Self-rated health according to sex and associated factors in Manaus, Brazil, 2019: a population-based cross-sectional study.

OBJECTIVE: To assess the prevalence and factors associated with poor self-rated health according to respondents' sex in Manaus, Brazil. METHODS: This was a cross-sectional population-based study with adults in Manaus in 2019. Adjusted prevalence ratios and 95% confidence intervals (95%CI) were calculated using Poisson regression following a hierarchical model. RESULTS: Poor self-rated health occurred in 35.2% (95%CI 33.3;37.2) of the 2,321 participants and was higher in females (PR = 1.27; 95%CI 1.13;1.43). In the general population, among both sexes, poor self-rated health was higher among the oldest, those with moderate and severe food insecurity and with chronic diseases (p-value < 0.05). Among females, poor health was also higher among the evangelical and those with mild food insecurity. Among males, self-rated health was also poorer among the retired and those with education below elementary level (p-value < 0.001). CONCLUSION: The female sex had the poorest health rating, influenced by morbidity and access to food.

Pharmaceutical policies: effects of policies regulating drug marketing.

BACKGROUND: The costs of developing new treatments and bringing them to the market are substantial. The pharmaceutical industry uses drug promotion to gain a competitive market share, and drive sale volumes and industry profitability. This involves disseminating information about new treatments to relevant targets. However, conflicts of interest can arise when profits are prioritised over patient care and its benefits. Drug promotion regulations are complex interventions that aim to prevent potential harm associated with these activities. OBJECTIVES: To assess the effects of policies that regulate drug promotion on drug utilisation, coverage or access, healthcare utilisation, patient outcomes, adverse events and costs. SEARCH METHODS: We searched Epistemonikos for related reviews and their included studies. To find primary studies we searched MEDLINE, CENTRAL, Embase, EconLit, Global Index Medicus, Virtual Health Library, INRUD Bibliography, two trial registries and two sources of grey literature. All databases and sources were searched in January 2023. SELECTION CRITERIA: We planned to include studies that assessed policies regulating drug promotion to consumers, healthcare professionals or regulators and third-party payers, or any combination of these groups.In this review we defined policies as laws, rules, guidelines, codes of practice, and financial or administrative orders made by governments, non-government organisations or private insurers. One of the following outcomes had to be reported: drug utilisation, coverage or access, healthcare utilisation, patient health outcomes, any adverse effects (unintended consequences), and costs. The study had to be a randomised or non-randomised trial, an interrupted time series analysis (ITS), a repeated measures (RM) study or a controlled before-after (CBA) study. DATA COLLECTION AND ANALYSIS: At least two review authors independently assessed eligibility for inclusion of studies. When consensus was not reached, any disagreements were discussed with a third review author.  We planned to use the criteria suggested by Cochrane Effective Practice and Organisation of Care (EPOC) to assess the risk of bias of included studies. For randomised trials, non-randomised trials, and CBA studies, we planned to estimate relative effects, with 95% confidence intervals (CI). For dichotomous outcomes, we planned to report the risk ratio (RR) when possible and adjusted for baseline differences in the outcome measures. For ITS and RM, we planned to compute changes along two dimensions: change in level and change in slope. We planned to undertake a structured synthesis following EPOC guidance.  MAIN RESULTS: The search yielded 4593 citations, and 13 studies were selected for full-text review. No study met the inclusion criteria. AUTHORS' CONCLUSIONS: We sought to assess the effects of policies that regulate drug promotion on drug use, coverage or access, use of health services, patient outcomes, adverse events, and costs, however we did not find studies that met the review's inclusion criteria. As pharmaceutical policies that regulate drug promotion have untested effects, their impact, as well as their positive and negative influences, is currently only a matter of opinion, debate, informal or descriptive reporting. There is an urgent need to assess the effects of pharmaceutical policies that regulate drug promotion using well-conducted studies with high methodological rigour.

Cost-utility analysis of diagnostic methods for arterial hypertension in primary care for Brazil: ABPM vs. OBPM vs. HBPM.

INTRODUCTION: Arterial hypertension (AH) is diagnosed using three methods: office blood pressure measurement (OBPM), home blood pressure monitoring (HBPM), and ambulatory blood pressure monitoring (ABPM). No economic studies have evaluated the impact of incorporating these strategies for AH diagnosis into the Brazilian public health system. METHODS: A Markov model was created to evaluate the costs associated with AH diagnosis using the ABPM, HBPM, and OBPM. Patients were entered into the model with SBP ≥ 130 mmHg or DBP ≥ 85 mmHg obtained using OBPM. The model was based on cost, quality adjusted life-years (QALYs), and incremental costs per QALY. In the economic analysis, the costs were calculated from the perspective of the payer of the Brazilian public health system. RESULTS: In the cost-utility analysis of the three methods, ABPM was the most cost-effective strategy compared to HBPM and OBPM in all groups over 35 years of age. Compared with OBPM, ABPM was a cost-effective strategy, as it presented higher costs in all scenarios, but with better QALYs. Compared to HBPM, ABPM was the dominant strategy for all age groups, presenting lower costs and higher QALYs. When comparing HBPM with OBPM, the results were similar to those described for ABPM (i.e. it was a cost-effective strategy). CONCLUSION: With a willingness-to-pay threshold of R$35 000 per QALY gained, both ABPM and HBPM are cost-effective methods compared with OBPM in all scenarios. In Brazilian healthcare facilities that currently diagnose AH using OBPM, both ABPM and HBPM may be more cost-effective choices.

Prevalence of psychotropic and antidepressant use in a Brazilian Amazon city: analysis of two cross-sectional studies.

This article aims to assess the prevalence of psychotropic and antidepressant use and associated factors in a Brazilian Amazon city. Two cross-sectional studies conducted in Manaus in 2015 and 2019 with adults selected by probabilistic sampling. Prevalence ratios (PR) and 95% confidence intervals (95%CI) were calculated by Poisson regression with robust variance. 3,479 participants were included in 2015 and 2,321 in 2019; 2.0% used psychotropics in 2015 and 2.7% in 2019. Antidepressants were used by 0.4% (2015) and 1.4% (2019). Psychotropic use was lower in younger (PR = 0.41; 95%CI: 0.19-0.90), partnerless (PR = 0.64; 95%CI: 0.44-0.93), and informal workers (PR=0.47; 95%CI: 0.25-0.86), but higher in people with poor health (PR=2.86; 95%CI: 1.71-4.80), multimorbidity (PR = 3.24; 95%CI: 1.87-5.60), and who visited doctors (PR = 3.04; 95%CI: 1.45-6.38) or dentists (PR = 1.50; 95%CI: 1.08-2.10). Antidepressant use was higher in 2019 (PR = 2.90; 95%CI: 1.52-5.54), people with poor health (PR = 2.77; 95%CI: 1.16-6.62), and multimorbidity (PR = 8.72; 95%CI: 2.71-28.00), while lower in informal workers (PR = 0.33; 95%CI: 0.12-0.87) and unemployed (PR = 0.26; 95%CI: 0.08-0.81). Use of psychotropics remained stable in Manaus from 2015 to 2019, while antidepressant use more than tripled, which was marked by social inequalities.

Health services utilization in the Brazilian Amazon: panel of two cross-sectional studies.

OBJECTIVE: To investigate the use of health services among adults living in Manaus, Amazonas. METHODS: This was a panel of two cross-sectional studies conducted in Manaus in 2015 and 2019. Individuals aged ≥ 18 years were selected by probabilistic sampling and interviewed at home. The study outcomes were doctor visits and hospitalizations in the previous 12 months, and unmet surgical needs. Variations between 2015 and 2019 were tested using chi-squared goodness-of-fit test. Poisson regression with robust variance was employed to calculate the prevalence ratios (PR) of the outcomes with 95% confidence intervals (95%CI). RESULTS: The surveys included 5,800 participants in total. Visits to the doctor decreased from 2015 (78.7%) to 2019 (76.3%; p < 0.001), hospital admissions increased from 2015 (7.9%) to 2019 (11.5%; p < 0.001), and unmet surgical needs decreased in the period (15.9% to 12.1%; p < 0.001). These variations were particularly observed in vulnerable individuals - sicker; poorer; non-whites; and those belonging to lower social classes, with less access to education, formal jobs, and health insurance (p < 0.05). Doctor visits were higher in people with fair health status (PR = 1.09; 95%CI 1.06-1.12), health insurance (PR = 1.13; 95%CI 1.09-1.17), and chronic diseases (p < 0.001) but lower in men (PR = 0.87; 95%CI 0.84-0.90) and informal workers (PR = 0.89; 95%CI 0.84-0.94). Hospitalizations were higher in people with worse health statuses (p < 0.001), without partners (PR = 1.27; 95%CI 1.05-1.53), and with multimorbidity (PR = 1.68; 95%CI 1.33-2.12) but lower in men (PR = 0.55; 95%CI 0.44-0.68), older adults (p < 0.001), informal workers (PR = 0.67; 95%CI 0.51-0.89), and unemployed (PR = 0.72; 95%CI 0.53-0.97). Unmet surgical needs were higher in older adults (p < 0.001), middle-class people (PR = 1.24; 95%CI 1.01-1.55), worse health statuses (p < 0.001), and chronic diseases (p < 0.001) but lower in men (PR = 0.76; 95%CI 0.65-0.86). CONCLUSIONS: From 2015 to 2019, less people visited the doctor, more were admitted to hospitals, and less were in need of surgery or aware of that need, potentially indicating poorer access to health services.

Perceived discrimination in health services and associated factors in Manaus Metropolitan Region, Brazil: a cross-sectional population-based study.

Objectives: Discrimination is the differentiated treatment of individuals due to prejudgments. Discriminatory practices in health care result in negative effects on patients' health. In Brazil, skin color represents the main form of racial discrimination, which may have an impact on the accessibility and quality of health care. The Brazilian Amazon lacks investigations on this topic at the population level. This study aims to estimate the prevalence of perceived discrimination in health services and associated factors in the Manaus Metropolitan Region, state of Amazonas, Brazil.Design: A population-based cross-sectional study was conducted with a probabilistic sample of adults interviewed in 2015. The associated factors were investigated by calculating the prevalence ratio (PR) using Poisson regression with robust variance.Results: A total of 4,001 participants were included. The overall prevalence of perceived discrimination was 12.9% (95% confidence interval [CI]: 11.8-13.9%). When compared to the reference categories, women (PR = 1.43; 95%CI: 1.20-1.70), individuals with brown skin color (Brazilian mixed race; PR = 1.33; 95%CI: 1.04-1.71), people who suffer from hypertension (PR = 1.27;95%CI: 1.03-1.57), and people who frequently used health services (p≤0.03) experienced more discrimination from health professionals.Conclusions: The prevalence of perceived discrimination in health services in Manaus Metropolitan Region is frequent and is associated with ethnic, social and health-related factors. Investments in inclusive public health policies and a better quality of health assistance are required to tackle this problem.

Health services utilization in the Brazilian Amazon: panel of two cross-sectional studies

ABSTRACT OBJECTIVE To investigate the use of health services among adults living in Manaus, Amazonas. METHODS This was a panel of two cross-sectional studies conducted in Manaus in 2015 and 2019. Individuals aged ≥ 18 years were selected by probabilistic sampling and interviewed at home. The study outcomes were doctor visits and hospitalizations in the previous 12 months, and unmet surgical needs. Variations between 2015 and 2019 were tested using chi-squared goodness-of-fit test. Poisson regression with robust variance was employed to calculate the prevalence ratios (PR) of the outcomes with 95% confidence intervals (95%CI). RESULTS The surveys included 5,800 participants in total. Visits to the doctor decreased from 2015 (78.7%) to 2019 (76.3%; p < 0.001), hospital admissions increased from 2015 (7.9%) to 2019 (11.5%; p < 0.001), and unmet surgical needs decreased in the period (15.9% to 12.1%; p < 0.001). These variations were particularly observed in vulnerable individuals - sicker; poorer; non-whites; and those belonging to lower social classes, with less access to education, formal jobs, and health insurance (p < 0.05). Doctor visits were higher in people with fair health status (PR = 1.09; 95%CI 1.06-1.12), health insurance (PR = 1.13; 95%CI 1.09-1.17), and chronic diseases (p < 0.001) but lower in men (PR = 0.87; 95%CI 0.84-0.90) and informal workers (PR = 0.89; 95%CI 0.84-0.94). Hospitalizations were higher in people with worse health statuses (p < 0.001), without partners (PR = 1.27; 95%CI 1.05-1.53), and with multimorbidity (PR = 1.68; 95%CI 1.33-2.12) but lower in men (PR = 0.55; 95%CI 0.44-0.68), older adults (p < 0.001), informal workers (PR = 0.67; 95%CI 0.51-0.89), and unemployed (PR = 0.72; 95%CI 0.53-0.97). Unmet surgical needs were higher in older adults (p < 0.001), middle-class people (PR = 1.24; 95%CI 1.01-1.55), worse health statuses (p < 0.001), and chronic diseases (p < 0.001) but lower in men (PR = 0.76; 95%CI 0.65-0.86). CONCLUSIONS From 2015 to 2019, less people visited the doctor, more were admitted to hospitals, and less were in need of surgery or aware of that need, potentially indicating poorer access to health services.

Is the HPV-test more cost-effective than cytology in cervical cancer screening? An economic analysis from a middle-income country.

OBJECTIVE: To report a modelling study using local health care costs and epidemiological inputs from a population-based program to access the cost-effectiveness of adopting hrHPV test. METHODS: A cost-effectiveness analysis based on a microsimulation dynamic Markov model. Data and costs were based on data from the local setting and literature review. The setting was Indaiatuba, Brazil, that has adopted the hrHPV test in place of cytology since 2017. After calibrating the model, one million women were simulated in hypothetical cohorts. Three strategies were tested: cytology to women aged 25 to 64 every three years; hrHPV test to women 25-64 every five years; cytology to women 25-29 years every three years and hrHPV test to women 30-64 every five years (hybrid strategy). Outcomes were Quality-adjusted life-years (QALY) and Incremental Cost-Effectiveness Ratio (ICER). RESULTS: The hrHPV testing and the hybrid strategy were the dominant strategies. Costs were lower and provided a more effective option at a negative incremental ratio of US$ 37.87 for the hybrid strategy, and negative US$ 6.16 for the HPV strategy per QALY gained. Reduction on treatment costs would influence a decrease in ICER, and an increase in the costs of the hrHPV test would increase ICER. CONCLUSIONS: Using population-based data, the switch from cytology to hrHPV testing in the cervical cancer screening program of Indaiatuba is less costly and cost-effective than the old cytology program.

Occupational exposures and health-related quality of life in the Manaus Metropolitan Region, Amazonas State, Brazil: a cross-sectional study.

We aimed to investigate the association between occupational exposures and health-related quality of life among both informal and formal workers in the Brazilian Amazon. We conducted a cross-sectional study with working adults in the Manaus Metropolitan Region, Amazonas State, in 2015. Participants were selected through a three-step probabilistic sampling. The primary outcome was the health-related quality of life indicator, measured by the Brazilian validated version of the European Quality of Life 5-Dimensions 3-Levels (EQ-5D-3L) tool. Adjusted multivariate analysis was performed by Tobit regression and considered the complex sampling design. Results were converted to odds ratio (OR). Out of the 1,910 working individuals from the sample, 60.2% were formal workers. Informal workers were significantly more exposed to occupational risks than formal workers (p ≤ 0.05). Mean utility score for informal and formal workers was 0.886 (95%CI: 0.881; 0.890). Quality of life of informal workers was negatively impacted by exposure to noise (OR = 1.28; 95%CI: 1.13; 1.52), occupational stress (OR = 1.95; 95%CI: 1.65; 2.21), and industrial dust (OR = 1.46; 95%CI: 1.28; 1.72), while formal workers were negatively associated with exposure to chemical substances (OR = 1.58; 95%CI: 1.28; 1.87), noise (OR = 1.40; 95%CI: 1.23; 1.65), sun (OR = 1.65; 95%CI: 1.09; 1.40), occupational stress (OR = 1.65; 95%CI: 1.46; 1.87), biological material (OR = 2.61; 95%CI: 1.72; 3.97), and industrial dust (OR = 1.46; 95%CI: 1.28; 1.65). Exposure to occupational risks among workers from the Manaus Metropolitan Region was high, affecting both informal and formal workers. Brazilian policies need to be enforced to reduce the impacts on quality of life among workers in this region.

Waiting time and medical consultation length in the Manaus metropolitan region, Brazil: a cross-sectional, population-based study, 2015. / Tempo de espera e duração da consulta médica na região metropolitana de Manaus, Brasil: estudo transversal de base populacional, 2015.

Objective . To assess waiting times and length of medical consultations in the Manaus metropolitan region, Brazil. Methods . This was a cross-sectional study conducted with adults living in the region in 2015. Waiting time for consultation and length of consultation in minutes were reported by the participants. Analysis was performed using Tobit regression and weighted by the sample design. Results . 4,001 individuals were interviewed. Average waiting time was 125.4 minutes (95%CI 120.2;130.5), while consultations lasted an average of 52.5 minutes (95%CI 48.0;57.0). Women, poor people, people with less education, indigenous people, people resident in the state interior, people without health insurance, and individuals seen by gynecologists waited longer for their consultation (p <0.05). Consultation time was shorter for non-White people, those with poor health status and those who had health insurance (p <0.05). Conclusion . On average length of medical consultations was half the waiting time. Social inequalities were observed in these lengths of time.

Access to private health insurance in the metropolitan region of Manaus, AM, Brazil, in 2015: a cross-sectional population-based study. / Acesso a planos de saúde na região metropolitana de Manaus em 2015: estudo transversal de base populacional.

OBJECTIVE: to analyze the frequency and factors associated with coverage by health insurance in the metropolitan region of Manaus, AM, Brazil. METHOD: a cross-sectional population-based study was conducted in 2015, with data collected through household interviews; prevalence ratios (PR) and confidence intervals (95%CI) were calculated using Poisson regression with robust variance adjusted for sex and age. RESULTS: we interviewed 4,001 individuals; 13% (95%CI - 12.0;14.1%) had health insurance; greater insurance coverage was observed among military personnel (PR=3.18 - 95%CI 1.64;6.15), private sector employees (PR=1.91 - 95%CI 1.46;2.52) and public sector employees (PR=1.75 - 95%CI 1.23;2.49); health insurance was lower among poorer people (PR=0.21 - 95%CI 0.13;0.33), and those with less schooling (PR=0.66 - 95%CI 0.46;0.99). CONCLUSION: frequency of health insurance was low and was associated with better purchasing power, schooling, and employment.

Acesso a planos de saúde na região metropolitana de Manaus em 2015: estudo transversal de base populacional / Acceso a planes de salud en la región metropolitana de Manaus, AM, Brasil, en 2015: estudio transversal de base poblacional / Access to private health insurance in the metropolitan region of Manaus, AM, Brazil, in 2015: a cross-sectional population-based study

Objetivo: analisar a frequência e fatores associados à cobertura por planos privados de saúde na região metropolitana de Manaus, AM, Brasil. Métodos: estudo transversal de base populacional realizado em 2015, por meio de entrevista domiciliar; as razões de prevalência (RP) e intervalos de confiança (IC95%) foram calculadas pela regressão de Poisson, com variância robusta ajustada por sexo e faixa etária. Resultados: foram entrevistados 4.001 indivíduos, dos quais 13% (IC95% 12,0 a 14,1%) tinham plano de saúde; maior cobertura por planos foi observada entre militares (RP=3,18 - IC95% 1,64;6,15), empregados dos setores privado (RP=1,91 - IC95% 1,46;2,52) e público (RP=1,75 - IC95% 1,23;2,49); a cobertura por planos de saúde foi menor entre pessoas mais pobres (RP=0,21 - IC95% 0,13;0,33) e de menor escolaridade (RP=0,66 - IC95% 0,46;0,99). Conclusão: a frequência de planos de saúde foi baixa e associou-se a melhor poder aquisitivo, escolaridade e situação de trabalho.

Objetivo: analizar la frecuencia y los factores asociados a la cobertura por planes de salud en la región metropolitana de Manaus, AM, Brasil. Métodos: estudio transversal de base poblacional por entrevista domiciliar. Las razones de prevalencia (RP) e intervalo de confianza (IC95%) fueron calculadas por regresión de Poisson con varianza robusta, ajustadas por sexo y edad. Resultados: se entrevistaron 4.001 individuos; 13% (IC95%: 12,0 a 14,1%) tenían plan de salud; la mayor cobertura por planes fue observada entre militares (RP=3,18 - IC95% 1,64;6,15), empleados del sector privado (RP=1,91 - IC95% 1,46;2,52) y del sector público (RP=1,75 - IC95% 1,23;2,49); la cobertura fue menor en personas más pobres (RP=0,21 - IC95% 0,13;0,33) y de menor escolaridad (RP=0,66 - IC95% 0,46;0,99). Conclusión: la frecuencia de planes de salud fue baja y se asoció con mejor poder adquisitivo, escolaridad y situación de trabajo.

Objective: to analyze the frequency and factors associated with coverage by health insurance in the metropolitan region of Manaus, AM, Brazil. Method: a cross-sectional population-based study was conducted in 2015, with data collected through household interviews; prevalence ratios (PR) and confidence intervals (95%CI) were calculated using Poisson regression with robust variance adjusted for sex and age. Results: we interviewed 4,001 individuals; 13% (95%CI - 12.0;14.1%) had health insurance; greater insurance coverage was observed among military personnel (PR=3.18 - 95%CI 1.64;6.15), private sector employees (PR=1.91 - 95%CI 1.46;2.52) and public sector employees (PR=1.75 - 95%CI 1.23;2.49); health insurance was lower among poorer people (PR=0.21 - 95%CI 0.13;0.33), and those with less schooling (PR=0.66 - 95%CI 0.46;0.99). Conclusion: frequency of health insurance was low and was associated with better purchasing power, schooling, and employment.

Medication use by adults in greater Manaus: a population-based cross-sectional study, 2015

The use of medicines can be an indicator of healthcare access. Our aim was to evaluate the consumption of medicine and associated factors among adults in Manaus Metropolitan Region, located in the north of Brazil. A cross-sectional population-based study was conducted with adults, ≥18 years old, selected by probabilistic sampling. The outcome was the use of medicine in the previous 15 days. Poisson regression with robust variance was used to calculate the prevalence ratio (PR) of medicine consumption, with 95% confidence interval (CI). Use of medicines was reported by 29% (95% CI: 28-31%) of the participants. People with good (PR: 0.82, 95% CI: 0.72-0.94) and fair (PR: 0.77, 95% CI: 0.65-0.90) health status were shown to use less medication than those with very good health. People with partners (PR: 1.19, 95% CI: 1.08-1.31), and people who had sought healthcare service in the fortnight (PR: 2.16, 95% CI: 1.97-2.37) showed higher medicine consumption. Medical prescription (80.1%) was the main inductor of consumption; purchasing at a drug store (46.4%), and acquiring through the Brazilian Unified Health System (39.6%) were the main ways to obtain medicines. About one-third of adults in the Metropolitan Region of Manaus used medicines regularly, mainly people with very good health, living with partners, and with recent use of a health service.

Tempo de espera e duração da consulta médica na região metropolitana de Manaus, Brasil: estudo transversal de base populacional, 2015 / Tiempo de espera y duración de la consulta médica en la región metropolitana de Manaus, Brasil: estudio transversal de base poblacional, 2015 / Waiting time and medical consultation length in the Manaus metropolitan region, Brazil: a cross-sectional, population-based study, 2015

Objetivo; Analisar o tempo de espera e a duração de consulta médica na região metropolitana de Manaus, Brasil. Métodos: Estudo transversal, realizado com adultos residentes na região em 2015. O tempo de espera para consulta e a duração da consulta, em minutos, foram referidos pelos participantes. A análise foi realizada por regressão de Tobit e ponderada pelo desenho amostral. Resultados: Foram entrevistados 4.001 indivíduos. O tempo médio de espera foi de 125,4 minutos (IC95% 120,2;130,5), enquanto a consulta durou, em média, 52,5 minutos (IC95% 48,0;57,0). Mulheres, pessoas pobres, pessoas com baixa escolaridade, indígenas, residentes em municípios do interior, sem seguro de saúde e atendidos por ginecologistas esperaram mais pela consulta (p<0,05). O tempo de consulta foi menor em pessoas não brancas, com estado de saúde ruim e com plano de saúde (p<0,05). Conclusão: A consulta médica durou, em média, metade do tempo de espera. Observaram-se iniquidades sociais nesses períodos de tempo.

Objetivo: Analizar el tiempo de espera y la duración de la consulta médica en la región metropolitana de Manaus, Brasil. Métodos: Estudio transversal realizado con adultos que viven en la región en 2015. El tiempo de espera y la duración de la consulta en minutos fueron informados por los participantes. El análisis se realizó mediante regresión de Tobit y ponderado por el diseño amostral. Resultados: 4,001 personas fueron entrevistadas. El tiempo de espera promedio fue de 125,4 minutos (IC95% 120,2;130,5) y la consulta duró un promedio de 52,5 minutos (IC95% 48.0;57.0). Mujeres, personas pobres, con baja educación, indígenas, residentes del interior, sin seguro médico y atendidas por ginecólogos esperaron más tiempo para la consulta (p<0.05). El tiempo de consulta fue más corto con personas no blancas, con mala salud y con seguro de salud (p<0.05). Conclusión: La duración de la consulta médica fue, en promedio, la mitad del tiempo de espera. Se observaron desigualdades sociales en estes tiempos.

Objective: To assess waiting times and length of medical consultations in the Manaus metropolitan region, Brazil. Methods:This was a cross-sectional study conducted with adults living in the region in 2015. Waiting time for consultation and length of consultation in minutes were reported by the participants. Analysis was performed using Tobit regression and weighted by the sample design. Results: 4,001 individuals were interviewed. Average waiting time was 125.4 minutes (95%CI 120.2;130.5), while consultations lasted an average of 52.5 minutes (95%CI 48.0;57.0). Women, poor people, people with less education, indigenous people, people resident in the state interior, people without health insurance, and individuals seen by gynecologists waited longer for their consultation (p <0.05). Consultation time was shorter for non-White people, those with poor health status and those who had health insurance (p <0.05). Conclusion: On average length of medical consultations was half the waiting time. Social inequalities were observed in these lengths of time.

Occupational exposures and health-related quality of life in the Manaus Metropolitan Region, Amazonas State, Brazil: a cross-sectional study / Exposições ocupacionais e qualidade de vida relacionada à saúde na Região Metropolitana de Manaus, Estado do Amazonas, Brasil: um estudo transversal / Exposiciones ocupacionales y calidad de vida relacionada con la salud en la región metropolitana de Manaus, estado del Amazonas, Brasil: estudio transversal

Abstract: We aimed to investigate the association between occupational exposures and health-related quality of life among both informal and formal workers in the Brazilian Amazon. We conducted a cross-sectional study with working adults in the Manaus Metropolitan Region, Amazonas State, in 2015. Participants were selected through a three-step probabilistic sampling. The primary outcome was the health-related quality of life indicator, measured by the Brazilian validated version of the European Quality of Life 5-Dimensions 3-Levels (EQ-5D-3L) tool. Adjusted multivariate analysis was performed by Tobit regression and considered the complex sampling design. Results were converted to odds ratio (OR). Out of the 1,910 working individuals from the sample, 60.2% were formal workers. Informal workers were significantly more exposed to occupational risks than formal workers (p ≤ 0.05). Mean utility score for informal and formal workers was 0.886 (95%CI: 0.881; 0.890). Quality of life of informal workers was negatively impacted by exposure to noise (OR = 1.28; 95%CI: 1.13; 1.52), occupational stress (OR = 1.95; 95%CI: 1.65; 2.21), and industrial dust (OR = 1.46; 95%CI: 1.28; 1.72), while formal workers were negatively associated with exposure to chemical substances (OR = 1.58; 95%CI: 1.28; 1.87), noise (OR = 1.40; 95%CI: 1.23; 1.65), sun (OR = 1.65; 95%CI: 1.09; 1.40), occupational stress (OR = 1.65; 95%CI: 1.46; 1.87), biological material (OR = 2.61; 95%CI: 1.72; 3.97), and industrial dust (OR = 1.46; 95%CI: 1.28; 1.65). Exposure to occupational risks among workers from the Manaus Metropolitan Region was high, affecting both informal and formal workers. Brazilian policies need to be enforced to reduce the impacts on quality of life among workers in this region.

Resumo: O estudo buscou investigar a associação entre exposições ocupacionais e qualidade de vida relacionada à saúde entre trabalhadores informais e formais na Amazônia brasileira. Realizamos um estudo transversal com trabalhadores adultos na Região Metropolitana de Manaus, Amazonas, em 2015. Os participantes foram selecionados por amostragem probabilística em três estágios. O desfecho primário foi a qualidade de vida relacionada à saúde, medida pela versão brasileira validada do instrumento European Quality of Life 5-Dimensions 3-Levels (EQ-5D-3L). Foi realizada a análise multivariada ajustada por regressão de Tobit, considerando o desenho complexo da amostra. Os resultados foram convertidos em razão de chances (OR). Entre os 1.910 indivíduos na amostra que estavam trabalhando, 60,2% eram trabalhadores formais. Os trabalhadores informais foram mais expostos aos riscos ocupacionais (p ≤ 0,05). A média de utilidade para trabalhadores informais e formais foi 0,886 (IC95%: 0,881; 0,890). A qualidade de vida dos trabalhadores informais foi impactada negativamente pela exposição ao ruído (OR = 1,28; IC95%: 1,13; 1,52), estresse ocupacional (OR = 1,95; IC95%: 1,65; 2,21) e poeiras industriais (OR = 1,46; IC95%: 1,28; 1,72), enquanto trabalhadores formais mostraram uma associação negativa com exposição a substâncias químicas (OR = 1,58; IC95%: 1,28; 1,87), ruído (OR = 1,40; IC95%: 1,23; 1,65), luz solar (OR = 1,65; IC95%: 1,09; 1,40), estresse ocupacional (OR = 1,65; IC95%: 1,46; 1,87), material biológico (OR = 2,61; IC95%: 1,72; 3,97) e poeiras industriais (OR = 1,46; IC95%: 1,28; 1,65). A exposição a riscos ocupacionais entre trabalhadores na Região Metropolitana de Manaus é alta, afetando trabalhadores informais e formais. Políticas brasileiras devem ser implementadas para reduzir os impactos sobre a qualidade de vida dos trabalhadores nessa região do país.

Resumen: El objetivo era investigar la asociación entre exposiciones ocupacionales y calidad de vida relacionada con la salud entre trabajadores formales e informales en la Amazonia Brasileña. Realizamos un estudio transversal con trabajadores adultos en la región metropolitana de Manaus, estado del Amazonas, en 2015. Los participantes fueron seleccionados a través de una muestra probabilística en tres pasos. El resultado primario fue la calidad de vida relacionada con la salud, medida por la versión brasileña validada de la herramienta European Quality of Life 5-Dimensions 3-Levels (EQ-5D-3L). Se realizó un análisis ajustado multivariado mediante la regresión Tobit y se consideró el diseño complejo de la muestra. Los resultados se convertieron en odds ratio (OR). De los 1.910 trabajadores procedentes de la muestra, un 60,2% fueron trabajadores formales. Los trabajadores informales estuvieron significativamente más expuestos a los riesgos ocupacionales que los trabajadores formales (p ≤ 0,05). La puntuación media de utilidad para los trabajadores informales y formales fue 0,886 (IC95%: 0,881; 0,890). La calidad de vida de los trabajadores informales estuvo negativamente impactada por la exposición al ruido (OR = 1,28; IC95%: 1,13; 1,52), estrés ocupacional (OR = 1,95; IC95%: 1,65; 2,21), y polvos industriales OR = 1,46; IC95%: 1,28; 1,72), mientras que los trabajadores formales estuvieron negativamente asociados con la exposición a sustancias químicas (OR = 1,58; IC95%: 1,28; 1,87), ruido (OR = 1,40; IC95%: 1,23; 1,65), sol (OR = 1,65; IC95%: 1,09; 1,40), estrés ocupacional (OR = 1,65; IC95%: 1,46; 1,87), material biológico (OR = 2,61; IC95%: 1,72; 3,97), y polvos industriales (OR = 1,46; IC95%: 1,28; 1,65). La exposición a riesgos ocupacionales entre trabajadores en la región metropolitana de Manaus es alta, afectando tanto a trabajadores informales como formales. Se necesitan imponer políticas brasileñas para reducir los impactos en la calidad de vida entre trabajadores en esta región.

Cost-Effectiveness Analysis of Influenza A (H1N1) Chemoprophylaxis in Brazil.

Background: Oseltamivir and zanamivir are recommended for treating and preventing influenza A (H1N1) worldwide. In Brazil, this official recommendation lacks an economic evaluation. Our objective was to assess the efficiency of influenza A chemoprophylaxis in the Brazilian context. Methods: We assessed the cost-effectiveness of oseltamivir and zanamivir for prophylaxis of influenza for high risk population, compared to no prophylaxis, in the perspective of Brazilian public health system. Quality-adjusted life years (QALY) and effectiveness data were based on literature review and costs in Brazilian real (BRL) were estimated from official sources and micro-costing of 2016's H1N1 admissions at a university hospital. We used a decision-tree model considering prophylaxis and no prophylaxis and the probabilities of H1N1, ambulatory care, admission to hospital, intensive care, patient discharge, and death. Adherence and adverse events from prophylaxis were included. Incremental cost-effectiveness ratio was converted to 2016 United States dollar (USD). Uncertainty was assessed with univariated and probabilistic sensitivity analysis. Results: Adherence to prophylaxis was 0.70 [95% confidence interval (CI) 0.54; 0.83]; adverse events, 0.09 (95% CI 0.02; 0.18); relative risk of H1N1 infection in chemoprophylaxis, 0.43 (95% CI 0.33; 0.57); incidence of H1N1, 0.14 (95% CI 0.11; 0.16); ambulatory care, 0.67 (95% CI 0.58; 0.75); hospital admission, 0.43 (CI 95% 0.39; 0.42); hospital mortality, 0.14 (CI 95% 0.12; 0.15); intensive care unit admission, 0.23 (95% CI 0.20; 0.27); and intensive care mortality, 0.40 (95% CI 0.29; 0.52). QALY in H1N1 state was 0.50 (95% CI 0.46; 0.53); in H1N1 inpatients, 0.23 (95% CI 0.18; 0.28); healthy, 0.885 (95% CI 0.879; 0.891); death, 0. Adverse events estimated to affect QALY in -0.185 (95% CI -0.290; -0.050). Cost for chemoprophylaxis was BRL 39.42 [standard deviation (SD) 17.94]; ambulatory care, BRL 12.47 (SD 5.21); hospital admission, BRL 5,727.59 (SD 7,758.28); intensive care admission, BRL 19,217.25 (SD 7,917.33); and adverse events, BRL 292.05 (SD 724.95). Incremental cost-effectiveness ratio was BRL -4,080.63 (USD -1,263.74)/QALY and -982.39 (USD -304.24)/H1N1 prevented. Results were robust to sensitivity analysis. Conclusion: Chemoprophylaxis of influenza A (H1N1) is cost-saving in Brazilian health system context.

Inequity in utilizing health services in the Brazilian Amazon: A population-based survey, 2015.

BACKGROUND: Although Brazil has a public and universal healthcare system, utilization of health services is marked by social and regional discrepancies. OBJECTIVE: To assess the prevalence and factors associated with underutilization of healthcare services in the Brazilian Amazon. METHOD: Cross-sectional, population-based study. Adults aged over 18 years old were selected through probabilistic sampling. Underutilization of healthcare services was defined as never seeing a physician or a dentist. Poisson regression with robust variance was performed to calculate prevalence ratios (PRs) and 95% confidence intervals (CIs). A complex sample design was considered. RESULTS: A total of 4001 individuals were included, of which 419 (10.4%; 95% CI, 9.5-11.4%) never visited a physician or a dentist. In the adjusted analysis, underutilization was higher among poorer people (PR = 3.32; 95% CI, 2.16-5.11), men (PR = 1.34; 95% CI, 1.10-1.65), people with brown skin color (Brazilian mixed race; PR = 1.34; 95% CI, 1.02-1.76), and people who are separated (PR = 1.40; 95% CI, 1.01-1.94) and widowed (PR = 1.55; 95% CI, 1.02-2.37), when compared with the reference categories. Individuals with informal jobs, those who are retired, students/housewives, and unemployed people were more vulnerable to underutilization than formal workers (P < .04). CONCLUSION: Underutilization of healthcare services occurs in one-tenth of adults in Manaus Metropolitan Region and is associated with social and economic inequities.

Use of health services by adults in Manaus, 2019: Protocol of a population-based survey.

INTRODUCTION: Health services utilization is an indirect measure of the rights and equity of a health system. A 2015 survey conducted in the Manaus metropolitan region showed that in the previous year, over 70% of adults visited the doctor and 1 in 3 had visited a dentist. Socioeconomic factors and inequality played a central role in the usage of healthcare services and health situation in this population. Since then, political and economic crisis are evolving in Brazil. This project aims to estimate the prevalence of use of health services and the health status of the adults residing in Manaus in 2019. METHODS AND ANALYSIS: This is a population-based survey of adults (≥18 years old) residing in Manaus. This survey will be conducted in the first half of 2019 with 2300 participants who will be interviewed at home, selected from a probabilistic sampling in 3 stages (census tracts, household, and dweller), and stratified by sex and age quotas based on official estimates. The participants will be interviewed using previously validated tools and questions employed in Brazilian official surveys, which will cover use of health services and supplies, health status, and lifestyle. Primary outcome will be any healthcare usage in the last 15 days. Associations between health services usage and socioeconomic data and health outcomes will be assessed using a Poisson regression with a complex sampling design correction. Results will be reported according to the strengthening the reporting of observational studies in epidemiology statement. ETHICS AND DISSEMINATION: This project was approved by the Ethics Committee of the Federal University of Amazonas, Manaus, Amazonas, Brazil. All participants will sign an informed consent before the interview. The results will be disseminated in peer-reviewed manuscripts, reports, conference presentations, and through the media.