Socio-economic status, psychosocial factors, health behaviours and incidence of dental caries in 12-year-old children living in deprived communities in Manaus, Brazil.

OBJECTIVES: This study examines the relationships between socio-economic status, psychosocial factors, health-related behaviours and the incidence of dental caries amongst 12-year-old schoolchildren living in deprived communities in Manaus, Brazil. METHODS: A longitudinal study involving 312 children aged 12 years was conducted in the city of Manaus, Brazil. Baseline data including socio-economic status (number of goods, household overcrowding, parents' schooling, family income), psychosocial factors (sense of coherence [SOC-13], social support [Social Support Appraisals questionnaire]) and health-related behaviours (frequency of toothbrushing, sugar consumption, sedentary behaviour) were collected through structured questionnaires. The number of decayed teeth was clinically assessed at baseline and one-year follow-up. A hypothesised model evaluating the direct and indirect pathways between the variables was tested using confirmatory factor analysis and structural equation modelling. RESULTS: The incidence of dental caries at the one-year follow-up was 25.6%. Sugar consumption (ß = 0.103) and sedentary behaviour (ß = 0.102) directly predicted the incidence of dental caries. A higher socio-economic status was directly linked with lower sugar consumption (ß = -0.243) and higher sedentary behaviour (ß = 0.227). Higher social support directly predicted lower sugar consumption (ß = -0.114). Lower socio-economic status (ß = -0.046) and lower social support (ß = -0.026) indirectly predicted the incidence of dental caries via sugar consumption and sedentary behaviour. CONCLUSIONS: In the population studied, sugar consumption and sedentary behaviour are meaningful predictors of the incidence of dental caries amongst schoolchildren living in deprived communities. Indirect pathways of lower socio-economic status and low social support with dental caries incidence via sugar consumption and sedentary behaviour were detected. These findings should be considered in oral interventions and oral health care policies to prevent dental caries amongst children living in deprivation. CLINICAL SIGNIFICANCE: Social conditions, social support, sedentary behaviour and sugar consumption directly influence dental caries in children.

Apoio institucional à gestão e prestação de serviços de saúde em unidade básica fluvial na Amazônia / Institutional support for the management and delivery of health services by a mobile river clinic unit in the Amazon / Apoyo institucional a la gestión y prestación de servicios de salud en unidad básica fluvial en la Amazonía

O estudo analisou o processo de trabalho do apoiador institucional ao atendimento ofertado em Unidade Básica de Saúde Fluvial. Neste estudo qualitativo, foi entrevistada 100% da equipe de gestão das unidades móveis fluviais que atendem à população rural residente entre Manaus e Novo Airão. Resultados evidenciaram baixa institucionalidade do trabalho de apoiador, em paralelo à importância da imersão nas atividades itinerantes desenvolvidas no meio rural e à centralidade do trabalho vivo cotidianamente realizado. A carência de suporte administrativo às atividades da unidade fluvial obriga o apoiador a desenvolver amplo leque de ações logísticas, requeridas pelo regime de trabalho itinerante rural. Práticas verticalizadas de tomada de decisão e restrições de investimento em infraestrutura e logística fragilizam a interveniência do apoiador e das equipes multiprofissionais, em que pese a contribuição delas à extensão de cobertura provida pelas unidades móveis fluviais rurais.(AU)

This study analysed work processes of the institutional supporter to the care services delivered by a mobile river clinic. We conducted a qualitive study using interviews with all members of the mobile river unit management team, which provides care services to the rural population between Manaus and Novo Airão. The findings show a low level of institutionalization of the work of supporters, the importance of immersion in the mobile activities developed in rural areas, and the centrality of daily living work. The lack of administrative support for the activities of the river unit means that the supporter has to develop a wide range of logistical actions required under the mobile rural work routine. Vertical decision-making and underfunding of infra-structure and logistics weaken the interventions of the supporter and multiprofessional teams, despite their contribution to the extent of coverage provided by mobile river units.(AU)

El estudio analizó el proceso de trabajo del apoyador institucional a la atención ofrecida en unidad básica fluvial de salud de la familia. Estudio cualitativo, se entrevistó al 100% del equipo de gestión de las unidades móviles fluviales que atienden a la población residente entre Manaus y Novo Airão. Los resultados mostraron una baja institucionalidad del trabajo de apoyador, en paralelo con la importancia de la inmersión en las actividades itinerantes desarrolladas en el medio rural y la centralidad del trabajo vivo cotidianamente realizado. La falta de apoyo administrativo a las actividades de la unidad fluvial obliga al apoyador a desarrollar una amplia gama de acciones logísticas, requeridas por el régimen de trabajo itinerante rural. Las prácticas verticalizadas de toma de decisiones y restricciones de inversión en infraestructura y logística fragilizan la intervención del apoyador y de los equipos multiprofesionales, a pesar de la contribución que realizan para la ampliación de la cobertura proporcionada por las unidades móviles fluviales rurales.(AU)

Barriers to access and organization of primary health care services for rural riverside populations in the Amazon.

BACKGROUND: The ways of life in the Amazon are diverse and not widely known. In addition, social inequities, large geographic distances and inadequate health care network noticeably limit access to health services in rural areas. Over the last decades, Brazilian health authorities have implemented fluvial mobile units (FMU) as an alternative to increase access and healthcare coverage. The aim of the study was to identify the strategies of access and utilization of primary health care (PHC) services by assessing the strengths and limitations of the healthcare model offered by the FMU to reduce barriers to services and ensure the right to healthcare. METHODS: Qualitative and ethnographic research involving participant observation and semi-structured interviews. Data collection consisted of interviews with users and health professionals and the observation of service organization and healthcare delivered by the FMU, in addition to the therapeutic itineraries that determine demand, access and interaction of users with healthcare services. RESULTS: Primary care is offered by the monthly locomotion of the FMU that serves approximately 20 rural riverside communities. The effectiveness of the actions of the FMU proved to be adequate for conditions such as antenatal care for low-risk pregnancy, which require periodic consultations. However, conditions that require continued attention are not adequately met through the organization of care established in the FMU. The underutilization of the workforce of community health workers and disarrangement between their tasks and those of the rest of the multi-professional team are some of the reasons pointed out, making the healthcare continuity unfeasible within the intervals between the trips of the FMU. From the users' perspective, although the presence of the FMU provides healthcare coverage, the financial burden generated by the pursuit for services persists, since the dispersed housing pattern requires the locomotion of users to reach the mobile unit services as well as for specialized care in the urban centers. CONCLUSIONS: The implementation of the FMU represents an advance in terms of accessibility to PHC. However, the organization of their activity uncritically replicates the routines adopted in the daily routine of health services located in urban spaces, proving to be inadequate for providing healthcare strategies capable of mitigating social and health inequalities faced by the users.

Socioeconomic status, social support, oral health beliefs, psychosocial factors, health behaviours and health-related quality of life in adolescents.

PURPOSE: This study assessed the relationships between socioecononic status (SES), social support, oral health beliefs, psychosocial factors, health-related behaviours and health-related quality of life (HRQoL) in adolescents. METHODS: A school-based follow-up study involving 376 12-year-old adolescents was conducted in Manaus, Brazil. Baseline data included sociodemographic characteristics (sex, parental schooling, family income, household overcrowding and number of goods), social support (SSA questionnaire), oral health beliefs and psychosocial factors (Sense of Coherence [SOC-13 scale] and self-esteem [Rosenberg Self-Esteem Scale]). Health-related behaviours (toothbrushing frequency, sedentary behaviour, smoking and sugar consumption) and HRQoL [KINDL questionnaire] were assessed at 6-month follow-up. Structural Equation Modelling assessed the relationships between variables. RESULTS: Greater social support (ß = 0.30), higher SOC (ß = 0.23), higher self-esteem (ß = 0.23), higher toothbrushing frequency (ß = 0.14) and less smoking (ß = - 0.14) were directly linked with better HRQoL. SES (ß = 0.05), social support (ß = 0.26), oral health beliefs (ß = - 0.02) were indirectly linked to HRQoL. Higher SES directly predicted higher toothbrushing frequency (ß = 0.14) and less smoking (ß = - 0.22). Greater social support also directly predicted higher SOC (ß = 0.55), positive oral health beliefs (ß = - 0.31) and higher self-esteem (ß = 0.58). Greater social support indirectly predicted less smoking via oral health beliefs (ß = - 0.05) and less sugar consumption via SOC (ß = - 0.07). CONCLUSION: Socioeconomic status, social support, oral health beliefs and psychosocial factors were important predictors of adolescent's health behaviours and HRQoL over 6-month period through direct and indirect mechanisms. Health behaviours also directly influenced HRQoL.

Acesso e cobertura da Atenção Primária à Saúde para populações rurais e urbanas na região norte do Brasil / Access and coverage of Primary Health Care for rural and urban populations in the northern region of Brazil

RESUMO Iniquidades de acesso ao Sistema Único de Saúde comprometem a garantia de cuidados primários de saúde para populações rurais e para outros grupos em situação de vulnerabilidade. Estudo transversal que avaliou acesso de usuários e cobertura assistencial de Equipes de Saúde da Família (EqSF) dos sete estados da região norte do Brasil e que aderiram à avaliação externa do segundo ciclo Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB). Os dados do PMAQ-AB foram relacionados a indicadores demográficos, socioeconômicos e de saúde, por meio do coeficiente de correlação de Spearman. Para o conjunto da região, a cobertura assistencial de equipes sediadas em área rural, urbana e urbana que declararam atender a populações rurais foi de 83,3%. Coberturas entre 90-100% foram encontradas para o Acre, o Amapá, Roraima e o Tocantins. Menores percentuais foram encontrados no Pará (50,5%) e no Amazonas (60,5%). A extensão de cobertura encobre barreiras de acesso geográfico ligadas à concentração de equipes da Estratégia Saúde da Família nos espaços urbanos, situação que se estende a 451 (25,3%) unidades e a 494 (22,9%) equipes encarregadas do atendimento de populações rurais, mas que atuam em espaço urbano, adicionando barreiras à chegada dos usuários às unidades. Dificuldades no acolhimento à demanda espontânea, agendamento de consulta e disponibilidade de transporte para o atendimento também foram reportadas.(AU)

ABSTRACT Access inequities to the Unified Health System compromise the assurance of primary health care for rural populations and other groups in situations of vulnerability. A cross-sectional study that evaluated users' access and coverage of Family Health Teams (FHT) from the seven states of the Northern region of Brazil and that joined the external evaluation of the second cycle of the National Program for Access and Quality Improvement in Primary Care (PMAQ-AB). The PMAQ-AB data were related to demographic, socioeconomic and health indicators, using the Spearman correlation coefficient. For the region as a whole, the assistance coverage of teams based in rural, urban and urban areas that declared covering rural populations was 83.3%. Coverages between 90-100% were found for Acre, Amapá, Roraima and Tocantins. Lower percentages were found in Pará (50.5%) and Amazonas (60.5%). The coverage extension hides geographical access barriers related to the concentration of Family Health Strategy teams in urban areas, a situation that involves 451 (25.3%) units and 494 (22.9%) teams in charge of serving rural populations, but which act in urban area, adding barriers to the arrival of users to the units. Difficulties in welcoming spontaneous demand, appointment scheduling and availability of transportation for care were also reported.(AU)

Contextual and individual factors associated with dental services utilisation by Brazilian adults: A multilevel analysis.

BACKGROUND: Inequalities in the utilisation of dental services in Brazil are remarkable. The aim of this study was to evaluate the association of contextual and individual factors with the utilisation of dental services by Brazilian adults using the Andersen's behavioural model. METHODS: Individual-level data from 27,017 adults residents in the State capitals who were interviewed in the 2013 Brazilian National Health Survey were pooled with contextual city-level data. The outcomes were non-utilisation of dental services and last dental visit over 12 months ago. Individual predisposing variables were age, sex, race/skin colour, schooling and social network. Individual enabling variables included income, health insurance and registration in primary health care. Individual need variables were self-perceived dental health and self-reported missing teeth. Multilevel logistic regression models were performed to estimate odds ratio (OR) and 95% confidence intervals (95% CIs) of the association of contextual and individual predisposing, enabling and need-related variables with dental services outcomes. RESULTS: Predisposing (OR = 0.89; 95% CI 0.81-0.97) and enabling (OR = 0.90; 95% CI 0.85-0.96) contextual factors were associated with non-utilisation of dental services. Individual predisposing (sex, race/skin colour, schooling), enabling (income, health insurance) and need (self-perceived oral health, missing teeth) were associated with non-utilisation of dental services and last dental visit over 12 months ago. The latter was also associated with other individual predisposing (age, social network) and need (eating difficulties due to oral problems) characteristics. CONCLUSIONS: Individual and contextual determinants influenced dental services utilisation in Brazilian adults. These factors should be on the policy agenda and considered in the organisation of health services aiming to reduce oral health inequalities related to access and utilisation of dental services.

Need of Dental Prosthesis in Older People and the Offer of Specialized Care in the Unified Health System, Brazil

Objective: To analyze the offer of dental prosthesis by Centers of Dental Specialties (CEO) considering the need by individuals aged 65-74 years in state capitals and other regions of the country. Material and Methods: The study was conducted with data from the external evaluation of the Improving Access and Quality Program (AVE/PMAQ CEO) and with data from the SBBRASIL 2010 project. AVE / PMAQ CEO is an evaluative investigation using a cross-sectional research design, performed in all CEOs of Brazil, totaling 932 services evaluated. The analysis of data and distribution of CEOs that offered dental prosthesis was described by maps, using TabWin (DATASUS) and quantitative description of the following variables: need for total and partial dentures, CEO, Regional Prosthodontic Laboratories (RLDP), average monthly number of delivered prostheses and the proportion of capitals with RLDP, number of CEOs, RLDP and prostheses delivered per 100,000 inhabitants in state capitals and other regions. Results: Of the 5,570 municipalities in the country, 780 have CEO, mainly located on municipalities with larger populations. Most CEOs were located in the northeastern (38.3%) and southeastern regions of Brazil (36.2%) with the northern and mid-western regions presenting the lowest absolute number of units. Low offer of prostheses was observed, considering the high need of dentures, as well as an unequal distribution among Brazilian regions. A high percentage of older adults aged 65-74 years require total (74.6%) or partial (99.8%) prosthetic rehabilitation, more critical situation is observed in the northern and northeastern regions. Conclusion: The provision of dental services in CEOs is still limited and unevenly distributed, especially for PPR, compromising the universality and integrality of oral health care.

Equity in the Accessibility to Specialized Care in Oral Health in Brazil: Analysis of PMAQ-CEO External Evaluation Data According to the User's Perspective

Objective: To analyze the distribution of Centers of Dental Specialties (CEO) implemented in Brazil until 2014 and identify the contextual and individual variables associated with the geographical accessibility, considering the user's perspective. Material and Methods: The study was conducted with data from the Improving Access and Quality of CEOs (AVE/PMAQ CEO) External Evaluation and contextual characteristics of states and municipalities. The AVE/PMAQ CEO was an evaluative research with cross-sectional observational character, performed in all CEOs in Brazil, with 932 services evaluated and 8,897 users interviewed. Data analysis was conducted in two stages, considering the study dimensions. Analyses were conducted on the availability of units by region, state, population size of the municipality and contextual variables. Then, the relationship between explanatory variables and the user's displacement time and with the intention to change the service location was evaluated using generalized linear regression analysis. Results: The 932 CEOs evaluated were located in 780 of the 5,570 municipalities of the country and the majority was located in the northeastern (38.3%) and southeastern regions (36.2%), with the northern and midwestern regions presenting the lowest absolute number of units. The average displacement time to the CEO was 28.4 minutes, while the intention to change CEO location due to the distance from home was reported by 7.8% of users. Lower geographical accessibility was reported in the northern region and for individuals who reported living in the rural area and in cities with larger populations. Conclusion: The availability of CEOs in the country is still low and not equitably distributed among states and regions.

Fatores contextuais e individuais associados com a utilização dos serviços de saúde bucal por adultos no Brasil / Contextual and individual factors associated with dental services utilization by adults in Brazil

A utilização dos serviços de saúde é determinada por uma interação complexa de diversos fatores. Considerando a busca pela universalidade e integralidade impostas pelas políticas públicas de saúde bucal, a avaliação da utilização dos serviços de saúde bucal e seus determinantes torna-se relevante para subsidiar o planejamento e a gestão das ações e serviços. Assim, este estudo teve por objetivo avaliar os determinantes contextuais e individuais e os mecanismos da utilização dos serviços odontológicos no Brasil por adultos. Foram utilizados dados secundários da Pesquisa Nacional de Saúde 2013 e avaliados os desfechos de não utilização e intervalo de tempo desde a última consulta dentre aqueles que já haviam ido ao dentista. No primeiro artigo foram conduzidas análises de regressão logística multinível para estimação dos efeitos de variáveis contextuais e individuais nos desfechos avaliados para as capitais do país. As modelagens hierárquicas foram orientadas pelo modelo teórico comportamental de utilização de serviços de saúde proposto por Andersen. O segundo artigo utilizou a análise de equações estruturais com o objetivo de identificar os efeitos diretos e indiretos (mecanismos) entre os construtos, variáveis observadas e o uso dos serviços de saúde bucal por adultos no Brasil, conforme modelo de análise inicial especificado também a partir do modelo teórico comportamental. Foram realizadas análises multigrupos com o intuito de avaliar em que medida os modelos eram equivalentes (invariantes) para as áreas rurais e urbanas do país. Características contextuais predisponentes e capacitantes mostraram-se associadas ao uso dos serviços de saúde bucal. Sexo, idade, cor/raça, escolaridade, renda, rede social, possuir plano de saúde, autopercepção da saúde bucal e perda dentária também influenciaram os desfechos. Foi encontrada maior proporção de indivíduos que nunca haviam ido ao dentista dentre os residentes em áreas rurais, além de um contato há maior tempo com o serviço dentre aqueles que já haviam se consultado. O modelo de mensuração mostrou-se invariante, o que não ocorreu com os modelos estruturais. As variáveis se relacionaram de maneira diferente nas áreas urbanas e rurais e também entre os dois desfechos avaliados. O estudo revelou possibilidades de intervenção para reduzir as desigualdades no uso de serviços de saúde bucal, incluindo o desenvolvimento de novas estratégias e fortalecimento das ações existentes para a inclusão ativa de grupos com menor acesso aos serviços odontológicos, incluindo homens, idosos, pretos, pardos e indígenas, bem como indivíduos com baixa escolaridade e renda e edêntulos. Uma maior disponibilidade de serviços nas áreas rurais, com uma mudança no modelo de atenção e a organização de fluxos de referência pode aumentar o acesso potencial e minimizar as necessidades de saúde bucal das populações rurais. Ações inclusivas para idosos e indivíduos do sexo masculino residentes nestas áreas também podem ajudar a reduzir as barreiras aos serviços. O planejamento das ações deve considerar os mecanismos que determinam o uso dos serviços. Além disso, a implementação de ações intersetoriais pode proporcionar um uso mais racional e efetivo dos recursos disponíveis