Does pay-for-performance design matter? Evidence from Brazil.

Pay-for-performance (P4P) schemes have been shown to have mixed effects on health care outcomes. A challenge in interpreting this evidence is that P4P is often considered a homogenous intervention, when in practice schemes vary widely in their design. Our study contributes to this literature by providing a detailed depiction of incentive design across municipalities within a national P4P scheme in Brazil [Primary Care Access and Quality (PMAQ)] and exploring the association of alternative design typologies with the performance of primary health care providers. We carried out a nation-wide survey of municipal health managers to characterize the scheme design, based on the size of the bonus, the providers incentivized and the frequency of payment. Using OLS regressions and controlling for municipality characteristics, we examined whether each design feature was associated with better family health team (FHT) performance. To capture potential interactions between design features, we used cluster analysis to group municipalities into five design typologies and then examined associations with quality of care. A majority of the municipalities included in our study used some of the PMAQ funds to provide bonuses to FHT workers, while the remaining municipalities spent the funds in the traditional way using input-based budgets. Frequent bonus payments (monthly) and higher size bonus allocations (share of 20-80%) were strongly associated with better team performance, while who within a team was eligible to receive bonuses did not in isolation appear to influence performance. The cluster analysis showed what combinations of design features were associated with better performance. The PMAQ score in the 'large bonus/many workers/high-frequency' cluster was 8.44 points higher than the 'no bonus' cluster, equivalent to a difference of 21.7% in the mean PMAQ score. Evidence from our study shows how design features can potentially influence health provider performance, informing the design of more effective P4P schemes.

Factors associated with bariatric surgery rates in federative units in Brazil.

OBJECTIVE: To analyze the socioeconomic, demographic and health management factors associated with bariatric surgery rates performed by the Brazilian Unified Health System (SUS) in the federative units in Brazil. METHODS: Description and analysis of bariatric surgeries rates (per 100,000 inhabitants) performed by SUS in adults from 18 to 65 years old, in the 27 federative units of Brazil, between 2008 and 2018; thus, the econometric methodology of count panel with negative binomial distribution (population-averaged, fixed effects and random effects) was used. Socioeconomic and demographic factors were also investigated, considering the real gross domestic product per capita, the average years of study of adults and life expectancy at birth, and those of health management, given the primary health care coverage, the rate of digestive system surgeons and the rate of hospitals accredited in high complexity care to patients with obesity in the SUS. RESULTS: In regional terms, the performance of public bariatric surgeries in Brazil over the period analyzed suffered a great disparity; the procedures happen mostly in the South and Southeast regions, and scarcely in the North region. Moreover, we found a positive relationship between the rate of bariatric surgeries and life expectancy, the rate of digestive system surgeons and the rate of hospitals accredited in high complexity care; however, the average number of years of adult study and coverage of primary health care is a negative association regarding real gross domestic product per capita. CONCLUSION: In the period analyzed, the investigated factors explained the rate of bariatric surgeries. Therefore, to train specialized health professionals, the accreditation of hospitals according to the legal framework, preventive actions of primary care, and socioeconomic and demographic factors, conditioning for the offer of surgical treatment by the SUS were crucial. Thus, these are all relevant factors for the formulation of public policies in this area.

Performance bonuses and the quality of primary health care delivered by family health teams in Brazil: A difference-in-differences analysis.

BACKGROUND: Pay-for-performance (P4P) programmes to incentivise health providers to improve quality of care have been widely implemented globally. Despite intuitive appeal, evidence on the effectiveness of P4P is mixed, potentially due to differences in how schemes are designed. We exploited municipality variation in the design features of Brazil's National Programme for Improving Primary Care Access and Quality (PMAQ) to examine whether performance bonuses given to family health team workers were associated with changes in the quality of care and whether the size of bonus mattered. METHODS AND FINDINGS: For this quasi-experimental study, we used a difference-in-differences approach combined with matching. We compared changes over time in the quality of care delivered by family health teams between (bonus) municipalities that chose to use some or all of the PMAQ money to provide performance-related bonuses to team workers with (nonbonus) municipalities that invested the funds using traditional input-based budgets. The primary outcome was the PMAQ score, a quality of care index on a scale of 0 to 100, based on several hundred indicators (ranging from 598 to 660) of health care delivery. We did one-to-one matching of bonus municipalities to nonbonus municipalities based on baseline demographic and economic characteristics. On the matched sample, we used ordinary least squares regression to estimate the association of any bonus and size of bonus with the prepost change over time (between November 2011 and October 2015) in the PMAQ score. We performed subgroup analyses with respect to the local area income of the family health team. The matched analytical sample comprised 2,346 municipalities (1,173 nonbonus municipalities; 1,173 bonus municipalities), containing 10,275 family health teams that participated in PMAQ from the outset. Bonus municipalities were associated with a 4.6 (95% CI: 2.7 to 6.4; p < 0.001) percentage point increase in the PMAQ score compared with nonbonus municipalities. The association with quality of care increased with the size of bonus: the largest bonus group saw an improvement of 8.2 percentage points (95% CI: 6.2 to 10.2; p < 0.001) compared with the control. The subgroup analysis showed that the observed improvement in performance was most pronounced in the poorest two-fifths of localities. The limitations of the study include the potential for bias from unmeasured time-varying confounding and the fact that the PMAQ score has not been validated as a measure of quality of care. CONCLUSIONS: Performance bonuses to family health team workers compared with traditional input-based budgets were associated with an improvement in the quality of care.

The disruption of elective procedures due to COVID-19 in Brazil in 2020.

Elective procedures were temporarily suspended several times over the course of the pandemic of COVID-19. Monthly data from the Unified Health System (SUS) were used for the period between January 2008 and December 2020 and the interrupted time series method was used to estimate the effect of the pandemic on the number of elective surgeries and elective procedures that were not performed. Considering a 9-month period, a reduction of 46% in the number of elective procedures carried out in the SUS could be attributed to COVID-19, corresponding to about 828,429 elective procedures cancelled, ranging from 549,921 to 1,106,936. To a full recovery of pre-pandemic performance, SUS would need to increase about 21,362 hospital beds, ranging from 12,370 to 36,392 hospital beds during a 6 month-period. This effort would represent an increase of 8.48% (ranging from 4.91 to 14.45%) in relation to the total number of SUS's hospital beds in 2019. As a result, the pandemic will leave a large number of elective procedures to be carried out, which will require efforts by health agencies to meet this demand.

Association of the new zero-tolerance drinking and driving law with hospitalization rate due to road traffic injuries in Brazil.

We investigated the association of the new zero-tolerance drinking and driving law (Law 12,760, Dec. 2012) with hospital admissions due to road traffic injuries in Brazil by using interrupted time series from 2008 to 2019. We used linear regression designed to adjust for autocorrelation and Cumby-Huizinga test for residual autocorrelation. Newey-West standard errors was used to handle heteroscedasticity. We used ICD-10 codes for land transport accidents (V01-V89). The hospitalization rate was calculated per 100,000 inhabitants. The sources were the Hospital Information System and the Brazilian Institute for Geography and Statistics. Pre- and postintervention consist of 59 and 85 months, respectively. For Brazil, the hospitalization rate was associated with a reduction of 0.34 (p = 0.097; 95% CI - 0.74 to 0.06) in the first month of the intervention (Dec. 2012), followed by a significant change in the hospitalization trend. Compared to the period prior to the intervention, the monthly trend was associated with a reduction of 0.05 (p < 0.01; 95% CI - 0.06 to - 0.04) in the post period. These results stand in agreement with subgroup analyses for the Brazilian regions, although North and Northeast regions did not immediately reduce hospitalization rates (level change). Our results suggested that 440,599 hospitalizations for land transport accidents would be averted by the new zero-tolerance drinking and driving law from Dec. 2012 to Dec. 2019 in Brazil. Even using a quasi-experimental approach, our findings must be interpreted with caution due to observational design and registration flaws surrounding our data.

Factors associated with bariatric surgery rates in federative units in Brazil / Fatores associados às taxas de cirurgias bariátricas nas Unidades Federativas do Brasil

ABSTRACT OBJECTIVE To analyze the socioeconomic, demographic and health management factors associated with bariatric surgery rates performed by the Brazilian Unified Health System (SUS) in the federative units in Brazil. METHODS Description and analysis of bariatric surgeries rates (per 100,000 inhabitants) performed by SUS in adults from 18 to 65 years old, in the 27 federative units of Brazil, between 2008 and 2018; thus, the econometric methodology of count panel with negative binomial distribution (population-averaged, fixed effects and random effects) was used. Socioeconomic and demographic factors were also investigated, considering the real gross domestic product per capita, the average years of study of adults and life expectancy at birth, and those of health management, given the primary health care coverage, the rate of digestive system surgeons and the rate of hospitals accredited in high complexity care to patients with obesity in the SUS. RESULTS In regional terms, the performance of public bariatric surgeries in Brazil over the period analyzed suffered a great disparity; the procedures happen mostly in the South and Southeast regions, and scarcely in the North region. Moreover, we found a positive relationship between the rate of bariatric surgeries and life expectancy, the rate of digestive system surgeons and the rate of hospitals accredited in high complexity care; however, the average number of years of adult study and coverage of primary health care is a negative association regarding real gross domestic product per capita. CONCLUSION In the period analyzed, the investigated factors explained the rate of bariatric surgeries. Therefore, to train specialized health professionals, the accreditation of hospitals according to the legal framework, preventive actions of primary care, and socioeconomic and demographic factors, conditioning for the offer of surgical treatment by the SUS were crucial. Thus, these are all relevant factors for the formulation of public policies in this area.

RESUMO OBJETIVO Analisar os fatores socioeconômicos, demográficos e de gestão em saúde associados às taxas de cirurgias bariátricas realizadas pelo Sistema Único de Saúde (SUS) nas unidades federativas (UF) do Brasil. MÉTODOS Descrição e análise da taxa de cirurgias bariátricas (por 100 mil habitantes) realizadas pelo SUS em adultos de 18 a 65 anos, nas 27 unidades federativas do Brasil, entre 2008 e 2018; para isso, utilizou-se a metodologia econométrica de painel de contagem com distribuição binomial negativa (population-averaged, efeitos fixos e efeitos aleatórios). Investigou-se, também, os fatores socioeconômicos e demográficos, considerando o produto interno bruto (PIB) real per capita, a média de anos de estudo de adultos e a expectativa de vida ao nascer, e os da gestão em saúde, tendo em vista a cobertura da atenção básica, a taxa de cirurgiões de aparelho digestivo e a taxa de hospitais credenciados na assistência de alta complexidade (AAC) ao indivíduo obeso no SUS. RESULTADOS Em termos regionais, verificou-se grande disparidade na realização de cirurgias bariátricas públicas no Brasil ao longo do período analisado: os procedimentos estão concentrados nas regiões Sul e Sudeste, sendo escassos na região Norte. Além disso, encontrou-se uma relação positiva entre a taxa de cirurgias bariátricas e a expectativa de vida, a taxa de cirurgiões de aparelho digestivo e a taxa de hospitais credenciados na assistência de alta complexidade; havendo, porém, uma associação negativa em relação ao PIB real per capita, a média de anos de estudo de adultos e a cobertura da atenção básica. CONCLUSÕES No período analisado, o índice de cirurgias bariátricas foi explicado pelos fatores investigados. Portanto, mostrou-se de fundamental importância a formação de profissionais de saúde especializados, o credenciamento de hospitais conforme o marco legal, as ações preventivas da atenção básica, e os fatores socioeconômicos e demográficos, condicionantes da oferta do tratamento cirúrgico pelo Sistema Único de Saúde. Sendo assim, todos fatores relevantes para a formulação de políticas públicas nessa área.

Relação entre saúde mental e uso de substâncias psicoativas em escolares / Relationship between mental health and use of psychoactive substances in students / Relación entre salud mental y consumo de sustancias psicoactivas en escolares

Resumo A adolescência é uma fase do desenvolvimento de grande exposição e vulnerabilidade a comportamentos de risco, como os relacionados às substâncias psicoativas. Devido ao elevado número de usuários e a experimentação precoce dessas substâncias, há um interesse crescente em identificar os fatores de risco e mecanismos subjacentes associados a esse comportamento. Nesse sentido, o presente artigo busca analisar a relação entre o estado de saúde mental e a experimentação e frequência do uso de drogas lícitas (álcool e tabaco) em escolares. Foram consideradas três variáveis de saúde mental: insônia, solidão e ausência de amigos. Com base nos dados da Pesquisa Nacional de Saúde do Escolar (PeNSE) de 2015, o modelo de regressão logit ordenado foi estimado. As características individuais, o contexto familiar e a região de residência foram incluídas no modelo como covariáveis. Observou-se uma menor probabilidade de nunca ter experimentado substâncias psicoativas, tanto álcool quanto cigarro, em escolares que se sentem sozinhos e apresentam dificuldades para dormir. Além disso, solidão e insônia foram relacionadas com maior frequência ao uso dessas substâncias. Tais resultados fornecem evidências da importância de integrar a saúde mental às políticas públicas e práticas educativas de prevenção e redução do uso de substâncias psicoativas na adolescência.

Abstract Adolescence is a developmental stage of great exposure and vulnerability to risk behaviors, such as those related to psychoactive substances. Given the high number of users and early experimentation of these substances, there is a growing interest in identifying the risk factors and underlying mechanisms associated with this behavior. In this regard, this work aims to analyze the relationship between mental health status and the experimentation and frequency of legal drug use (alcohol and tobacco) among students. We included three variables of mental health, insomnia, loneliness and lack of friends. Using data from the 2015 National Adolescent School-based Health Survey (PeNSE), the ordered logit regression model was estimated. Individual characteristics, family context and region were included in the model as covariates. It was observed that students who feel alone and have sleep issues are less likely to have never used psychoactive substances, both alcohol and cigarettes. Furthermore, loneliness and insomnia were associated with higher frequency of substance use. These findings provide evidence of the importance of integrating mental health into public policies and school-based interventions to prevent and reduce the use of substances among adolescents.

Resumen La adolescencia es una etapa del desarrollo de gran exposición y vulnerabilidad a conductas de riesgo, como las relacionadas con las sustancias psicoactivas. Debido al elevado número de consumidores y a la temprana experimentación con estas sustancias, hay un creciente interés por identificar los factores de riesgo y los mecanismos subyacentes asociados a esta conducta. En ese sentido, este artículo busca analizar la relación entre el estado de la salud mental y la experimentación y la frecuencia de uso de drogas legales (alcohol y tabaco) en escolares. Para ello se consideraron tres variables de salud mental: insomnio, soledad y ausencia de amistades. Con base en datos de la Encuesta Nacional de Salud Escolar (PeNSE) de 2015, se estimó el modelo de regresión logit ordenado. Las características individuales, el contexto familiar y la región se incluyeron en el modelo como covariables. Se observó una menor probabilidad de no haber probado nunca sustancias psicoactivas legales (alcohol o cigarrillos) en escolares que se sienten solos y tienen dificultades para dormir. Además, la soledad y el insomnio se asociaron con una mayor frecuencia de uso de drogas. Estos resultados evidencian la importancia de integrar la salud mental en las políticas públicas y las prácticas educativas para prevenir y reducir el consumo de sustancias psicoactivas en la adolescencia.

Pay for performance in primary care: the contribution of the Programme for Improving Access and Quality of Primary Care (PMAQ) on avoidable hospitalisations in Brazil, 2009-2018.

BACKGROUND: Evidence on the effect of pay-for-performance (P4P) schemes on provider performance is mixed in low-income and middle-income countries. Brazil introduced its first national-level P4P scheme in 2011 (PMAQ-Brazilian National Programme for Improving Primary Care Access and Quality). PMAQ is likely one of the largest P4P schemes in the world. We estimate the association between PMAQ and hospitalisations for ambulatory care sensitive conditions (ACSCs) based on a panel of 5564 municipalities. METHODS: We conducted a fixed effect panel data analysis over the period of 2009-2018, controlling for coverage of primary healthcare, hospital beds per 10 000 population, education, real gross domestic product per capita and population density. The outcome is the hospitalisation rate for ACSCs among people aged 64 years and under per 10 000 population. Our exposure variable is defined as the percentage of family health teams participating in PMAQ, which captures the roll-out of PMAQ over time. We also provided several sensitivity analyses, by using alternative measures of the exposure and outcome variables, and a placebo test using transport accident hospitalisations instead of ACSCs. RESULTS: The results show a negative and statistically significant association between the rollout of PMAQ and ACSC rates for all age groups. An increase in PMAQ participating of one percentage point decreased the hospitalisation rate for ACSC by 0.0356 (SE 0.0123, p=0.004) per 10 000 population (aged 0-64 years). This corresponds to a reduction of approximately 60 829 hospitalisations in 2018. The impact is stronger for children under 5 years (-0.0940, SE 0.0375, p=0.012), representing a reduction of around 11 936 hospitalisations. Our placebo test shows that the association of PMAQ on the hospitalisation rate for transport accidents is not statistically significant, as expected. CONCLUSION: We find that PMAQ was associated with a modest reduction in hospitalisation for ACSCs.

Effect of More Doctors (Mais Médicos) Program on geographic distribution of primary care physicians.

This study assesses the effect of More Doctors Program (Programa Mais Médicos - PMM) on the equality in the distribution of primary care physicians (PCPs) in Brazil. Spatial data analysis, Lorenz curve and Gini coefficient were used to evaluate the geographic distribution of PCPs before and after the implementation of PMM (2012 and 2016). Data from 5,564 municipalities were used in the analyses. The results indicate that the distribution of PCPs has become more equal after PMM implementation. Between 2012 and 2016, overall Gini coefficient decreased by 11% from 0.255 to 0.227. At the state level, a statistically significant trend towards a more equal distribution of PCPs was found in 21 out of 26 Brazilian states. However, there still remains a substantial difference in the level of equality in PCP distribution, especially across states, with Gini coefficient ranging from 0.093 to 0.341 in 2016.

Effect of More Doctors (Mais Médicos) Program on geographic distribution of primary care physicians / Efeito do Programa Mais Médicos na distribuição geográfica dos médicos na atenção básica

Abstract This study assesses the effect of More Doctors Program (Programa Mais Médicos - PMM) on the equality in the distribution of primary care physicians (PCPs) in Brazil. Spatial data analysis, Lorenz curve and Gini coefficient were used to evaluate the geographic distribution of PCPs before and after the implementation of PMM (2012 and 2016). Data from 5,564 municipalities were used in the analyses. The results indicate that the distribution of PCPs has become more equal after PMM implementation. Between 2012 and 2016, overall Gini coefficient decreased by 11% from 0.255 to 0.227. At the state level, a statistically significant trend towards a more equal distribution of PCPs was found in 21 out of 26 Brazilian states. However, there still remains a substantial difference in the level of equality in PCP distribution, especially across states, with Gini coefficient ranging from 0.093 to 0.341 in 2016.

Resumo Este artigo avalia o efeito do Programa Mais Médicos (PMM) na distribuição de médicos na atenção básica no Brasil. As técnicas de análise de dados espaciais, curva de Lorenz e coeficiente de Gini foram empregadas para avaliar a distribuição geográfica dos médicos antes e após a implementação do PMM (2012 e 2016). Para tanto, foram utilizados dados secundários de 5.564 municípios. Os resultados indicaram que a distribuição de médicos se tornou mais igualitária após a implementação do PMM. Entre 2012 e 2016, o coeficiente geral de Gini diminuiu 11%, passando de 0,255 para 0,227. No âmbito estadual, uma tendência estatisticamente significativa em direção a uma distribuição mais igualitária de médicos foi encontrada em 21 estados brasileiros. No entanto, ainda persiste uma diferença substancial na distribuição de médicos na atenção básica, especialmente entre os estados, com o coeficiente de Gini variando de 0,093 a 0,341 em 2016.

Delivering maternal and childcare at primary healthcare level: The role of PMAQ as a pay for performance strategy in Brazil.

BACKGROUND: Improving access and quality in health care is a pressing issue worldwide and pay for performance (P4P) strategies have emerged as an alternative to enhance structure, process and outcomes in health. In 2011, Brazil adopted its first P4P scheme at national level, the National Programme for Improving Primary Care Access and Quality (PMAQ). The contribution of PMAQ in achieving the Sustainable Development Goals related to maternal and childcare remains under investigated in Brazil. OBJECTIVE: To estimate the association of PMAQ with the provision of maternal and childcare in Brazil, controlling for socioeconomic, geographic and family health team characteristics. METHOD: We used cross-sectional quantile regression (QR) models for two periods, corresponding to 33,368 Family Health Teams (FHTs) in the first cycle and 39,211 FHTs in the second cycle of PMAQ. FHTs were analysed using data from the Brazilian Ministry of Health (SIAB and CNES) and the Brazilian Institute for Geography and Statistics (IBGE). RESULTS: The average number of antenatal consultations per month were positively associated with PMAQ participating teams, with larger effect in the lower tail (10th and 25th quantiles) of the conditional distribution of the response variable. There was a positive association between PMAQ and the average number of consultations under 2 years old per month in the 10th and 25th quantiles, but a negative association in the upper tail (75th and 90th quantiles). For the average number of physician consultations for children under 1 year old per month, PMAQ participating teams were positively associated with the response variable in the lower tail, but different from the previous models, there is no clear evidence that the second cycle gives larger coefficients compared with first cycle. CONCLUSION: PMAQ has contributed to increase the provision of care to pregnant women and children under 2 years at primary healthcare level. Teams with lower average number of antenatal or child consultations benefited the most by participating in PMAQ, which suggests that PMAQ might motivate worse performing health providers to catch up.

[Association of victimization from bullying with body mass index in schoolchildren]. / Associação entre vitimização por bullying e índice de massa corporal em escolares.

Many schoolchildren report bullying by their classmates because of their physical appearance. Teenagers' body weight is one of the main reasons for this victimization. The current study aims to investigate the association between victimization from bullying and body mass index (BMI) in Brazilian schoolchildren. This was a cross-sectional study using data from the Brazilian National School Health Survey (PeNSE) in 2015 for students from 11 to 15 years of age. The analysis used the Probit model. The probability of victimization from bullying was 46% in Brazilian schoolchildren in this age bracket. There was a significant non-linear association between BMI and bullying. Both underweight and overweight/obese schoolchildren were more likely to suffer bullying, compared to their peers with adequate weight for age. The association was found in both sexes, and the U-shaped curve was more accentuated in girls. Risk factors included feeling misunderstood by parents, dissatisfaction with one's own body, and enrollment in public schools. Living with the mother, mother's schooling, and a proxy for family income were neither risk factors nor protective factors for bullying. The results show that overweight/obese and underweight students should be considered a risk group for bullying.

Um elevado número de escolares relata já ter sido vítima de bullying pelos seus pares devido à sua aparência física. O peso corporal do adolescente destaca-se como uma das principais razões dessa vitimização. O presente trabalho tem como objetivo investigar a associação entre vitimização por bullying e índice de massa corporal (IMC) em escolares brasileiros. Trata-se de um estudo transversal utilizando dados da Pesquisa Nacional de Saúde do Escolar (PeNSE) de 2015 para estudantes com idades entre 11 e 15 anos. Para a análise foi usado o modelo Probit. A probabilidade de vitimização por bullying foi de 46% em escolares brasileiros. Foi encontrada uma associação não linear significativa entre IMC e bullying. Observou-se que tanto os estudantes abaixo do peso quanto os sobrepesados/obesos apresentaram maior probabilidade de vitimização por bullying em relação a escolares com peso adequado para a idade. A associação foi encontrada para ambos os sexos, sendo a curva em forma de U mais acentuada para escolares do sexo feminino. Além disso, foram identificados como fatores de risco sentir-se incompreendido pelos pais, insatisfeito com o próprio corpo e frequentar escola pública. Morar com a mãe, escolaridade da mãe e proxy para renda familiar não são fatores de risco ou de proteção para a vitimização por bullying. Os resultados apontam que, além de escolares sobrepesados/obesos, os que estão abaixo do peso também devem ser considerados como grupo de risco.

Un elevado número de escolares relata ya haber sido víctima de acoso (bullying) por parte de sus compañeros, debido a su apariencia física. El peso corporal del adolescente destaca como una de las principales razones de esa victimización. El objetivo del presente estudio es investigar la asociación entre victimización por acoso e índice de masa corporal (IMC) en escolares brasileños. Se trata de un estudio transversal, utilizando datos de la Encuesta Nacional de Salud del Escolar (PeNSE por sus siglas en portugués) de 2015 para escolares con edades entre 11 y 15 años. Para el análisis, se utilizó el modelo Probit. La probabilidad de victimización por acoso fue de 46% en escolares brasileños. Se encontró una asociación no-lineal significativa entre IMC y acoso. Se observó que tanto escolares por debajo del peso, así como escolares con sobrepeso/obesos presentaron una mayor probabilidad de victimización por acoso, en relación con escolares con un peso adecuado para la edad. La asociación se encontró para ambos sexos, siendo la curva en forma de U más acentuada para escolares del sexo femenino. Asimismo, se identificaron como factores de riesgo sentirse incomprendido por los padres, insatisfecho con el propio cuerpo y frecuentar la escuela pública. Vivir con la madre, escolaridad de la madre y proxy para renta familiar no se mostraron factores de riesgo o de protección para la victimización por acoso. Los resultados indican que, además de escolares con sobrepeso/obesos, escolares por debajo del peso también deben ser considerados como grupo de riesgo.

Associação entre vitimização por bullying e índice de massa corporal em escolares / Association of victimization from bullying with body mass index in schoolchildren / Asociación entre victimización por acoso e índice de masa corporal en escolares

Um elevado número de escolares relata já ter sido vítima de bullying pelos seus pares devido à sua aparência física. O peso corporal do adolescente destaca-se como uma das principais razões dessa vitimização. O presente trabalho tem como objetivo investigar a associação entre vitimização por bullying e índice de massa corporal (IMC) em escolares brasileiros. Trata-se de um estudo transversal utilizando dados da Pesquisa Nacional de Saúde do Escolar (PeNSE) de 2015 para estudantes com idades entre 11 e 15 anos. Para a análise foi usado o modelo Probit. A probabilidade de vitimização por bullying foi de 46% em escolares brasileiros. Foi encontrada uma associação não linear significativa entre IMC e bullying. Observou-se que tanto os estudantes abaixo do peso quanto os sobrepesados/obesos apresentaram maior probabilidade de vitimização por bullying em relação a escolares com peso adequado para a idade. A associação foi encontrada para ambos os sexos, sendo a curva em forma de U mais acentuada para escolares do sexo feminino. Além disso, foram identificados como fatores de risco sentir-se incompreendido pelos pais, insatisfeito com o próprio corpo e frequentar escola pública. Morar com a mãe, escolaridade da mãe e proxy para renda familiar não são fatores de risco ou de proteção para a vitimização por bullying. Os resultados apontam que, além de escolares sobrepesados/obesos, os que estão abaixo do peso também devem ser considerados como grupo de risco.

Many schoolchildren report bullying by their classmates because of their physical appearance. Teenagers' body weight is one of the main reasons for this victimization. The current study aims to investigate the association between victimization from bullying and body mass index (BMI) in Brazilian schoolchildren. This was a cross-sectional study using data from the Brazilian National School Health Survey (PeNSE) in 2015 for students from 11 to 15 years of age. The analysis used the Probit model. The probability of victimization from bullying was 46% in Brazilian schoolchildren in this age bracket. There was a significant non-linear association between BMI and bullying. Both underweight and overweight/obese schoolchildren were more likely to suffer bullying, compared to their peers with adequate weight for age. The association was found in both sexes, and the U-shaped curve was more accentuated in girls. Risk factors included feeling misunderstood by parents, dissatisfaction with one's own body, and enrollment in public schools. Living with the mother, mother's schooling, and a proxy for family income were neither risk factors nor protective factors for bullying. The results show that overweight/obese and underweight students should be considered a risk group for bullying.

Un elevado número de escolares relata ya haber sido víctima de acoso (bullying) por parte de sus compañeros, debido a su apariencia física. El peso corporal del adolescente destaca como una de las principales razones de esa victimización. El objetivo del presente estudio es investigar la asociación entre victimización por acoso e índice de masa corporal (IMC) en escolares brasileños. Se trata de un estudio transversal, utilizando datos de la Encuesta Nacional de Salud del Escolar (PeNSE por sus siglas en portugués) de 2015 para escolares con edades entre 11 y 15 años. Para el análisis, se utilizó el modelo Probit. La probabilidad de victimización por acoso fue de 46% en escolares brasileños. Se encontró una asociación no-lineal significativa entre IMC y acoso. Se observó que tanto escolares por debajo del peso, así como escolares con sobrepeso/obesos presentaron una mayor probabilidad de victimización por acoso, en relación con escolares con un peso adecuado para la edad. La asociación se encontró para ambos sexos, siendo la curva en forma de U más acentuada para escolares del sexo femenino. Asimismo, se identificaron como factores de riesgo sentirse incomprendido por los padres, insatisfecho con el propio cuerpo y frecuentar la escuela pública. Vivir con la madre, escolaridad de la madre y proxy para renta familiar no se mostraron factores de riesgo o de protección para la victimización por acoso. Los resultados indican que, además de escolares con sobrepeso/obesos, escolares por debajo del peso también deben ser considerados como grupo de riesgo.

Efeito do Programa Mais Médicos sobre internações sensíveis à atenção primária / Effect of the More Doctors Program on primary care sensitive conditions in Brazil / Efecto del Programa Más Médicos en las tasas de hospitalización por enfermedades que podrían tratarse en la atención primaria

O presente artigo teve como objetivo avaliar o efeito do Programa Mais Médicos (PMM) nas taxas de internação por condições sensíveis à atenção primária (ICSAP) por faixa etária no Brasil. Realizou-se um estudo longitudinal com abordagem em painel dinâmico. A unidade de análise foi o município, considerando os 5 570 municípios brasileiros no período de 2008 a 2016. Para avaliar o efeito do PMM, considerou-se a exposição do município ao programa. Identificaram-se os municípios em que pelo menos 50% dos médicos da atenção primária eram do PMM. Testes de robustez com exposições alternativas ao programa (30%, 40%, 60% e 70%) foram realizados. Um conjunto de variáveis de vulnerabilidade foi incluído como controle: número de médicos da APS e de enfermeiros/técnicos de enfermagem/auxiliares de enfermagem da Estratégia Saúde da Família por 10 000 habitantes; número de leitos hospitalares por 10 000 habitantes; índice de desenvolvimento municipal de educação e de renda e emprego; percentual da população com plano de saúde; e percentual de domicílios com rede de esgoto. Detectou-se um efeito consistente do PMM na redução das ICSAP. Esse resultado foi encontrado para todas as faixas etárias, apresentando maior efeito entre crianças (0 a 4 anos), com redução correspondente a 3,7% nas taxas de ICSAP. Em adultos (20 a 64 anos), a redução foi de 3,1%. Além disso, verificou-se que quanto maior a exposição do município ao PMM, maior o efeito na redução das ICSAP. Os municípios mais expostos ao PMM foram os municípios em maior condição de vulnerabilidade. Em conclusão, o PMM contribuiu para a melhoria da saúde da população, principalmente em áreas de alta vulnerabilidade.(AU)

The present article aimed at evaluating the effect of the More Doctors Program (PMM) on primary care sensitive conditions (PCSC) by age group in Brazil. A longitudinal study was performed using a dynamic panel data approach. Municipalities were considered as the unit of analysis; the 5 570 Brazilian municipalities existing in Brazil from 2008 to 2016 were analyzed. The effect of the PMM was evaluated according to the exposure of municipalities to the program. For that, the municipalities in which at least 50% of primary care physicians were linked to the PMM were identified. Robustness tests with alternative exposures to the program (30%, 40%, 60% and 70%) were performed. A set of vulnerability variables was included for control: number or primary care physicians, number of Family Health Strategy nurses/nursing technicians or assistants per 10 000 population; number of hospital beds per 10 000 population; municipal education development and income/employment indices; percentage of population with health insurance plans; and percentage of households with sewer lines. A consistent effect of the PMM on PCSC reduction was detected. This result was observed for all age groups, with greater impact on the 0 to 4 year-old group, in which a 3.7% reduction in PCSC rates was recorded. In adults (20 to 64 years), a 3.1% reduction was recorded. The results show that the higher the exposure to the PMM, the stronger the effect on PCSC reduction. Also, the municipalities with higher exposure to the PMM were the most vulnerable. In conclusion, the PMM contributed to improve the health of the population, especially in high vulnerability areas.(AU)

El objetivo de este artículo fue evaluar el efecto del Programa Más Médicos (PMM) en las tasas de hospitalización por enfermedades que podrían tratarse en la atención primaria por grupo etario en Brasil. Se realizó un estudio longitudinal con un método basado en una cohorte dinámica. Con el municipio como unidad de análisis, el estudio se extendió a los 5 570 municipios brasileños en el período 2008-2016. Para evaluar el efecto del PMM, se consideró la exposición de cada municipio al programa. Se identificaron los municipios donde al menos 50% de los médicos de atención primaria pertenecían al PMM. Se realizaron pruebas de robustez con diferentes grados de exposición al programa (30%, 40%, 60% y 70%). Se empleó como testigo un conjunto de variables de vulnerabilidad, a saber, el número de médicos de atención primaria de salud y de miembros del personal profesional, técnico y auxiliar de enfermería de la estrategia de salud de la familia por 10 000 habitantes; el número de camas hospitalarias por 10 000 habitantes; el índice de desarrollo municipal en materia de educación, ingresos y empleo; el porcentaje de la población con planes de atención de salud y el porcentaje de domicilios con red de alcantarillado. Se observó un marcado efecto del PMM en la reducción de la tasa de hospitalización por enfermedades que podrían tratarse en la atención primaria. Ese resultado se obtuvo en todos los grupos etarios, con un mayor efecto en los niños (de 0 a 4 años) cuyas tasas de hospitalización disminuyeron 3,7%. En adultos (de 20 a 64 años), la reducción fue de 3,1%. Además, se verificó que cuanto mayor era la exposición del municipio al PMM, más intenso era el efecto del programa en la reducción de dichas tasas. Los municipios más expuestos al PMM fueron los más vulnerables. En conclusión, el PMM contribuyó a mejorar la salud de la población, principalmente en las zonas con un alto índice de vulnerabilidade.(AU)

Primary care physicians and infant mortality: Evidence from Brazil.

Primary health care has been recognized as a critical strategy for improving population health in developing countries. This paper investigates the effect of primary care physicians on the infant mortality rate in Brazil using a dynamic panel data approach. This method accounts for the endogeneity problem and the persistence of infant mortality over time. The empirical analysis uses an eight-year panel of municipalities between 2005 and 2012. The results indicate that primary care physician supply contributed to the decline of infant mortality in Brazil. An increase of one primary care physician per 10,000 population was associated with 7.08 fewer infant deaths per 10,000 live births. This suggests that, in addition to other determinants, primary care physicians can play an important role in accounting for the reduction of infant mortality rates.