examine the impact of socioeconomic, demographic, and health status-related factors on out-of-pocket expenditure on health care for children. METHODS: Data were obtained from a birth cohort study conducted in the city of Pelotas, state of Rio Grande do Sul (RS), southern Brazil, in 2004. The final sample is a result of adjusts made in order to keep in the analysis only those that attended to 3 follow-ups (at 12, 24 and 48 months of age). Estimates were carried out using the Panel Data Tobit Model with random effects. RESULTS: The study showed that expenditure on medicines was 20 % less likely in those considered healthy children by their mothers and, if there was any expenditure with healthy children, the expected expenditure was reduced by 58 %. A 1 % increase in household income increased the expected expenditure on medicines by 16 %, and by 23 % in children with private health insurance coverage. CONCLUSIONS: All types of health care expenditures examined were higher for children covered by private health insurance. Although total health care expenditure was higher for children of better-off families, it represented a lower share of these families' income evidencing income inequality in health care expenditures.

Pai pobre, filho pobre? Uma análise da mobilidade intergeracional de renda na coorte de nascimentos de 1982, Pelotas, Rio Grande do Sul, Brasil / Poor dad, poor child? An investigation of intergenerational income mobility in the 1982 Birth Cohort in Pelotas, Rio Grande do Sul State, Brazil / ¿Padre pobre, hijo pobre? Un análisis de la movilidad intergeneracional de ingresos en la cohorte de nacimientos de 1982, Pelotas, Rio Grande do Sul, Brasil

O Brasil é apontado como um dos países com as menores mobilidades intergeracionais de renda do mundo. O principal objetivo do artigo é analisar a mobilidade intergeracional de renda na coorte de nascimentos de 1982 em Pelotas, Rio Grande do Sul. São utilizados dois métodos de estimação: elasticidade intergeracional de renda e regressões quantílicas para mensuração de possíveis heterogeneidades na mobilidade intergeracional em função dos diferentes níveis de renda dos pais no passado. Os resultados mostram uma mobilidade intergeracional de renda relativamente alta para os padrões brasileiros. A explicação reside, sobretudo, no fato de terem sido usados dados de renda dos filhos em idade jovem, em torno de 23 anos. As análises das regressões quantílicas indicam que a maior mobilidade social acontece nas camadas sociais intermediárias. Os resultados encontrados reforçam a existência de dois polos opostos de armadilhas: armadilha da pobreza e da riqueza.

Brazil is one of the countries with the lowest intergenerational income mobility. This article aimed to analyze intergenerational income mobility in the 1982 Birth Cohort in Pelotas, Rio Grande do Sul State. Two methods were used, intergenerational income elasticity and quantile regressions, in order to measure heterogeneity in income mobility as a function of different levels of parents’ past income. The results show relatively high income mobility for Brazilian standards. The main explanation is that the data cover the children’s income at a younger age (about 23 years). Quantile regressions show higher social mobility in the intermediary social stratum. The results reinforce the notion of two opposite “traps”, poverty and wealth.

Brasil está considerado como uno de los países con menor movilidad intergeneracional de ingresos del mundo. El principal objetivo de este estudio es examinar la movilidad intergeneracional de ingresos en la cohorte de nacimientos de 1982 en Pelotas, Rio Grande do Sul. Se utilizan dos métodos para la estimación: la elasticidad intergeneracional de los ingresos y regresiones por cuartiles de ingresos para los diferentes niveles de ingresos de los padres en el pasado. Los resultados sugieren una movilidad intergeneracional de ingresos relativamente alta para los estándares brasileños. La explicación radica principalmente en el hecho de que fueron utilizados datos de ingresos de los hijos cuando eran muy jóvenes, alrededor de 23 años. Los análisis de regresiones por cuartiles indican que una mayor movilidad social se produce en las capas intermedias. Los resultados refuerzan la existencia de dos polos opuestos: el de la pobreza y el de la riqueza.

Efforts to secure universal access to HIV/AIDS treatment: a comparison of BRICS countries.

This article illustrates how the BRICS countries have been building their focused leadership, making important high level commitment and national policy changes, and improving their health systems, in addressing the HIV/AIDS epidemics in respective settings. Specific aspects are focused on efforts of creating public provisions to secure universal access to ARVs from the aspects of active responsive system and national program, health system strengthening, fostering local production of ARVs, supply chain management, and information system strengthening. Challenges in each BRICS country are analyzed respectively. The most important contributors to the success of response to HIV/AIDS include: creating legal basis for healthcare as a fundamental human right; political commitment to necessary funding for universal access and concrete actions to secure equal quality care; comprehensive system to secure demands that all people in need are capable of accessing prevention, treatment and care; active community involvement; decentralization of the management system considering the local settings; integration of treatment and prevention; taking horizontal approach to strengthen health systems; fully use of the TRIPS flexibility; and regular monitoring and evaluation to serve evidence based decision making.

Epidemiology, management, complications and costs associated with type 2 diabetes in Brazil: a comprehensive literature review.

BACKGROUND: With an estimated 74% of all deaths attributable to non-communicable diseases (NCDs) in 2010, NCDs have become a major health priority in Brazil. The objective of the study was to conduct a comprehensive literature review on diabetes in Brazil; specifically: the epidemiology of type 2 diabetes, the availability of national and regional sources of data (particularly in terms of direct and indirect costs) and health policies for the management of diabetes and its complications. METHODS: A literature search was conducted using PubMed to identify articles containing information on diabetes in Brazil. Official documents from the Brazilian government and the World Health Organization, as well as other grey literature and official government websites were also reviewed. RESULTS: From 2006 to 2010, an approximate 20% increase in the prevalence of self-reported diabetes was observed. In 2010, it was estimated that 6.3% of Brazilians aged 18 years or over had diabetes. Diabetes was estimated to be responsible for 278,778 years of potential life lost for every 100,000 people. In 2013, it is estimated that about 7% of patients with diabetes has had one or more of the following complications: diabetic foot ulcers, amputation, kidney disease, and fundus changes. The estimated annual direct cost of diabetes was USD $3.952 billion in 2000; the estimated annual indirect cost was USD $18.6 billion. The two main sources of data on diabetes are the information systems of the Ministry of Health and surveys. In the last few years, the Brazilian Ministry of Health has invested considerably in improving surveillance systems for NCDs as well as implementing specific programmes to improve diagnosis and access to treatment. CONCLUSIONS: Brazil has the capacity to address and respond to NCDs due to the leadership of the Ministry of Health in NCD prevention activities, including an integrated programme currently in place for diabetes. Strengthening the surveillance of NCDs is a national priority along with recognising the urgent need to invest in improving the coverage and quality of mortality data. It is also essential to conduct regular surveys of risk factors on a national scale in order to design effective preventive strategies.

Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries.

BACKGROUND: Countdown to 2015 tracks progress towards achievement of Millennium Development Goals (MDGs) 4 and 5, with particular emphasis on within-country inequalities. We assessed how inequalities in maternal, newborn, and child health interventions vary by intervention and country. METHODS: We reanalysed data for 12 maternal, newborn, and child health interventions from national surveys done in 54 Countdown countries between Jan 1, 2000, and Dec 31, 2008. We calculated coverage indicators for interventions according to standard definitions, and stratified them by wealth quintiles on the basis of asset indices. We assessed inequalities with two summary indices for absolute inequality and two for relative inequality. FINDINGS: Skilled birth attendant coverage was the least equitable intervention, according to all four summary indices, followed by four or more antenatal care visits. The most equitable intervention was early initation of breastfeeding. Chad, Nigeria, Somalia, Ethiopia, Laos, and Niger were the most inequitable countries for the interventions examined, followed by Madagascar, Pakistan, and India. The most equitable countries were Uzbekistan and Kyrgyzstan. Community-based interventions were more equally distributed than those delivered in health facilities. For all interventions, variability in coverage between countries was larger for the poorest than for the richest individuals. INTERPRETATION: We noted substantial variations in coverage levels between interventions and countries. The most inequitable interventions should receive attention to ensure that all social groups are reached. Interventions delivered in health facilities need specific strategies to enable the countries' poorest individuals to be reached. The most inequitable countries need additional efforts to reduce the gap between the poorest individuals and those who are more affluent. FUNDING: Bill & Melinda Gates Foundation, Norad, The World Bank.

Household expenditures for medicines and the role of free medicines in the Brazilian public health system.

OBJECTIVES: We sought to investigate, across different socioeconomic groups, the proportion of household medicine expenses that were paid by households and the proportion paid by the Brazilian national health system. METHODS: We carried out a survey in Porto Alegre, Brazil, that included 2988 individuals of all ages. We defined 2 expenditure variables: "out-of-pocket medicines value" (the sum of retail prices of all medicines used by family members within the previous 15 days and paid for out of pocket) and "free medicines value" (a similar definition for medicines obtained without charge). RESULTS: In 2003, the Brazilian national health system provided, free of charge, 78% of the monetary value of medicines reported (79% in the bottom wealth quintile and 32% in the top 2 quintiles). The mean out-of-pocket expense for medicines was 6 times greater among the top wealth quintiles compared with those in lower quintiles, but free medicines constituted a 3-times-greater proportion of potential expenditures for medicines among the bottom quintile than among the top 2 quintiles. CONCLUSIONS: Free provision of medicines seems to be saving substantial amounts of medicine expenditures for poor people in Brazil.