Absolute income is a better predictor of coverage by skilled birth attendance than relative wealth quintiles in a multicountry analysis: comparison of 100 low- and middle-income countries.

BACKGROUND: Having high-quality data available by 2020, disaggregated by income, is one of the Sustainable Development Goals (SGD). We explored how well coverage with skilled birth attendance (SBA) is predicted by asset-based wealth quintiles and by absolute income. METHODS: We used data from 293 national surveys conducted in 100 low and middle-income countries (LMICs) from 1991 to 2014. Data on household income were computed using national income levels and income inequality data available from the World Bank and the Standardized World Income Inequality Database. Multivariate regression was used to explore the predictive capacity of absolute income compared to the traditional measure of quintiles of wealth index. RESULTS: The mean SBA coverage was 68.9% (SD: 24.2), compared to 64.7% (SD: 26.6) for institutional delivery coverage. Median daily family income in the same period was US$ 6.4 (IQR: 3.5-14.0). In cross-country analyses, log absolute income predicts 51.5% of the variability in SBA coverage compared to 22.0% predicted by the wealth index. For within-country analysis, use of absolute income improved the understanding of the gap in SBA coverage among the richest and poorest families. Information on income allowed identification of countries - such as Burkina Faso, Cambodia, Egypt, Nepal and Rwanda - which were well above what would be expected solely from changes in income. CONCLUSION: Absolute income is a better predictor of SBA and institutional delivery coverage than the relative measure of quintiles of wealth index and may help identify countries where increased coverage is likely due to interventions other than increased income.

[Coverage by health insurance or discount cards: a household survey in the coverage area of the Family Health Strategy]. / Cobertura por plano de saúde ou cartão de desconto: inquérito domiciliar na área de abrangência da Estratégia Saúde da Família.

This study was designed to assess the reasons for health insurance coverage in a population covered by the Family Health Strategy in Brazil. We describe overall health insurance coverage and according to types, and analyze its association with health-related and socio-demographic characteristics. Among the 31.3% of persons (95%CI: 23.8-39.9) who reported "health insurance" coverage, 57.0% (95%CI: 45.2-68.0) were covered only by discount cards, which do not offer any kind of coverage for medical care, but only discounts in pharmacies, clinics, and hospitals. Both for health insurance and discount cards, the most frequently cited reasons for such coverage were "to be on the safe side" and "to receive better care". Both types of coverage were associated statistically with age (+65 vs. 15-24 years: adjusted odds ratios, aOR = 2.98, 95%CI: 1.28-6.90; and aOR = 3.67; 95%CI: 2.22-6.07, respectively) and socioeconomic status (additional standard deviation: aOR = 2.25, 95%CI: 1.62-3.14; and aOR = 1.96, 95%CI: 1.34-2.97). In addition, health insurance coverage was associated with schooling (aOR = 7.59, 95%CI: 4.44-13.00) for complete University Education and aOR = 3.74 (95%CI: 1.61-8.68) for complete Secondary Education, compared to less than complete Primary Education. Meanwhile, neither health insurance nor discount card was associated with health status or number of diagnosed diseases. In conclusion, studies that aim to assess private health insurance should be planned to distinguish between discount cards and formal health insurance.

Resumo: Este estudo foi desenhado para avaliar a cobertura por plano de saúde e seus motivos em uma população coberta pela Estratégia Saúde da Família. Nesta análise, descrevemos a cobertura por plano de saúde, total e por tipos, e analisamos sua associação com características de saúde e sociodemográficas. Entre os 31,3% (IC95%: 23,8-39,9) de pessoas que relatavam cobertura por "plano de saúde", 57,0% (IC95%: 45,2-68,0) estavam cobertos por cartões de desconto, que não oferecem qualquer tipo de cobertura para assistência médica, apenas descontos em farmácias, clínicas e hospitais. Tanto no caso dos planos de saúde quanto no dos cartões de desconto, os motivos para cobertura mais frequentemente relatados foram "para a segurança" e "para ter melhor atendimento". Ambas as coberturas se associaram à idade (65+ versus 15-24 anos: odds ratio ajustada, ORa = 2,98; IC95%: 1,28-6,90; e ORa = 3,67; IC95%: 2,22-6,07, respectivamente) e ao nível econômico (desvio padrão adicional: ORa = 2,25; IC95%: 1,62-3,14; e ORa = 1,96; IC95%: 1,34-2,97). Além disso, a cobertura por plano de saúde se associou à escolaridade (ORa = 7,59; IC95%: 4,44-13,00) para Ensino Superior completo e ORa = 3,74 (IC95%: 1,61-8,68) para Ensino Médio completo, em comparação a menos do que o Ensino Fundamental completo. Por outro lado, nem a cobertura por plano de saúde nem a por cartão de desconto se mostraram associadas ao estado de saúde ou ao número de doenças diagnosticadas. Em conclusão, estudos que pretendam avaliar a cobertura por saúde suplementar deveriam ser planejados de forma a poderem distinguir entre cartões de desconto e planos de saúde formais.

Resumen: Este estudio se diseñó para evaluar la cobertura por seguro de salud y sus causas en una población cubierta por la Estrategia Salud de la Familia. En este análisis, describimos la cobertura por seguro de salud, total y por tipos, y analizamos su asociación con características de salud y sociodemográficas. Dentro del 31,3% (IC95%: 23,8-39,9) de personas que informaban contar con una cobertura por "seguro de salud" un 57,0% (IC95%: 45,2-68,0) estaban cubiertas por tarjetas de descuento, que no ofrecen cualquier tipo de cobertura para la asistencia médica, solamente descuentos en farmacias, clínicas y hospitales. Tanto en el caso de los seguros de salud, como en el de las tarjetas de descuento, los motivos de cobertura más frecuentemente relatados fueron "por seguridad" y "para tener una mejor atención". Ambas coberturas se asociaron a la edad (65+ versus 15-24 años: odds ratio ajustada, ORa = 2,98; IC95%: 1,28-6,90; y ORa = 3,67; IC95%: 2,22-6,07, respectivamente), y al nivel económico (desvío patrón adicional: ORa = 2,25; IC95%: 1,62-3,14; y ORa = 1,96; IC95%: 1,34-2,97). Además, la cobertura por seguro de salud se asoció a la escolaridad (ORa = 7,59; IC95%: 4,44-13,00) para la Enseñanza Superior completa y ORa = 3,74 (IC95%: 1,61-8,68) para el Nivel Medio completo, en comparación con los menores índices por la Enseñanza Fundamental completa. Por otro lado, ni la cobertura por seguro de salud, ni la por tarjeta de descuento, se mostraron asociadas al estado de salud o al número de enfermedades diagnosticadas. En conclusión, los estudios que pretendan evaluar la cobertura de seguro de salud privado se deberían planear de tal forma que puedan distinguir entre tarjetas de descuento y seguros de salud formales.

Cobertura por plano de saúde ou cartão de desconto: inquérito domiciliar na área de abrangência da Estratégia Saúde da Família / Coverage by health insurance or discount cards: a household survey in the coverage area of the Family Health Strategy / Cobertura por seguro de salud o tarjeta de descuento: encuesta domiciliaria en un área cubierta por la Estrategia Salud de la Familia

Resumo: Este estudo foi desenhado para avaliar a cobertura por plano de saúde e seus motivos em uma população coberta pela Estratégia Saúde da Família. Nesta análise, descrevemos a cobertura por plano de saúde, total e por tipos, e analisamos sua associação com características de saúde e sociodemográficas. Entre os 31,3% (IC95%: 23,8-39,9) de pessoas que relatavam cobertura por "plano de saúde", 57,0% (IC95%: 45,2-68,0) estavam cobertos por cartões de desconto, que não oferecem qualquer tipo de cobertura para assistência médica, apenas descontos em farmácias, clínicas e hospitais. Tanto no caso dos planos de saúde quanto no dos cartões de desconto, os motivos para cobertura mais frequentemente relatados foram "para a segurança" e "para ter melhor atendimento". Ambas as coberturas se associaram à idade (65+ versus 15-24 anos: odds ratio ajustada, ORa = 2,98; IC95%: 1,28-6,90; e ORa = 3,67; IC95%: 2,22-6,07, respectivamente) e ao nível econômico (desvio padrão adicional: ORa = 2,25; IC95%: 1,62-3,14; e ORa = 1,96; IC95%: 1,34-2,97). Além disso, a cobertura por plano de saúde se associou à escolaridade (ORa = 7,59; IC95%: 4,44-13,00) para Ensino Superior completo e ORa = 3,74 (IC95%: 1,61-8,68) para Ensino Médio completo, em comparação a menos do que o Ensino Fundamental completo. Por outro lado, nem a cobertura por plano de saúde nem a por cartão de desconto se mostraram associadas ao estado de saúde ou ao número de doenças diagnosticadas. Em conclusão, estudos que pretendam avaliar a cobertura por saúde suplementar deveriam ser planejados de forma a poderem distinguir entre cartões de desconto e planos de saúde formais.

Abstract: This study was designed to assess the reasons for health insurance coverage in a population covered by the Family Health Strategy in Brazil. We describe overall health insurance coverage and according to types, and analyze its association with health-related and socio-demographic characteristics. Among the 31.3% of persons (95%CI: 23.8-39.9) who reported "health insurance" coverage, 57.0% (95%CI: 45.2-68.0) were covered only by discount cards, which do not offer any kind of coverage for medical care, but only discounts in pharmacies, clinics, and hospitals. Both for health insurance and discount cards, the most frequently cited reasons for such coverage were "to be on the safe side" and "to receive better care". Both types of coverage were associated statistically with age (+65 vs. 15-24 years: adjusted odds ratios, aOR = 2.98, 95%CI: 1.28-6.90; and aOR = 3.67; 95%CI: 2.22-6.07, respectively) and socioeconomic status (additional standard deviation: aOR = 2.25, 95%CI: 1.62-3.14; and aOR = 1.96, 95%CI: 1.34-2.97). In addition, health insurance coverage was associated with schooling (aOR = 7.59, 95%CI: 4.44-13.00) for complete University Education and aOR = 3.74 (95%CI: 1.61-8.68) for complete Secondary Education, compared to less than complete Primary Education. Meanwhile, neither health insurance nor discount card was associated with health status or number of diagnosed diseases. In conclusion, studies that aim to assess private health insurance should be planned to distinguish between discount cards and formal health insurance.

Resumen: Este estudio se diseñó para evaluar la cobertura por seguro de salud y sus causas en una población cubierta por la Estrategia Salud de la Familia. En este análisis, describimos la cobertura por seguro de salud, total y por tipos, y analizamos su asociación con características de salud y sociodemográficas. Dentro del 31,3% (IC95%: 23,8-39,9) de personas que informaban contar con una cobertura por "seguro de salud" un 57,0% (IC95%: 45,2-68,0) estaban cubiertas por tarjetas de descuento, que no ofrecen cualquier tipo de cobertura para la asistencia médica, solamente descuentos en farmacias, clínicas y hospitales. Tanto en el caso de los seguros de salud, como en el de las tarjetas de descuento, los motivos de cobertura más frecuentemente relatados fueron "por seguridad" y "para tener una mejor atención". Ambas coberturas se asociaron a la edad (65+ versus 15-24 años: odds ratio ajustada, ORa = 2,98; IC95%: 1,28-6,90; y ORa = 3,67; IC95%: 2,22-6,07, respectivamente), y al nivel económico (desvío patrón adicional: ORa = 2,25; IC95%: 1,62-3,14; y ORa = 1,96; IC95%: 1,34-2,97). Además, la cobertura por seguro de salud se asoció a la escolaridad (ORa = 7,59; IC95%: 4,44-13,00) para la Enseñanza Superior completa y ORa = 3,74 (IC95%: 1,61-8,68) para el Nivel Medio completo, en comparación con los menores índices por la Enseñanza Fundamental completa. Por otro lado, ni la cobertura por seguro de salud, ni la por tarjeta de descuento, se mostraron asociadas al estado de salud o al número de enfermedades diagnosticadas. En conclusión, los estudios que pretendan evaluar la cobertura de seguro de salud privado se deberían planear de tal forma que puedan distinguir entre tarjetas de descuento y seguros de salud formales.

Socioeconomic inequalities in skilled birth attendance and child stunting in selected low and middle income countries: Wealth quintiles or deciles?

BACKGROUND: Wealth quintiles derived from household asset indices are routinely used for measuring socioeconomic inequalities in the health of women and children in low and middle-income countries. We explore whether the use of wealth deciles rather than quintiles may be advantageous. METHODS: We selected 46 countries with available national surveys carried out between 2003 and 2013 and with a sample size of at least 3000 children. The outcomes were prevalence of under-five stunting and delivery by a skilled birth attendant (SBA). Differences and ratios between extreme groups for deciles (D1 and D10) and quintiles (Q1 and Q5) were calculated, as well as two summary measures: the slope index of inequality (SII) and concentration index (CIX). RESULTS: In virtually all countries, stunting prevalence was highest among the poor, and there were larger differences between D1 and D10 than between Q1 and Q5. SBA coverage showed pro-rich patterns in all countries; in four countries the gap was greater than 80 pct points. With one exception, differences between extreme deciles were larger than between quintiles. Similar patterns emerged when using ratios instead of differences. The two summary measures provide very similar results for quintiles and deciles. Patterns of top or bottom inequality varied with national coverage levels. CONCLUSION: Researchers and policymakers should consider breakdowns by wealth deciles, when sample sizes allow. Use of deciles may contribute to advocacy efforts, monitoring inequalities over time, and targeting health interventions. Summary indices of inequalities were unaffected by the use of quintiles or deciles in their calculation.

Inequalities in the coverage of place of delivery and skilled birth attendance: analyses of cross-sectional surveys in 80 low and middle-income countries.

BACKGROUND: Having a health worker with midwifery skills present at delivery is one of the key interventions to reduce maternal and newborn mortality. We sought to estimate the frequencies of (a) skilled birth attendant coverage, (b) institutional delivery, and (c) the combination of place of delivery and type of attendant, in LMICs. METHODS: National surveys (DHS and MICS) performed in 80 LMICs since 2005 were analyzed to estimate these four categories of delivery care. Results were stratified by wealth quintile based on asset indices, and by urban/rural residence. The combination of place of delivery and type of attendant were also calculated for seven world regions. RESULTS: The proportion of institutional SBA deliveries was above 90 % in 25 of the 80 countries, and below 40 % in 11 countries. A strong positive correlation between SBA and institutional delivery coverage (rho: 0.97, p <0,001) was observed. Eight countries had over 10 % of home SBA deliveries, and two countries had over 10 % of institutional non-SBA deliveries. Except for South Asia, all regions had over 80 % of urban deliveries in the institutional SBA category, but in rural areas, only two regions (CEE & CIS, Middle East & North Africa) presented average coverage above 80 %. In all regions, institutional SBA deliveries were over 80 % in the richest quintile. Home SBA deliveries were more common in rural than in urban areas, and in the poorest quintiles in all regions. Facility non-SBA deliveries also tended to be more common in rural areas and among the poorest. CONCLUSION: Four different categories of delivery assistance were identified worldwide. Pro-urban and pro-rich inequalities were observed for coverage of institutional SBA deliveries.

Missed opportunities in full immunization coverage: findings from low- and lower-middle-income countries.

BACKGROUND: An estimated 23 million infants are still not being benefitted from routine immunization services. We assessed how many children failed to be fully immunized even though they or their mothers were in contact with health services to receive other interventions. DESIGN: Fourteen countries with Demographic and Health Surveys and Multiple Indicator Cluster Surveys carried out after 2000 and with coverage for DPT (Diphtheria-tetanus-pertussis) vaccine below 70% were selected. We defined full immunization coverage (FIC) as having received one dose of BCG (bacille Calmette-Guérin), one dose of measles, three doses of polio, and three doses of DPT vaccines. We tabulated FIC against: antenatal care (ANC), skilled birth attendance (SBA), postnatal care for the mother (PNC), vitamin A supplementation (VitA) for the child, and sleeping under an insecticide-treated bed-net (ITN). Missed opportunities were defined as the percentage of children who failed to be fully immunized among those receiving one or more other interventions. RESULTS: Children who received other health interventions were also more likely to be fully immunized. In nearly all countries, FIC was lowest among children born to mothers who failed to attend ANC, and highest when the mother had four or more ANC visits Côte d'Ivoire presented the largest difference in FIC: 54 percentage points (pp) between having four or more ANC visits and lack of ANC. SBA was also related with higher FIC. For instance, the coverage in children without SBA was 36 pp lower than for those with SBA in Nigeria. The largest absolute difference on FIC in relation to PNC was observed for Ethiopia: 31 pp between those without and with PNC. FIC was also positively related with having received VitA. The largest absolute difference was observed in DR Congo: 41 pp. The differences in FIC among whether or not children slept under ITN were much smaller than for other interventions. Haiti presented the largest absolute difference: 16 pp. CONCLUSIONS: Our results show the need to develop and implement strategies to vaccinate all children who contact health services in order to receive other interventions.

The double task of preventing malnutrition and overweight: a quasi-experimental community-based trial.

BACKGROUND: The Maternal-Child Pastoral is a volunteer-based community organization of the Dominican Republic that works with families to improve child survival and development. A program that promotes key practices of maternal and child care through meetings with pregnant women and home visits to promote child growth and development was designed and implemented. This study aims to evaluate the impact of the program on nutritional status indicators of children in the first two years of age. METHODS: A quasi-experimental design was used, with groups paired according to a socioeconomic index, comparing eight geographical areas of intervention with eight control areas. The intervention was carried out by lay health volunteers. Mothers in the intervention areas received home visits each month and participated in a group activity held biweekly during pregnancy and monthly after birth. The primary outcomes were length and body mass index for age. Statistical analyses were based on linear and logistic regression models. RESULTS: 196 children in the intervention group and 263 in the control group were evaluated. The intervention did not show statistically significant effects on length, but point estimates found were in the desired direction: mean difference 0.21 (95%CI -0.02; 0.44) for length-for-age Z-score and OR 0.50 (95%CI 0.22; 1.10) for stunting. Significant reductions of BMI-for-age Z-score (-0.31, 95%CI -0.49; -0.12) and of BMI-for-age > 85th percentile (0.43, 95%CI 0.23; 0.77) were observed. The intervention showed positive effects in some indicators of intermediary factors such as growth monitoring, health promotion activities, micronutrient supplementation, exclusive breastfeeding and complementary feeding. CONCLUSIONS: Despite finding effect measures pointing to effects in the desired direction related to malnutrition, we could only detect a reduction in the risk of overweight attributable to the intervention. The findings related to obesity prevention may be of interest in the context of the nutritional transition. Given the size of this study, the results are encouraging and we believe a larger study is warranted.

Flour fortification with iron has no impact on anaemia in urban Brazilian children.

OBJECTIVE: To verify the impact of flour fortification on anaemia in Brazilian children. The survey also investigated the role of Fe deficiency as a cause of anaemia and estimated the bioavailability of the Fe in the children's diet. This local study was complemented by a nationwide survey of the types of Fe compounds added to flour. DESIGN: Series of population-based surveys conducted in 2004 (baseline study), 2005, 2006 and 2008. SETTING: Pelotas, Rio Grande do Sul, Brazil. SUBJECTS: Children under 6 years of age residing in the urban area of the city of Pelotas, Southern Brazil (n 507 in 2004; n 960 in 2005; n 893 in 2006; n 799 in 2008). In 2008, a sub-sample of children (n 114) provided venous blood samples to measure body Fe reserve parameters (ferritin and transferrin saturation). RESULTS: We found no impact of fortification, with an increase in anaemia prevalence among children under 24 months of age. Hb levels decreased by 0.9 g/dl in this age group between 2004 and 2008 (10.9 g/dl to 10.0 g/dl; P < 0.001). Roughly 50 % of cases of anaemia were estimated to be due to Fe deficiency. Half of the mills surveyed used reduced Fe to fortify wheat flour. Total Fe intake from all foodstuffs was adequate for 88.6 % of the children, but its bioavailability was only 5 %. CONCLUSIONS: The low bioavailability of the Fe compounds added to flours, combined with the poor quality of children's diets, account for the lack of impact of mandatory fortification.

Avaliação das necessidades de tratamento odontológico e da capacidade produtiva da rede de atenção básica em saúde bucal no município de Pelotas, estado do Rio Grande do Sul, Brasil, 2009 / Assessment of dental treatment needs and productive capacity of primary dental care in the municipality of Pelotas, state of Rio Grande do Sul, Brazil, 2009

Objetivo: descrever as necessidades de tratamento odontológico da população e a capacidade produtiva da atenção básica no município de Pelotas, Rio Grande do Sul. Métodos: foram utilizados dados do inquérito de saúde bucal de 2003 para estimar indicadores de necessidade de restaurações, extrações e tratamento periodontal entre indivíduos com 15 anos ou mais de idade, segundo faixa etária e renda. O potencial produtivo foi estimado a partir dos dados do Sistema de Informações Ambulatoriais (SIA/SUS). Resultados: mais de 234 mil indivíduos tinham necessidade de tratamento, incluindo 274.085 elementos dentários necessitando de restauração, 107.659 de extração, 282.986 sextantes necessitando remoção de cálculo e 17.803 de tratamento periodontal. Assim, seriam necessárias mais de 680 mil consultas clínicas, em grande desproporção com a produção ambulatorial do município no ano de 2008, de 47.179 procedimentos. Conclusão: o potencial produtivo do serviço odontológico era deficitário para atender a todas as necessidades da população.

Objective: to describe dental treatment requirements and productive capacity of primary health care in the municipality of Pelotas, Brazil. Methods: This study used data from the 2003 National Oral Health Survey to estimate the indicators of individuals 15 years or above, that needed restorations in the teeth, extractions, and periodontal treatment, by age and income. The productive potential of the city was estimated using data from the Ambulatory Care Information System/National Health System. Results: over 234,000 individuals showed a need of dental treatment; 274,085 needed teeth restoration; 107,659 needed extraction; 282,986 sextants with needs of calculus removal; and 17,803 needed periodontal treatment. The 680,000 dental visits that were necessary are hugely disproportional compared with the 47,179 procedures performed in the municipality in 2008. Conclusion: productive capacity of the public oral health care in Pelotas-RS was far from being sufficient to cater to all the needs of the population.

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.

Efeito da fortificação de farinhas com ferro sobre anemia em pré-escolares, Pelotas, RS / Effect of iron fortification of flour on anemia in preschool children in Pelotas, Brazil

OBJETIVO: A fortificação de farinhas com ferro foi estabelecida por lei no Brasil, em 2004. O objetivo do estudo foi avaliar o impacto da fortificação sobre nível de hemoglobina em crianças menores de seis anos. MÉTODOS: O estudo foi realizado em Pelotas, RS, sendo uma série temporal com três avaliações a cada 12 meses. Em maio de 2004, antes da fortificação das farinhas, foram medidos níveis de hemoglobina em amostra probabilística de 453 crianças. Após 12 e 24 meses, foram estudadas amostras de 923 e 863 crianças, respectivamente. RESULTADOS: Os três grupos estudados foram comparáveis em relação a características demográficas e socioeconômicas. No estudo de linha de base, as médias de hemoglobina foram 11,3±2,8 g/dL. Após a fortificação esses valores foram 11,2±2,8 (12 meses) e 11,3±2,5 g/dL (24 meses), não havendo diferença estatisticamente significativa entre os três momentos estudados (p=0,16). CONCLUSÕES: Nenhum efeito da fortificação foi observado nos níveis de hemoglobina das crianças estudadas, o que pode ser parcialmente explicado pelo consumo insuficiente de farinhas e/ou pela baixa biodisponibilidade do ferro adicionado.

OBJECTIVE: Iron fortification of flour has been sanctioned by the Brazilian government since 2004. The objective of the study was to assess the impact of flour fortification on hemoglobin level in children under six. METHODS: A time-series study was carried out in Pelotas, southern Brazil, consisting of three assessments at a 12-month interval. In May 2004, before flour fortification, hemoglobin measurements were obtained in a probabilistic sample of 453 children. Twelve and 24 months later, samples of 923 and 863 children were studied, respectively. RESULTS: The three groups studied were comparable in terms of demographic and socioeconomic characteristics. At baseline, mean hemoglobin was 11.3±2.8 g/dL. In the post-fortification period, means were 11.2±2.8 (at 12 months) and 11.3±2.5 g/dL (at 24 months), with no statistically significant difference among the three time periods studied (p=0.16). CONCLUSIONS: Fortification had no effect on hemoglobin levels of the children studied. This finding could be partially due to inadequate flour intake and/or low bioavailability of dietary iron.

[Effect of iron fortification of flour on anemia in preschool children in Pelotas, Brazil]. / Efeito da fortificação de farinhas com ferro sobre anemia em pré-escolares, Pelotas, RS.

OBJECTIVE: Iron fortification of flour has been sanctioned by the Brazilian government since 2004. The objective of the study was to assess the impact of flour fortification on hemoglobin level in children under six. METHODS: A time-series study was carried out in Pelotas, southern Brazil, consisting of three assessments at a 12-month interval. In May 2004, before flour fortification, hemoglobin measurements were obtained in a probabilistic sample of 453 children. Twelve and 24 months later, samples of 923 and 863 children were studied, respectively. RESULTS: The three groups studied were comparable in terms of demographic and socioeconomic characteristics. At baseline, mean hemoglobin was 11.3 +/- 2.8 g/dL. In the post-fortification period, means were 11.2 +/- 2.8 (at 12 months) and 11.3 +/- 2.5 g/dL (at 24 months), with no statistically significant difference among the three time periods studied (p=0.16). CONCLUSIONS: Fortification had no effect on hemoglobin levels of the children studied. This finding could be partially due to inadequate flour intake and/or low bioavailability of dietary iron.

Effect of maternal calcium intake during pregnancy on children's blood pressure: a systematic review of the literature.

BACKGROUND: Calcium supplementation during pregnancy has been shown to reduce the incidence of hypertension in the mother, but the effects on the offspring are uncertain. Assessing the impact on the offspring is very important given the now large body of evidence indicating that blood pressure levels in childhood and young adulthood can be influenced by factors operating during fetal life. We conducted a systematic review of the literature to summarize the evidence supporting an association between maternal dietary calcium intake during pregnancy and blood pressure in the offspring. METHODS: A systematic review was performed to identify randomized, quasi-randomized and cohort studies reporting the relationship between offspring blood pressure or incidence of hypertension and levels of maternal dietary calcium intake during pregnancy, either from supplements (i.e. pills) or food. MEDLINE, EMBASE and the Cochrane Library Registry were searched for relevant trials. RESULTS: Two randomized trial and three observational studies were identified and included in this review. In 4 of the 5 studies, loss to follow-up was a serious concern. There was heterogeneity between the studies, particularly those conducted on children below 12 month of age. Results were more consistent among the studies including older children (1 to 9 years) where a higher maternal calcium intake was associated with a reduction of -1.92 mm Hg (95% CI -3.14 to -0.71) in offspring systolic blood pressure. One large randomized trial found a clinically and statistically significant reduction in the incidence of hypertension in 7-year-old children (RR = 0.59, 95% CI 0.39 to 0.90). CONCLUSION: There is evidence in the literature to support an association between maternal calcium intake during pregnancy and offspring blood pressure. However, more research is needed to confirm these finding given the small sample sizes and the methodological problems in many of the studies conducted so far. More studies on populations with calcium deficit are also needed. If confirmed, these findings could have important public health implications. Calcium supplementation during pregnancy is simple and inexpensive and may be a way to reduce the risk of hypertension and its sequels in the next generation.

[A nationwide wealth score based on the 2000 Brazilian demographic census]. / Indicador econômico para o Brasil baseado no censo demográfico de 2000.

OBJECTIVE: To propose an asset based indicator of wealth for Brazil using variables present in the demographic census. METHODS: The indicator, named IEN (Indicador Econômico Nacional/ National Wealth Score), was developed using 12 assets and the schooling of the household head, through principal component analysis. Data from the 2000 Brazilian Demographic sample was used for deriving the score and for the calculation of decile cut-off points. RESULTS: The indicator, first component obtained from the analysis with the 13 variables, retained 38% of the total variability, and presented a Spearman correlation of 0,74 with total family income and of 0,67 with per capita income. The necessary scores to calculate the indicator are presented, as well as reference distributions for the 27 states and their capitals, the five major regions as for the whole country. An example of use of indicator is presented. CONCLUSIONS: Differently from other economic indicators, the Indicador Econômico Nacional has local reference distributions available, along with the national distribution. It is therefore possible to compare a study sample to the municipal, state or country distribution. The small number of variables allow investigators to calculate the Indicador Econômico Nacional in research studies where economic classification is of interest.

Inequalities in health in Latin America and the Caribbean: descriptive and exploratory results for self-reported health problems and health care in twelve countries

Objective: To explore and describe inequalities in health and use of health care as revealed by self-report in 12 countries of Latin America and the Caribbean. Methods: A descriptive and exploratory study was performed based on the responses to questions on health and health care utilization that were included in general purpose household surveys. Inequalities are described by quintile of household expenditures (or income) per capita, sex, age group (children, adults, and older adults), and place of residence (urban vs. rural area). For those who sought health care, median polishing was performed by economic status and sex, for the three age groups. Results: Although the study is exploratory and descriptive, its findings show large economic gradients in health care utilization in these countries, with generally small difference between males and females and higher percentages of women seeking health care than men, although there were some exceptions among the lower economic strata in urban areas. Conclusions: Inequalities in self-reported health problems among the different economic strata were small, and such problems were usually more common among women than men. The presence of small inequalities may be due to cultural and social differences in the perception of health. However, in most countries included in the study, large inequalities were found in the use of health care for the self-reported health problems. It is important to develop regional projects aimed at improving the questions on self-reported health in household interview surveys so that the determinants of the inequalities in health can be studied in depth. The authors conclude that due to the different patterns of economic gradients among different age groups, and among males and females, the practice of standardization used in constructing concentration curves and in computing concentration indices should be avoided. At the end is a set of recommendations on how to improve these sources of data. Despite their shortcomings, household interview surveys are very useful in understanding the dimensions of health inequalities in these countries (AU)