Do baseline participant characteristics impact the effectiveness of a mobile health intervention for depressive symptoms? A post-hoc subgroup analysis of the CONEMO trials.

OBJECTIVE: To ascertain whether sociodemographic and health-related characteristics known from previous research to have a substantive impact on recovery from depression modified the effect of a digital intervention designed to improve depressive symptoms (CONEMO). METHODS: The CONEMO study consisted of two randomized controlled trials, one conducted in Lima, Peru, and one in São Paulo, Brazil. As a secondary trial plan analysis, mixed logistic regression was used to explore interactions between the treatment arm and subgroups of interest defined by characteristics measured before randomization - suicidal ideation, race/color, age, gender, income, type of mobile phone, alcohol misuse, tobacco use, and diabetes/hypertension - in both trials. We estimated interaction effects between the treatment group and these subgroup factors for the secondary outcomes using linear mixed regression models. RESULTS: Increased effects of the CONEMO intervention on the primary outcome (reduction of at least 50% in depressive symptom scores at 3-month follow-up) were observed among older and wealthier participants in the Lima trial (p = 0.030 and p = 0.001, respectively). CONCLUSION: There was no evidence of such differential effects in São Paulo, and no evidence of impact of any other secondary outcomes in either trial. CLINICAL TRIAL REGISTRATION: NCT02846662 (São Paulo, Brazil - SP), NCT03026426 (Lima, Peru - LI).

Do baseline participant characteristics impact the effectiveness of a mobile health intervention for depressive symptoms? A post-hoc subgroup analysis of the CONEMO trials

Objective: To ascertain whether sociodemographic and health-related characteristics known from previous research to have a substantive impact on recovery from depression modified the effect of a digital intervention designed to improve depressive symptoms (CONEMO). Methods: The CONEMO study consisted of two randomized controlled trials, one conducted in Lima, Peru, and one in São Paulo, Brazil. As a secondary trial plan analysis, mixed logistic regression was used to explore interactions between the treatment arm and subgroups of interest defined by characteristics measured before randomization - suicidal ideation, race/color, age, gender, income, type of mobile phone, alcohol misuse, tobacco use, and diabetes/hypertension - in both trials. We estimated interaction effects between the treatment group and these subgroup factors for the secondary outcomes using linear mixed regression models. Results: Increased effects of the CONEMO intervention on the primary outcome (reduction of at least 50% in depressive symptom scores at 3-month follow-up) were observed among older and wealthier participants in the Lima trial (p = 0.030 and p = 0.001, respectively). Conclusion: There was no evidence of such differential effects in São Paulo, and no evidence of impact of any other secondary outcomes in either trial. Clinical trial registration: NCT02846662 (São Paulo, Brazil - SP), NCT03026426 (Lima, Peru - LI). Funded by the U.S. National Institute of Mental Health (grant U19MH098780).

A Mobile Health Intervention for Patients With Depressive Symptoms: Protocol for an Economic Evaluation Alongside Two Randomized Trials in Brazil and Peru.

BACKGROUND: Mobile health interventions provide significant strategies for improving access to health services, offering a potential solution to reduce the mental health treatment gap. Economic evaluation of this intervention is needed to help inform local mental health policy and program development. OBJECTIVE: This paper presents the protocol for an economic evaluation conducted alongside 2 randomized controlled trials (RCTs) to evaluate the cost-effectiveness of a psychological intervention delivered through a technological platform (CONEMO) to treat depressive symptoms in people with diabetes, hypertension, or both. METHODS: The economic evaluation uses a within-trial analysis to evaluate the incremental costs and health outcomes of CONEMO plus enhanced usual care in comparison with enhanced usual care from public health care system and societal perspectives. Participants are patients of the public health care services for hypertension, diabetes, or both conditions in São Paulo, Brazil (n=880) and Lima, Peru (n=432). Clinical effectiveness will be measured by reduction in depressive symptoms and gains in health-related quality of life. We will conduct cost-effectiveness and cost-utility analyses, providing estimates of the cost per at least 50% reduction in 9-item Patient Health Questionnaire scores, and cost per quality-adjusted life year gained. The measurement of clinical effectiveness and resource use will take place over baseline, 3-month follow-up, and 6-month follow-up in the intervention and control groups. We will use a mixed costing methodology (ie, a combination of top-down and bottom-up approaches) considering 4 cost categories: intervention (CONEMO related) costs, health care costs, patient and family costs, and productivity costs. We will collect unit costs from the RCTs and national administrative databases. The multinational economic evaluations will be fully split analyses with a multicountry costing approach. We will calculate incremental cost-effectiveness ratios and present 95% CIs from nonparametric bootstrapping (1000 replicates). We will perform deterministic and probabilistic sensitivity analyses. Finally, we will present cost-effectiveness acceptability curves to compare a range of possible cost-effectiveness thresholds. RESULTS: The economic evaluation project had its project charter in June 2018 and is expected to be completed in September 2021. The final results will be available in the second half of 2021. CONCLUSIONS: We expect to assess whether CONEMO plus enhanced usual care is a cost-effective strategy to improve depressive symptoms in this population compared with enhanced usual care. This study will contribute to the evidence base for health managers and policy makers in allocating additional resources for mental health initiatives. It also will provide a basis for further research on how this emerging technology and enhanced usual care can improve mental health and well-being in low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov NCT12345678 (Brazil) and NCT03026426 (Peru); https://clinicaltrials.gov/ct2/show/NCT02846662 and https://clinicaltrials.gov/ct2/show/NCT03026426. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/26164.

Effect of a Digital Intervention on Depressive Symptoms in Patients With Comorbid Hypertension or Diabetes in Brazil and Peru: Two Randomized Clinical Trials.

Importance: Depression is a leading contributor to disease burden globally. Digital mental health interventions can address the treatment gap in low- and middle-income countries, but the effectiveness in these countries is unknown. Objective: To investigate the effectiveness of a digital intervention in reducing depressive symptoms among people with diabetes and/or hypertension. Design, Setting, and Participants: Participants with clinically significant depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] score ≥10) who were being treated for hypertension and/or diabetes were enrolled in a cluster randomized clinical trial (RCT) at 20 sites in São Paulo, Brazil (N=880; from September 2016 to September 2017; final follow-up, April 2018), and in an individual-level RCT at 7 sites in Lima, Peru (N=432; from January 2017 to September 2017; final follow-up, March 2018). Interventions: An 18-session, low-intensity, digital intervention was delivered over 6 weeks via a provided smartphone, based on behavioral activation principles, and supported by nurse assistants (n = 440 participants in 10 clusters in São Paulo; n = 217 participants in Lima) vs enhanced usual care (n = 440 participants in 10 clusters in São Paulo; n = 215 participants in Lima). Main Outcomes and Measures: The primary outcome was a reduction of at least 50% from baseline in PHQ-9 scores (range, 0-27; higher score indicates more severe depression) at 3 months. Secondary outcomes included a reduction of at least 50% from baseline PHQ-9 scores at 6 months. Results: Among 880 patients cluster randomized in Brazil (mean age, 56.0 years; 761 [86.5%] women) and 432 patients individually randomized in Peru (mean age, 59.7 years; 352 [81.5%] women), 807 (91.7%) in Brazil and 426 (98.6%) in Peru completed at least 1 follow-up assessment. The proportion of participants in São Paulo with a reduction in PHQ-9 score of at least 50% at 3-month follow-up was 40.7% (159/391 participants) in the digital intervention group vs 28.6% (114/399 participants) in the enhanced usual care group (difference, 12.1 percentage points [95% CI, 5.5 to 18.7]; adjusted odds ratio [OR], 1.6 [95% CI, 1.2 to 2.2]; P = .001). In Lima, the proportion of participants with a reduction in PHQ-9 score of at least 50% at 3-month follow-up was 52.7% (108/205 participants) in the digital intervention group vs 34.1% (70/205 participants) in the enhanced usual care group (difference, 18.6 percentage points [95% CI, 9.1 to 28.0]; adjusted OR, 2.1 [95% CI, 1.4 to 3.2]; P < .001). At 6-month follow-up, differences across groups were no longer statistically significant. Conclusions and Relevance: In 2 RCTs of patients with hypertension or diabetes and depressive symptoms in Brazil and Peru, a digital intervention delivered over a 6-week period significantly improved depressive symptoms at 3 months when compared with enhanced usual care. However, the magnitude of the effect was small in the trial from Brazil and the effects were not sustained at 6 months. Trial Registration: ClinicalTrials.gov: NCT02846662 (São Paulo) and NCT03026426 (Lima).

Use of a Mobile Phone App to Treat Depression Comorbid With Hypertension or Diabetes: A Pilot Study in Brazil and Peru.

BACKGROUND: Depression is underdiagnosed and undertreated in primary health care. When associated with chronic physical disorders, it worsens outcomes. There is a clear gap in the treatment of depression in low- and middle-income countries (LMICs), where specialists and funds are scarce. Interventions supported by mobile health (mHealth) technologies may help to reduce this gap. Mobile phones are widely used in LMICs, offering potentially feasible and affordable alternatives for the management of depression among individuals with chronic disorders. OBJECTIVE: This study aimed to explore the potential effectiveness of an mHealth intervention to help people with depressive symptoms and comorbid hypertension or diabetes and explore the feasibility of conducting large randomized controlled trials (RCTs). METHODS: Emotional Control (CONEMO) is a low-intensity psychoeducational 6-week intervention delivered via mobile phones and assisted by a nurse for reducing depressive symptoms among individuals with diabetes or hypertension. CONEMO was tested in 3 pilot studies, 1 in São Paulo, Brazil, and 2 in Lima, Peru. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9) at enrollment and at 6-week follow-up. RESULTS: The 3 pilot studies included a total of 66 people. Most participants were females aged between 41 and 60 years. There was a reduction in depressive symptoms as measured by PHQ-9 in all pilot studies. In total, 58% (38/66) of the participants reached treatment success rate (PHQ-9 <10), with 62% (13/21) from São Paulo, 62% (13/21) from the first Lima pilot, and 50% (12/24) from the second Lima pilot study. The intervention, the app, and the support offered by the nurse and nurse assistants were well received by participants in both settings. CONCLUSIONS: The intervention was feasible in both settings. Clinical data suggested that CONEMO may help in decreasing participants' depressive symptoms. The findings also indicated that it was possible to conduct RCTs in these settings.

Enhancing mental health research capacity: emerging voices from the National Institute of Mental Health (NIMH) global hubs.

BACKGROUND: Emerging researchers in low- and middle-income countries (LMIC) face many barriers, including inadequacies in funding, international exposure and mentorship. In 2012, the National Institute of Mental Health (NIMH) funded five research hubs aimed at improving the research core for evidence-based mental health interventions, enhancing research skills in global mental health, and providing capacity building (CB) opportunities for early career investigators in LMIC. In this paper emerging researchers contextualize their experiences. CASE PRESENTATION: Each of the five hubs purposively selected an emerging researcher who had experienced more than one hub-related CB opportunity and actively participated in hub-related clinical trial activities. The five 'voices' were invited to contribute narratives on their professional backgrounds, CB experience, challenges and successes as an emerging mental health researcher, and suggestions for future CB activities. These narratives are presented as case studies. CB activities provided broader learning opportunities for emerging researchers. Benefits included the receipt of research funding, hands-on training and mentorship, as well as exposure to networks and collaborative opportunities on a global scale. To overcome ongoing challenges of access to funding, mentoring, networking and global exposure, the emerging voices recommend making mentorship and training opportunities available to a wider range of emerging mental health researchers. CONCLUSIONS: Investing in CB is not enough to ensure sustainability and leave a legacy unless it is accompanied by ongoing mentorship and international exposure. Financial investment in building research capacity, promotion of mentorship and supervision, and international networking are essential to yield well-prepared young investigators in LMIC as experienced by these rising stars. Governments and policymakers should prioritize educational policies to support the continuous development and international engagement of emerging researchers. This can advance strategies to deal with one of most important and costly problems faced by healthcare systems in LMIC: the mental health treatment gap.

The relationship between indicators of socioeconomic status and cesarean section in public hospitals.

OBJECTIVE: To assess the relationship between indicators of socioeconomic status and cesarean section in public hospitals that adopt standardized protocols of obstetrical care. METHODS: This was a prospective cohort study conducted between May 2005 and January 2006 with 831 pregnant women recruited from 10 public primary care clinics in São Paulo, Brazil. Demographic and clinical characteristics were collected during pregnancy. The three main exposures were schooling, monthly family income per capita, and residential crowding. The main outcome was cesarean section at three public hospitals located in the area. Crude and adjusted risk ratios (RR), with 95% confidence intervals were calculated using Poisson regression with robust variance. We examined the effects of each exposure variable on cesarean section accounting for potential confounders by using four different models: crude, adjusted by mother's characteristics, by obstetrical complications, and by the other two indicators of socioeconomic status. RESULTS: Among the 757 deliveries performed in the public hospitals, 215 (28.4%) were by cesarean section. In the bivariate analysis, cesarean section was associated with higher family income per capita, higher education, lower residential crowding, pregnancy planning, white skin color, having a partner, and advanced maternal age. In the multivariate analysis, after adjustment for covariates, none of the socioeconomic status variables remained associated with cesarean section. CONCLUSIONS: In this group, the chance of women undergoing cesarean section was not associated with indicators of socioeconomic status only, but was defined in accordance with major obstetric and clinical conditions.

Unplanned pregnancy and risk of maternal depression: secondary data analysis from a prospective pregnancy cohort.

PURPOSE: to evaluate the relationship between unplanned pregnancy (UP), a common problem in high and low income countries and maternal depression (MD). METHODS: Secondary analysis of data from a prospective cohort study with pregnant women recruited from 10 primary care clinics of the public sector in São Paulo, Brazil. Participants were questioned about pregnancy intention at 20-30 weeks of gestation. The Self Report Questionnaire score >7 was used to evaluated the presence of depression during pregnancy and 11 months after childbirth. Four groups of MD were defined: never; antenatal only; postnatal only; persistent (both antenatal/postnatal). Multinomial logistic regression was used to assess the relationship between UP and MD, controlling for confounding. RESULTS: Data were analysed for 701 at the postpartum period. Five hundred and sixty-two (67.8%) women did not plan the pregnancy. Women with UP had 2.5 more risk of being depressed during both assessments (during pregnancy and postpartum) when compared to women with a planned pregnancy (RR: 2.5; 95% CI: 1.47:4.30). In the adjusted models, women with UP were significantly more likely to have persistent depression (RR: 2.3; 95% CI: 1.2:4.3). CONCLUSION: UP is an independent risk factor for persistent depression, but not for postpartum depression.

The relationship between indicators of socioeconomic status and cesarean section in public hospitals

ABSTRACT OBJECTIVE To assess the relationship between indicators of socioeconomic status and cesarean section in public hospitals that adopt standardized protocols of obstetrical care. METHODS This was a prospective cohort study conducted between May 2005 and January 2006 with 831 pregnant women recruited from 10 public primary care clinics in São Paulo, Brazil. Demographic and clinical characteristics were collected during pregnancy. The three main exposures were schooling, monthly family income per capita, and residential crowding. The main outcome was cesarean section at three public hospitals located in the area. Crude and adjusted risk ratios (RR), with 95% confidence intervals were calculated using Poisson regression with robust variance. We examined the effects of each exposure variable on cesarean section accounting for potential confounders by using four different models: crude, adjusted by mother’s characteristics, by obstetrical complications, and by the other two indicators of socioeconomic status. RESULTS Among the 757 deliveries performed in the public hospitals, 215 (28.4%) were by cesarean section. In the bivariate analysis, cesarean section was associated with higher family income per capita, higher education, lower residential crowding, pregnancy planning, white skin color, having a partner, and advanced maternal age. In the multivariate analysis, after adjustment for covariates, none of the socioeconomic status variables remained associated with cesarean section. CONCLUSIONS In this group, the chance of women undergoing cesarean section was not associated with indicators of socioeconomic status only, but was defined in accordance with major obstetric and clinical conditions.

The relationship between socioeconomic indicators during pregnancy and gynecological appointment at any time after childbirth.

BACKGROUND: The rates of receipt of postnatal care vary widely between high and low-middle income countries. This study aimed to examine the association between indicators of socioeconomic status during pregnancy and gynecological appointment at any time after childbirth (GA). METHODS: a prospective cohort study with pregnant women recruited from 10 primary care clinics of the public sector in the city of São Paulo, Brazil. Socioeconomic characteristics and obstetric information were obtained through a questionnaire administered during pregnancy and in the postpartum period. Adjusted risk ratios (RR) with 95% confidence intervals (CI) were calculated using Poisson regression. RESULTS: Eight hundred and thirty one pregnant women were included in the study during the antenatal period and 701 were re-assessed during the postnatal period. Among them, 283 (59.6) attended a gynecological consultation. After adjusting for covariates, higher socioeconomic status during pregnancy was associated with greater risk of having a GA (RR:1.23, CI 95%:1.05:1.45 for family per capita monthly income; RR:1.19, CI 95 % 1.01:1.40 for asset score). CONCLUSION: In this sample, the attendance for GA was above average and women with higher socio-economic status were more likely to have receipt of such care. Special efforts should be made to improve the attendance and frequency of gynecological consultations after childbirth among poorer women.

Monoparentalidade programada e reprodução assistida: da “produção independente” à utilização de sêmen póst mortem / Orogrammed “Single” Parenthood and Human Assisted Reproduction: from the“Independent Production” to the Utilization of Post Mortem Semen

A utilização das técnicas de reprodução assistida vem possibilitando, nas últimas décadas, a realização da vontade de exercer a parentalidade em diferentes contextos e situações, muito além da infertilidade. Aqui são elaboradas reflexões associadas à monoparentalidade buscada, não acidental, considerando contingências específicas, tais como a utilização de sêmen post mortem e a denominada produção independente, seja em indivíduos hétero ou homossexuais. Tais reflexões são eliciadas em virtude da prática clínica à luz da revisão de literatura e debruçam-se sobre as condições que favorecem essa busca, muitas vezes de caráter narcísico e que necessitam de uma escuta e uma interlocução privilegiada no atendimento clínico. (AU)

In the last decades, the use of assisted reproduction techniques has favored the fulfillment of parenthood desires indifferent contexts and situations, beyond infertility it self. This paper discusses issues related to programmed single parenthood eagerly sought in specific situations, such as the use of post mortem semen and the so-called “independentproduction” among hetero and homosexual individuals. This reflexion is brought by the authors’ clinical experienceand addresses the conditions that favor this perhaps narcissistic search, which needs a specialized hearing and exchangewithin the clinical context. (AU)

Monoparentalidade programada e reprodução assistida: da “produção independente” à utilização de sêmen póst mortem / Orogrammed “Single” Parenthood and Human Assisted Reproduction: from the“Independent Production” to the Utilization of Post Mortem Semen

A utilização das técnicas de reprodução assistida vem possibilitando, nas últimas décadas, a realização da vontade de exercer a parentalidade em diferentes contextos e situações, muito além da infertilidade. Aqui são elaboradas reflexões associadas à monoparentalidade buscada, não acidental, considerando contingências específicas, tais como a utilização de sêmen post mortem e a denominada produção independente, seja em indivíduos hétero ou homossexuais. Tais reflexões são eliciadas em virtude da prática clínica à luz da revisão de literatura e debruçam-se sobre as condições que favorecem essa busca, muitas vezes de caráter narcísico e que necessitam de uma escuta e uma interlocução privilegiada no atendimento clínico...

In the last decades, the use of assisted reproduction techniques has favored the fulfillment of parenthood desires indifferent contexts and situations, beyond infertility it self. This paper discusses issues related to programmed single parenthood eagerly sought in specific situations, such as the use of post mortem semen and the so-called “independentproduction” among hetero and homosexual individuals. This reflexion is brought by the authors’ clinical experienceand addresses the conditions that favor this perhaps narcissistic search, which needs a specialized hearing and exchangewithin the clinical context...

The relationship between mode of delivery and sexual health outcomes after childbirth.

INTRODUCTION: Several factors are implicated in the women's sexuality after childbirth. Nevertheless, there is conflicting evidence about the influence of mode of delivery (MD) AIM: To prospectively evaluate the relationship between MD and sexual health outcomes after childbirth METHODS: A prospective cohort study conducted between May 2005 and March 2007 included 831 pregnant women recruited from primary care clinics of the public sector in São Paulo, Brazil. The exposure variable was MD: uncomplicated vaginal delivery (spontaneous vaginal delivery without episiotomy or any kind of perineal laceration); complicated vaginal delivery (either forceps or normal, with episiotomy or any kind of perineal laceration) and cesarean delivery. Socio-demographic and obstetric data were obtained through a questionnaire applied during the antenatal and postnatal period. Crude and adjusted risk ratios, with 95% confidence intervals, were calculated using Poisson regression to examine the associations between MD and sexual health outcomes. MAIN OUTCOME MEASURES: The three main sexual health outcomes were later resumption of sexual life, self-perception of decline of sexual life (DSL), and presence of sexual desire. RESULTS: One hundred and forty-one women (21.9%) resumed sexual life 3 or more months after delivery. Although 87.1% of women had desire, DSL occurred in 21.1% of the cohort. No associations were found between MD and sexual health outcomes. CONCLUSIONS: Women's sexuality after childbirth were not influenced by the type of delivery. Efforts to improve the treatment of sexual problems after childbirth should focus beyond MD.

A efetividade da intervenção psicológica no tratamento do tabagismo / The effectiveness of psychological interventions for smoking cessation

Este trabalho estudou a efetividade da intervenção psicológica por meio de comparação entre e intragrupo junto a pacientes tabagistas de ambos os sexos, entre 18 e 60 anos de idade, que referiam querer parar de fumar. A intervenção psicológica junto a esses pacientes foi feita por meio da terapia cognitivo-comportamental (TCC), associada ao uso de antidepressivo de reconhecido uso no mercado. Foram estudados 61 pacientes que passaram por avaliação médica e, concomitantemente, por acompanhamento psicológico com base na TCC. Neste caso, foram realizadas sessões em grupo de até 10 participantes por seis semanas consecutivas e uma sessão 30 dias após a sexta sessão. Estes grupos tiveram seguimento até seis meses após o término do tratamento. A média de idade dos participantes foi 42 anos (DP=11,13), sendo 44,3% do sexo masculino. Os resultados apontaram que 62,3% estavam no estágio motivacional da contemplação e 23% na preparação para parar de fumar. Ao final de seis semanas de intervenção, 93,5% da amostra havia cessado o tabagismo e, ao final de seis meses, 57,4% dos pacientes ainda estavam abstinentes. A curva de sobrevida destes pacientes estabeleceu um sucesso de 49,7% de pacientes abstinentes em um ano de tratamento. No caso de recaída, os motivos mais frequentes referidos pelos pacientes foram ansiedade (19%) e estresse (61,9%). Os resultados do inventário Beck de depressão (BDI) demonstram que 85,7% da amostra estava situada no grau mínimo e leve. Os dados apontam para a importância do tratamento psicológico do tabagista, uma vez que o emocional permeia este contexto e caso não seja tratado o índice de recaída pode ser maior.

This study investigated the effectiveness of psychological intervention on smokers of both sexes, ranging from 18 to 60 year old who wanted to quit smoking through comparison both between and intra-group. The psychological intervention among these patients was done through cognitive-behavioral therapy (CBT), associated with the use of na antidepressant vastly recognized in the Market. We studied 61 patients who underwent medical and psychological evaluation simultaneously, based on CBT. In this case, sessions were conducted in groups of up to 10 particiants for six consecutive weeks and a session 30 days after the sixth week. These groups were followed up until six months after the ende of treatment. The results showed that 44.3% of them were male with a mean age of 42.8% years and SD=11.13, 62,3% were in the motivational stage of contemplation and 23% in preparation for quitting smoking. 85,7% of the sample was located in the lowest degree of the Beck depression inventory (BDI). At the end of the six weeks, 93,5% of the sample had stopped smoking and at the end of six months, 57.4% of the patients were still abstinent and survival curve of theses patients had stablished a successful growth of 49,7% of abstinente patients in one year of treatment. In case of relapse, the most common reasons reported by patients were: 19% anxiety, 61,9% stress and 19% other reasons. In conclusion, the importance of the psychological treatment of smokers becomes clear, since emotional issues permeate this contexto, and, if not treated, the relapse rate may get higher.

Representação da relação mãe-bebê através do procedimento desenho-estória em gestantes adolescentes e tardias

O vínculo que a mãe estabelece com seu bebê começa a ser construído durante o processo gestacional e é influenciado por aspectos pessoais e culturais. O objetivo deste trabalho foi investigar a representação de gestantes primíparas adolescentes e tardias em relação a seu feto, por meio de entrevistas Semidirigidas e do procedimento Desenho-Estória de Trinca (1997). Participaram deste estudo qualitativo 14 mulheres com idades entre 15 e 44 anos. Observamos indícios de dificuldades nessa representação que podem estar associadas à ambivalência materna, bem como ao pensar essa criança como bebê, sujeito autônomo. Os resultados apontam para a importância de se disponibilizar um espaço de acolhimento e escuta durante a gestação para que tais aspectos possam ser mais facilmente elaborados. (AU)

The mother baby bond starts in the womb and is influenced by both personal and cultural aspects. This study objective is to investigate the representation of teenagers and older first time mothers in relation to her fetus through semi-structured interviews and Desenho-Estória procedure of Trinca. This qualitative study was applied on 14 pregnant women aged between 15 and 44 years. Both older and younger mothers showed representation difficulty that maybe associated with maternal ambivalence, and the belief of child being an autonomous subject. The results indicate the importance of providing those mom´s mean of support and listening during pregnancy where these issues can be more easily developed. (AU)

Representação da relação mãe-bebê através do procedimento desenho-estória em gestantes adolescentes e tardias

O vínculo que a mãe estabelece com seu bebê começa a ser construído durante o processo gestacional e é influenciado por aspectos pessoais e culturais. O objetivo deste trabalho foi investigar a representação de gestantes primíparas adolescentes e tardias em relação a seu feto, por meio de entrevistas Semidirigidas e do procedimento Desenho-Estória de Trinca (1997). Participaram deste estudo qualitativo 14 mulheres com idades entre 15 e 44 anos. Observamos indícios de dificuldades nessa representação que podem estar associadas à ambivalência materna, bem como ao pensar essa criança como bebê, sujeito autônomo. Os resultados apontam para a importância de se disponibilizar um espaço de acolhimento e escuta durante a gestação para que tais aspectos possam ser mais facilmente elaborados.

The mother baby bond starts in the womb and is influenced by both personal and cultural aspects. This study objective is to investigate the representation of teenagers and older first time mothers in relation to her fetus through semi-structured interviews and Desenho-Estória procedure of Trinca. This qualitative study was applied on 14 pregnant women aged between 15 and 44 years. Both older and younger mothers showed representation difficulty that maybe associated with maternal ambivalence, and the belief of child being an autonomous subject. The results indicate the importance of providing those mom´s mean of support and listening during pregnancy where these issues can be more easily developed.

Performance of elderly on the three words-three shapes test: a Brazilian study.

The three words-three shapes test is a brief bedside technique for assessment of learning and memory using verbal and non-verbal material. To the best of our knowledge, performance of Brazilian elderly on this test has not yet been reported. OBJECTIVE: To evaluate the performance of normal Brazilian elderly on the three words-three shapes test. METHOD: A total of 50 adult patients, 25 males and 25 females, with age ranging from 55 to 81 years (66.0±7.10 years), 1 to 8 years of schooling, different economic conditions and living in the São José do Rio Preto municipality, State of São Paulo, were evaluated. RESULTS: There was no statistically significant difference between performance of males and females. Performance on incidental recall was significantly lower than in delayed recall. The performance in the learning phase improved following at least two further presentations of the stimuli. Approximately 50% of the participants did not remember the six stimuli and had to proceed to the recognition stage. The performance in the recognition stage was significantly better than during spontaneous recall. Patients with low educational level (less years of schooling) had poorer performance on the recall of shapes and on the total score of the test. CONCLUSIONS: The three words-three shapes test is rapid, efficient and straightforward to apply in the elderly, but low educational level was associated with poorer performance on this test. Normal elderly individuals had greater difficulty in the encoding process and in searching for stored information.

O teste três figuras-três palavras é uma técnica simples e adequada para avaliação de aprendizagem e memória verbal e não verbal. Até o presente, estudos sobre o desempenho de idosos brasileiros nesse teste não foram encontrados na literatura. OBJETIVO: Estudar o desempenho de idosos normais em tarefas de memória e contribuir para obtenção de dados adequados sobre o desempenho desses idosos no teste três figuras-três palavras de Mesulam. MÉTODO: Foram avaliados 50 pacientes adultos, sendo 25 do sexo masculino e 25 do feminino, com idade variando entre 55 e 81 anos (66,0±7,1 anos), 1 a 8 anos de escolaridade, diferentes situações econômicas e residentes no município de São José do Rio Preto, Estado de São Paulo. RESULTADOS: Não foi encontrada diferença estatisticamente significativa entre o desempenho de homens e mulheres. O desempenho da memória incidental foi significativamente menor comparado ao desempenho obtido na etapa de evocação tardia. Idosos normais obtiveram melhora de desempenho com pelo menos duas novas apresentações ao estímulo. Indivíduos com menos tempo de instrução obtiveram desempenho inferior ao evocar figuras e no escore total do teste. Cerca de 50% dos participantes necessitaram realizar a etapa de reconhecimento. CONCLUSÕES: O teste três figuras-três palavras foi rápido, eficaz e de fácil aplicação para idosos. A escolaridade influenciou diretamente no desempenho do teste. Idosos normais tiveram maior dificuldade na codificação e busca da informação armazenada.

Torre de Hanói: proposta de utilização do instrumento para sujeitos de 13 a 16 anos / Tower of Hanoi: proposal to use the instrument for subjects 13 to 16 years

Este trabalho propõe padrão de aplicação e estudo normativo da Torre de Hanói (ToH) para população brasileira. Participaram 60 estudantes de 13 a 16 anos. Foram feitos treinos com 3 e 4 peças, 5 vezes cada um. Os resultados sugerem que houve efeito de aprendizagem, com queda do número de movimentos e do tempo. No primeiro treino com 4 peças, houve aumento dos movimentos e do tempo, que foi decrescendo com os treinos, sugerindo que aplicação repetida de ToH automatiza a resposta, requer uso do planejamento, da flexibilidade mental e busca de nova estratégia de sucesso. (AU)

This study proposes a standard application and normative data of Tower of Hanoi (ToH) for Brazilian population. 60 students, age 13 to 16, had participated. They did made trials with 3 and 4 pieces, 5 times each one. The results indicated that it had been learning effect, with the increase of number of movements and time. On the first trial with 4 pieces, it had been a time and movement increase, which was decreasing with the trials, suggesting that repeated application of ToH automatizes the response, and also requires planning, shifting and of new solution searching. (AU)