Study protocol: improving response to malaria in the Amazon through identification of inter-community networks and human mobility in border regions of Ecuador, Peru and Brazil.

INTRODUCTION: Understanding human mobility's role in malaria transmission is critical to successful control and elimination. However, common approaches to measuring mobility are ill-equipped for remote regions such as the Amazon. This study develops a network survey to quantify the effect of community connectivity and mobility on malaria transmission. METHODS: We measure community connectivity across the study area using a respondent driven sampling design among key informants who are at least 18 years of age. 45 initial communities will be selected: 10 in Brazil, 10 in Ecuador and 25 in Peru. Participants will be recruited in each initial node and administered a survey to obtain data on each community's mobility patterns. Survey responses will be ranked and the 2-3 most connected communities will then be selected and surveyed. This process will be repeated for a third round of data collection. Community network matrices will be linked with each country's malaria surveillance system to test the effects of mobility on disease risk. ETHICS AND DISSEMINATION: This study protocol has been approved by the institutional review boards of Duke University (USA), Universidad San Francisco de Quito (Ecuador), Universidad Peruana Cayetano Heredia (Peru) and Universidade Federal Minas Gerais (Brazil). Results will be disseminated in communities by the end of the study.

Network Profile: Improving Response to Malaria in the Amazon through Identification of Inter-Community Networks and Human Mobility in Border Regions of Ecuador, Peru, and Brazil.

Objectives: Understanding human mobility's role on malaria transmission is critical to successful control and elimination. However, common approaches to measuring mobility are ill-equipped for remote regions such as the Amazon. This study develops a network survey to quantify the effect of community connectivity and mobility on malaria transmission. Design: A community-level network survey. Setting: We collect data on community connectivity along three river systems in the Amazon basin: the Pastaza river corridor spanning the Ecuador-Peru border; and the Amazon and Javari river corridors spanning the Brazil-Peru border. Participants: We interviewed key informants in Brazil, Ecuador, and Peru, including from indigenous communities: Shuar, Achuar, Shiwiar, Kichwa, Ticuna, and Yagua. Key informants are at least 18 years of age and are considered community leaders. Primary outcome: Weekly, community-level malaria incidence during the study period. Methods: We measure community connectivity across the study area using a respondent driven sampling design. Forty-five communities were initially selected: 10 in Brazil, 10 in Ecuador, and 25 in Peru. Participants were recruited in each initial node and administered a survey to obtain data on each community's mobility patterns. Survey responses were ranked and the 2-3 most connected communities were then selected and surveyed. This process was repeated for a third round of data collection. Community network matrices will be linked with eadch country's malaria surveillance system to test the effects of mobility on disease risk. Findings: To date, 586 key informants were surveyed from 126 communities along the Pastaza river corridor. Data collection along the Amazon and Javari river corridors is ongoing. Initial results indicate that network sampling is a superior method to delineate migration flows between communities. Conclusions: Our study provides measures of mobility and connectivity in rural settings where traditional approaches are insufficient, and will allow us to understand mobility's effect on malaria transmission.

The association between multiple cardiovascular risk factors and overweight in Brazilian adolescents: an analysis based on the grade of membership.

The aim of the current research is to analyze the coexistence of modifiable risk behaviors for cardiovascular disease (CVD) in 12-to-17-year-old adolescents living in Brazil and their influence on overweight. National, cross-sectional, school-based epidemiological study focused on estimating the prevalence of cardiovascular risk factors and metabolic syndrome in 12 to 17 year old adolescents enrolled in public and private schools in Brazilian counties accounting for more than 100 thousand inhabitants. The grade of membership method was used to identify the coexistence of risk factors among adolescents. The analytical sample comprised 71,552 adolescents. According to the two herein generated profiles, adolescents classified under Profile 2 have shown behaviors such as smoking, alcohol consumption and diet rich in Ultra-processed food intake ≥ 80% of the percentage of total caloric value. In addition, adolescents presenting CVD risk profile have shown increased likelihood of being overweight. The study has found coexistence of risk factors for CVD in Brazilian adolescents, with emphasis on tobacco smoking and alcoholic beverage intake. In addition, it heads towards the analysis of the association between CVD risk factors and health outcomes, such as overweight.

The association between multiple cardiovascular risk factors and overweight in Brazilian adolescents: an analysis based on the grade of membership / A associação entre múltiplos fatores de risco cardiovascular e o excesso de peso em adolescentes brasileiros: uma análise baseada no grade of membership

Abstract The aim of the current research is to analyze the coexistence of modifiable risk behaviors for cardiovascular disease (CVD) in 12-to-17-year-old adolescents living in Brazil and their influence on overweight. National, cross-sectional, school-based epidemiological study focused on estimating the prevalence of cardiovascular risk factors and metabolic syndrome in 12 to 17 year old adolescents enrolled in public and private schools in Brazilian counties accounting for more than 100 thousand inhabitants. The grade of membership method was used to identify the coexistence of risk factors among adolescents. The analytical sample comprised 71,552 adolescents. According to the two herein generated profiles, adolescents classified under Profile 2 have shown behaviors such as smoking, alcohol consumption and diet rich in Ultra-processed food intake ≥ 80% of the percentage of total caloric value. In addition, adolescents presenting CVD risk profile have shown increased likelihood of being overweight. The study has found coexistence of risk factors for CVD in Brazilian adolescents, with emphasis on tobacco smoking and alcoholic beverage intake. In addition, it heads towards the analysis of the association between CVD risk factors and health outcomes, such as overweight.

Resumo O objetivo desta pesquisa é analisar a coexistência de comportamentos de risco modificáveis para doenças cardiovasculares (DCV) em adolescentes de 12 a 17 anos residentes no Brasil e sua influência no excesso de peso. Estudo epidemiológico nacional, transversal, de base escolar, com foco em estimar a prevalência de fatores de risco cardiovascular e síndrome metabólica em adolescentes de 12 a 17 anos matriculados em escolas públicas e privadas de municípios brasileiros que somam mais de 100 mil habitantes. O grade of membership foi utilizado para identificar a coexistência de fatores de risco entre os adolescentes. A amostra analítica foi composta por 71.552 adolescentes. De acordo com os dois perfis gerados, os adolescentes classificados no Perfil 2 mostraram comportamentos como fumar, consumo de álcool e dieta rica em alimentos ultraprocessados ≥ 80% da porcentagem do valor calórico total. Além disso, adolescentes com perfil de risco para DCV mostraram maior probabilidade de apresentar excesso de peso. O estudo encontrou coexistência de fatores de risco para DCV em adolescentes brasileiros, com destaque para tabagismo e consumo de bebidas alcoólicas. Além disso, demonstra associação entre fatores de risco para DCV e desfechos de saúde, como o excesso de peso.

The economic burden of malaria: a systematic review.

BACKGROUND: Quantifying disease costs is critical for policymakers to set priorities, allocate resources, select control and prevention strategies, and evaluate the cost-effectiveness of interventions. Although malaria carries a very large disease burden, the availability of comprehensive and comparable estimates of malaria costs across endemic countries is scarce. METHODS: A literature review to summarize methodologies utilized to estimate malaria treatment costs was conducted to identify gaps in knowledge. RESULTS: Only 45 publications met the inclusion criteria. They utilize different methods, include distinct cost components, have varied geographical coverage (a country vs a city), include different periods in the analysis, and focus on specific parasite types or population groups (e.g., pregnant women). CONCLUSIONS: Cost estimates currently available are not comparable, hindering broad statements on the costs of malaria, and constraining advocacy efforts towards investment in malaria control and elimination, particularly with the finance and development sectors of the government.

Spatial reorganization of the Brazilian Unified National Health System's inpatient care supply.

The joint provision of efficient and equitable healthcare service delivery is a critical factor in improving social welfare. However, healthcare services pose a particular challenge when balancing healthcare provider efficiency and equity. Typically characterized by economies of scale and scope, inpatient care involves a wide variety of medical care that usually demands a broad range of health professional expertise and technological complexity to ensure health care quality. This study analyzes the current spatial organization of the Brazilian general hospitals and their respective flow of patients to identify the possible benefits of closing inefficient hospitals. We studied how inpatient care referrals may be reallocated without increasing access inequities following the potential closure of inefficient public hospitals. We used data from the Brazilian Hospital Information System of the Brazilian Unified National Health System (SIH/SUS) and the Brazilian National Register of Health Establishments (CNES). The smallest and least efficient hospitals were selected as units for potential closure, conditioned on an optimization criterion that minimizes patient travel distances to the nearest efficient hospital. Our results show that there is room for hospital resource reorganization in Brazil without compromising health care access equity.

Health-related vulnerability to climate extremes in homoclimatic zones of Amazonia and Northeast region of Brazil.

Amazonia and the Northeast region of Brazil exhibit the highest levels of climate vulnerability in the country. While Amazonia is characterized by an extremely hot and humid climate and hosts the world largest rainforest, the Northeast is home to sharp climatic contrasts, ranging from rainy areas along the coast to semiarid regions that are often affected by droughts. Both regions are subject to extremely high temperatures and are susceptible to many tropical diseases. This study develops a multidimensional Extreme Climate Vulnerability Index (ECVI) for Brazilian Amazonia and the Northeast region based on the Alkire-Foster method. Vulnerability is defined by three components, encompassing exposure (proxied by seven climate extreme indicators), susceptibility (proxied by sociodemographic indicators), and adaptive capacity (proxied by sanitation conditions, urbanization rate, and healthcare provision). In addition to the estimated vulnerability levels and intensity, we break down the ECVI by indicators, dimensions, and regions, in order to explore how the incidence levels of climate-sensitive infectious and parasitic diseases correlate with regional vulnerability. We use the Grade of Membership method to reclassify the mesoregions into homoclimatic zones based on extreme climatic events, so climate and population/health data can be analyzed at comparable resolutions. We find two homoclimatic zones: Extreme Rain (ER) and Extreme Drought and High Temperature (ED-HT). Vulnerability is higher in the ED-HT areas than in the ER. The contribution of each dimension to overall vulnerability levels varies by homoclimatic zone. In the ER zone, adaptive capacity (39%) prevails as the main driver of vulnerability among the three dimensions, in contrast with the approximately even dimensional contribution in the ED-HT. When we compare areas by disease incidence levels, exposure emerges as the most influential dimension. Our results suggest that climate can exacerbate existing infrastructure deficiencies and socioeconomic conditions that are correlated with tropical disease incidence in impoverished areas.

[Interactions between drug treatment adherence, blood pressure targets, and depression in hypertensive individuals receiving care in the Family Health Strategy]. / Interações entre adesão ao tratamento medicamentoso, meta pressórica e depressão em hipertensos assistidos pela Estratégia Saúde da Família.

The study analyzes interactions between drug treatment adherence, blood pressure targets, and depression in a probabilistic sample of hypertensive individuals treated in the Family Health Strategy in Governador Valadares, Minas Gerais State, Brazil. This is a cross-sectional study with 641 hypertensive individuals 40 years or older, residing in the urban area of Governador Valadares. Structured scripts were used to collect data in home interviews, with a focus on the following indicators: Medication Assessment Questionnaire (MAQ), Beck Depression Inventory (BDI), and blood pressure measurement. Due to the simultaneity of the target events (depression, blood pressure target, and adherence), we applied a system of recursive and simultaneous nonlinear equations. The results suggest that the odds of meeting the blood pressure target increase significantly with adherence to treatment; they also suggest that individuals that meet the blood pressure target show 2.6 higher odds of treatment adherence. Adherence has a protective effect against depression: individuals with minimal adherence show 8.4 higher odds of developing depressive symptoms when compared to those with maximum adherence. Drug treatment adherence is related simultaneously to blood pressure control and lower levels of depression. Promoting drug treatment adherence is essential for ensuring that individuals remain normotensive, with the potential for reducing levels of depression. These positive externalities can reduce pressure on the health system, with simultaneous gains in quality of life for hypertensive individuals.

Este trabalho analisa de que forma ocorre a interação entre adesão ao tratamento medicamentoso, meta pressórica e depressão em uma amostra probabilística de hipertensos assistidos pela Estratégia de Saúde da Família, de Governador Valadares, Minas Gerais, Brasil. Trata-se de um estudo transversal com 641 hipertensos de 40 anos e mais, residentes na zona urbana do município. Foram utilizados roteiros estruturados para a coleta de dados em entrevistas domiciliares, com foco nos indicadores: Medication Assessment Questionnaire (MAQ), Beck Depression Inventory (BDI) e aferição da pressão arterial. Devido à simultaneidade dos eventos analisados (depressão, meta pressórica e adesão), aplicou-se um sistema de equações não lineares recursivas e simultâneas. Os resultados sugerem que a chance de estar na meta pressórica aumenta significativamente com a adesão ao tratamento; também sugerem que indivíduos que estão na meta pressórica apresentam uma chance 2,6 vezes maior de adesão ao tratamento. A adesão possui efeito protetor sobre a depressão: indivíduos com adesão mínima possuem chances 8,4 vezes maiores de desenvolver sintomas depressivos quando comparados aos de máxima adesão. A adesão ao tratamento medicamentoso está relacionada simultaneamente ao controle da pressão arterial e a menores níveis de depressão. Promover a adesão ao tratamento medicamentoso é essencial para garantir que os indivíduos se mantenham normotensos, com potencial de redução nos níveis de depressão. Essas externalidades positivas podem reduzir a pressão sobre o sistema de saúde, com ganhos simultâneos na qualidade de vida dos hipertensos.

Este trabajo analiza de qué forma se produce la interacción entre la adhesión al tratamiento medicamentoso, meta de presión y depresión en una muestra probabilística de hipertensos, asistidos por la Estrategia Salud de la Familia de Governador Valadares, Minas Gerais, Brasil. Se trata de un estudio transversal con 641 hipertensos de 40 años y más, residentes en la zona urbana del municipio. Se utilizaron itinerarios estructurados para la recogida de datos, mediante entrevistas domiciliarias, centradas en los indicadores: Medication Assessment Questionnaire (MAQ), Beck Depression Inventory (BDI) y comprobación de la presión arterial. Debido a la simultaneidad de los eventos analizados (depresión, meta de presión y adhesión), se aplicó un sistema de ecuaciones no lineales recursivas y simultáneas. Los resultados sugieren que la oportunidad de encontrarse dentro de la meta de presión aumenta significativamente con la adhesión al tratamiento; también indican que los individuos que están en la meta de presión presentan una oportunidad 2,6 veces mayor de adhesión al tratamiento. La adhesión posee un efecto protector sobre la depresión: individuos con una adhesión mínima tienen 8,4 veces mayores oportunidades de desarrollar síntomas depresivos, cuando se comparan con los de máxima adhesión. La adhesión al tratamiento medicamentoso está relacionada simultáneamente con el control de la presión arterial y a menores niveles de depresión. Promover la adhesión al tratamiento con medicamentos es esencial para garantizar que los individuos se mantengan normotensos, con una potencial de reducción en los niveles de depresión. Estas externalidades positivas pueden reducir la presión sobre el sistema de salud, con beneficios simultáneos en la calidad de vida de los hipertensos.

Estimation of Health-Related Quality of Life Losses Owing to a Technological Disaster in Brazil Using EQ-5D-3L: A Cross-Sectional Study.

OBJECTIVES: In 2015, a dam collapsed at Samarco iron ore mine in the municipality of Mariana, Brazil, and contaminated more than 600 km of watercourses and destroyed almost 1600 acres of vegetation. Nineteen people died and more than 600 families lost their homes. This study aimed to estimate health-related quality of life (HRQoL) losses owing to this disaster. METHODS: We collected data from a probabilistic sample of 459 individuals aged 15 years or older. Household face-to-face interviews were conducted in December 2018. Pre-event data were not available for this population, so respondents were asked to evaluate at present and in retrospect their health status using EQ-5D-3L. The Minas Gerais societal value sets for EQ-5D-3L health preferences, estimated in 2011, were used to calculate utility losses. The health loss estimation from EQ-5D will form the basis for the calculation of compensation payments for the victims. RESULTS: Approximately 74% of the study population suffered some HRQoL loss. On average, EQ-5D index values decreased from 0.95 to 0.76. The greatest effects were observed for the anxiety/depression dimension, followed by pain/discomfort. Before the tragedy, the proportion of individuals with severe anxiety/depression and pain/discomfort was equal to 1% rising to 23% and 11%, respectively. CONCLUSIONS: Catastrophic losses owing to the Samarco disaster were found. The EQ-5D-3L instrument showed feasibility and sensitiveness to measure HRQoL losses owing to a negative health shock in a low-income Brazilian population.

Interações entre adesão ao tratamento medicamentoso, meta pressórica e depressão em hipertensos assistidos pela Estratégia Saúde da Família / Interactions between drug treatment adherence, blood pressure targets, and depression in hypertensive individuals receiving care in the Family Health Strategy / Interacciones entre la adhesión al tratamiento con medicamentos, meta de presión y depresión en hipertensos asistidos por la Estrategia Salud de la Familia

Resumo: Este trabalho analisa de que forma ocorre a interação entre adesão ao tratamento medicamentoso, meta pressórica e depressão em uma amostra probabilística de hipertensos assistidos pela Estratégia de Saúde da Família, de Governador Valadares, Minas Gerais, Brasil. Trata-se de um estudo transversal com 641 hipertensos de 40 anos e mais, residentes na zona urbana do município. Foram utilizados roteiros estruturados para a coleta de dados em entrevistas domiciliares, com foco nos indicadores: Medication Assessment Questionnaire (MAQ), Beck Depression Inventory (BDI) e aferição da pressão arterial. Devido à simultaneidade dos eventos analisados (depressão, meta pressórica e adesão), aplicou-se um sistema de equações não lineares recursivas e simultâneas. Os resultados sugerem que a chance de estar na meta pressórica aumenta significativamente com a adesão ao tratamento; também sugerem que indivíduos que estão na meta pressórica apresentam uma chance 2,6 vezes maior de adesão ao tratamento. A adesão possui efeito protetor sobre a depressão: indivíduos com adesão mínima possuem chances 8,4 vezes maiores de desenvolver sintomas depressivos quando comparados aos de máxima adesão. A adesão ao tratamento medicamentoso está relacionada simultaneamente ao controle da pressão arterial e a menores níveis de depressão. Promover a adesão ao tratamento medicamentoso é essencial para garantir que os indivíduos se mantenham normotensos, com potencial de redução nos níveis de depressão. Essas externalidades positivas podem reduzir a pressão sobre o sistema de saúde, com ganhos simultâneos na qualidade de vida dos hipertensos.

Abstract: The study analyzes interactions between drug treatment adherence, blood pressure targets, and depression in a probabilistic sample of hypertensive individuals treated in the Family Health Strategy in Governador Valadares, Minas Gerais State, Brazil. This is a cross-sectional study with 641 hypertensive individuals 40 years or older, residing in the urban area of Governador Valadares. Structured scripts were used to collect data in home interviews, with a focus on the following indicators: Medication Assessment Questionnaire (MAQ), Beck Depression Inventory (BDI), and blood pressure measurement. Due to the simultaneity of the target events (depression, blood pressure target, and adherence), we applied a system of recursive and simultaneous nonlinear equations. The results suggest that the odds of meeting the blood pressure target increase significantly with adherence to treatment; they also suggest that individuals that meet the blood pressure target show 2.6 higher odds of treatment adherence. Adherence has a protective effect against depression: individuals with minimal adherence show 8.4 higher odds of developing depressive symptoms when compared to those with maximum adherence. Drug treatment adherence is related simultaneously to blood pressure control and lower levels of depression. Promoting drug treatment adherence is essential for ensuring that individuals remain normotensive, with the potential for reducing levels of depression. These positive externalities can reduce pressure on the health system, with simultaneous gains in quality of life for hypertensive individuals.

Resumen: Este trabajo analiza de qué forma se produce la interacción entre la adhesión al tratamiento medicamentoso, meta de presión y depresión en una muestra probabilística de hipertensos, asistidos por la Estrategia Salud de la Familia de Governador Valadares, Minas Gerais, Brasil. Se trata de un estudio transversal con 641 hipertensos de 40 años y más, residentes en la zona urbana del municipio. Se utilizaron itinerarios estructurados para la recogida de datos, mediante entrevistas domiciliarias, centradas en los indicadores: Medication Assessment Questionnaire (MAQ), Beck Depression Inventory (BDI) y comprobación de la presión arterial. Debido a la simultaneidad de los eventos analizados (depresión, meta de presión y adhesión), se aplicó un sistema de ecuaciones no lineales recursivas y simultáneas. Los resultados sugieren que la oportunidad de encontrarse dentro de la meta de presión aumenta significativamente con la adhesión al tratamiento; también indican que los individuos que están en la meta de presión presentan una oportunidad 2,6 veces mayor de adhesión al tratamiento. La adhesión posee un efecto protector sobre la depresión: individuos con una adhesión mínima tienen 8,4 veces mayores oportunidades de desarrollar síntomas depresivos, cuando se comparan con los de máxima adhesión. La adhesión al tratamiento medicamentoso está relacionada simultáneamente con el control de la presión arterial y a menores niveles de depresión. Promover la adhesión al tratamiento con medicamentos es esencial para garantizar que los individuos se mantengan normotensos, con una potencial de reducción en los niveles de depresión. Estas externalidades positivas pueden reducir la presión sobre el sistema de salud, con beneficios simultáneos en la calidad de vida de los hipertensos.

Profile of general hospitals in the Unified Health System.

OBJECTIVE To characterize the organization of Brazilian general hospitals that provide services to the Unified Health System using indicators that describe the main dimensions of hospital care. METHODS A 2015 cross-sectional observational study, comprising the range of general hospitals that serve the Unified Health System. We constructed the hospital indicators from two national administrative databases: the National Registry of Health Facilities and the Hospital Information System of the Unified Health System. The indicators include the main dimensions associated with hospital care: public-private mix, production, production factors, performance, quality, case-mix and geographic coverage. Latent class analysis of indicators with bootstrapping was used to identify hospital profiles. RESULTS We identified three profiles, with hospital size being the variable with the highest degree of belonging. Small hospitals show low occupancy rates (21.36%) and high participation of hospitalizations that could have been solved with outpatient care, besides attending only medium complexity cases. They receive few non-residents, indicating that they are mainly dedicated to the local population. Medium-sized hospitals are more similar to small-sized ones: about 100% of the visits are of medium complexity, low occupancy rate (45.81%), high rate of hospitalizations for primary care sensitive conditions (17.10%) and relative importance in the healthcare provision of non-residents (26%). Large hospitals provide high complexity care, have an average occupancy rate of 64.73% and show greater geographical coverage. CONCLUSIONS The indicators point to three hospital profiles, characterized mainly by the production scale. Small hospitals show low performance, suggesting the need to reorganize hospital care provision, especially at the municipal level. The set of proposed indicators includes the main dimensions of hospital care, providing a tool that can help to plan and continuously monitor the hospital network of the Unified Health System.

The COVID-19 pandemic in Brazil: analysis of supply and demand of hospital and ICU beds and mechanical ventilators under different scenarios. / Pandemia por COVID-19 no Brasil: análise da demanda e da oferta de leitos hospitalares e equipamentos de ventilação assistida segundo diferentes cenários.

This study aims to analyze the pressure on the Brazilian health system from the additional demand created by COVID-19. The authors performed a series of simulations to estimate the demand for hospital beds (health micro-regions) as well as to ICU beds, and mechanical ventilators (health macro-regions) under different scenarios of intensity (infection rates equivalent to 0.01, 0.1, and 1 case por 100 inhabitants) and time horizons (1, 3, and 6 months). The results reveal a critical situation in the system for meeting this potential demand, with numerous health micro-regions and macro-regions operating beyond their capacity, compromising the care for patients, especially those with more severe symptoms. The study presents three relevant messages. First, it is necessary to slow the spread of COVID-19 in the Brazilian population, allowing more time for the reorganization of the supply and relieve the pressure on the health system. Second, the expansion of the number of available beds will be the key. Even if the private sector helps offset the deficit, the combined supply from the two sectors (public and private) would be insufficient in various macro-regions. The construction of field hospitals is important, both in places with a history of "hospital deserts" and in those already pressured by demand. The third message involves the regionalized organization of health services, whose design may be adequate in situations of routine demand, but which suffer additional challenges during pandemics, especially if patients have to travel long distances to receive care.

O objetivo deste estudo é analisar a pressão sobre o sistema de saúde no Brasil decorrente da demanda adicional gerada pela COVID-19. Para tanto, foi realizado um conjunto de simulações para estimar a demanda de leitos gerais (microrregiões de saúde), leitos de UTI e equipamentos de ventilação assistida (macrorregiões de saúde) em diferentes cenários, para intensidade (taxas de infecção equivalentes a 0,01, 0,1 e 1 caso por 100 habitantes) e horizontes temporais (1, 3 e 6 meses). Os resultados evidenciam uma situação crítica do sistema para atender essa demanda potencial, uma vez que diversas microrregiões e macrorregiões de saúde operariam além de sua capacidade, comprometendo o atendimento a pacientes principalmente aqueles com sintomas mais severos. O estudo apresenta três mensagens relevantes. Em primeiro lugar, é necessário reduzir a velocidade de propagação da COVID-19 na população brasileira, permitindo um tempo maior para a reorganização da oferta e aliviando a pressão sobre o sistema de saúde. Segundo, é necessário expandir o número de leitos disponíveis. Ainda que o setor privado contribua para amortecer o déficit de demanda, a oferta conjunta dos dois setores não seria suficiente em várias macrorregiões. A construção de hospitais de campanha é importante, tanto em locais onde historicamente há vazios assistenciais como também naqueles onde já se observa uma pressão do lado da demanda. A terceira mensagem diz respeito à organização regionalizada dos serviços de saúde que, apesar de adequada em situações de demanda usual, em momentos de pandemia este desenho implica desafios adicionais, especialmente se a distância que o paciente tiver de percorrer for muito grande.

El objetivo de este estudio es analizar la presión sobre el sistema de salud brasileño, ocasionada por la demanda adicional de camas hospitalarias y equipos de ventilación mecánica, generada por el COVID-19. Para tal fin, se realizó un conjunto de simulaciones, con el fin de estimar la demanda de camas generales (microrregiones de salud), camas de UTI y equipamientos de ventilación asistida (macrorregiones de salud) en diferentes escenarios, según la intensidad (tasas de infección equivalentes a 0,01, 0,1 y 1 caso por 100 habitantes) y horizontes temporales (1, 3 y 6 meses). Los resultados evidencian una situación crítica del sistema para atender esa demanda potencial, ya que diversas microrregiones y macrorregiones de salud operarían más allá de su capacidad, comprometiendo la atención a pacientes principalmente aquellos con los síntomas más graves. El estudio presenta tres mensajes relevantes. En primer lugar, es necesario reducir la velocidad de propagación del COVID-19 en la población brasileña, permitiendo un tiempo mayor para la reorganización de la oferta y aliviando la presión sobre el sistema de salud. En segundo lugar, es necesario expandir el número de camas disponibles. A pesar de que el sector privado contribuya a amortiguar el déficit de demanda, la oferta conjunta de los dos sectores no sería suficiente en varias macrorregiones. La construcción de hospitales de campaña es importante, tanto en lugares donde históricamente existen lagunas asistenciales, como también en aquellos donde ya se observa una presión por parte de la demanda. El tercer mensaje se refiere a la organización por regiones de los servicios de salud que, a pesar de ser adecuada en situaciones de demanda habitual, en momentos de pandemia, este diseño implica desafíos adicionales, especialmente si la distancia que el paciente tuviera que recorrer fuera muy lejana.

Brazilian hospitals' performance: an assessment of the unified health system (SUS).

This paper assesses the economic efficiency of Brazilian general hospitals that provide inpatient care for the Unified Health System (SUS). We combined data envelopment analysis (DEA) and spatial analysis to identify predominant clusters, measure hospital inefficiency and analyze the spatial pattern of inefficiency throughout the country. Our findings pointed to a high level of hospital inefficiency, mostly associated with small size and distributed across all Brazilian states. Many of these hospitals could increase production and reduce inputs to achieve higher efficiency standards. These findings suggest room for optimization, but inequalities in access and the matching of demand and supply must be carefully considered in any attempt to reorganize the hospital system in Brazil.

Live Births and Fertility Amid the Zika Epidemic in Brazil.

In late 2015, the Brazilian Ministry of Health and the Pan American Health Organization classified the increase in congenital malformations associated with the Zika virus (ZIKV) as a public health emergency. The risk of ZIKV-related congenital syndrome poses a threat to reproductive outcomes that could result in declining numbers of live births and potentially fertility. Using monthly microdata on live births from the Brazilian Information System on Live Births (SINASC), this study examines live births and fertility trends amid the ZIKV epidemic in Brazil. Findings suggest a decline in live births that is stratified across educational and geographic lines, beginning approximately nine months after the link between ZIKV and microcephaly was publicly announced. Although declines in total fertility rates were small, fertility trends estimated by age and maternal education suggest important differences in how Zika might have impacted Brazil's fertility structure. Further findings confirm the significant declines in live births in mid-2016 even when characteristics of the municipality are controlled for; these results highlight important nuances in the timing and magnitude of the decline. Combined, our findings illustrate the value of understanding how the risk of a health threat directed at fetuses has led to declines in live births and fertility.

Profile of general hospitals in the Unified Health System / Perfil dos hospitais gerais do Sistema Único de Saúde

ABSTRACT OBJECTIVE To characterize the organization of Brazilian general hospitals that provide services to the Unified Health System using indicators that describe the main dimensions of hospital care. METHODS A 2015 cross-sectional observational study, comprising the range of general hospitals that serve the Unified Health System. We constructed the hospital indicators from two national administrative databases: the National Registry of Health Facilities and the Hospital Information System of the Unified Health System. The indicators include the main dimensions associated with hospital care: public-private mix, production, production factors, performance, quality, case-mix and geographic coverage. Latent class analysis of indicators with bootstrapping was used to identify hospital profiles. RESULTS We identified three profiles, with hospital size being the variable with the highest degree of belonging. Small hospitals show low occupancy rates (21.36%) and high participation of hospitalizations that could have been solved with outpatient care, besides attending only medium complexity cases. They receive few non-residents, indicating that they are mainly dedicated to the local population. Medium-sized hospitals are more similar to small-sized ones: about 100% of the visits are of medium complexity, low occupancy rate (45.81%), high rate of hospitalizations for primary care sensitive conditions (17.10%) and relative importance in the healthcare provision of non-residents (26%). Large hospitals provide high complexity care, have an average occupancy rate of 64.73% and show greater geographical coverage. CONCLUSIONS The indicators point to three hospital profiles, characterized mainly by the production scale. Small hospitals show low performance, suggesting the need to reorganize hospital care provision, especially at the municipal level. The set of proposed indicators includes the main dimensions of hospital care, providing a tool that can help to plan and continuously monitor the hospital network of the Unified Health System.

RESUMO OBJETIVO Caracterizar a organização dos hospitais gerais brasileiros que prestam serviço ao Sistema Único de Saúde por meio de indicadores que descrevem as principais dimensões do cuidado hospitalar. MÉTODOS Estudo observacional transversal para o ano de 2015, compreendendo o universo dos hospitais gerais que atendem o Sistema Único de Saúde. Os indicadores hospitalares foram construídos a partir de duas bases de dados administrativos nacionais: o Cadastro Nacional de Estabelecimento de Saúde e o Sistema de Informações Hospitalares do Sistema Único de Saúde. Os indicadores contemplam as principais dimensões associadas ao cuidado hospitalar: mix público-privado, produção, fatores de produção, desempenho, qualidade, case-mix e abrangência geográfica. A análise de classes latentes dos indicadores com implementação do bootstrapping foi utilizada para a identificação dos perfis hospitalares. RESULTADOS Foram identificados três perfis, sendo porte hospitalar a variável com grau de pertencimento mais elevado. Os hospitais pequenos apresentam baixas taxas de ocupação (21,36%) e elevada participação de internações que poderiam ter sido solucionadas com cuidado ambulatorial, além de atenderem somente a média complexidade. Recebem poucos não residentes, indicando que estão dedicados praticamente à população local. Os hospitais de médio porte se assemelham mais aos de pequeno porte: cerca de 100% dos atendimentos são de média complexidade, baixa taxa de ocupação (45,81%), elevada taxa de internações por condições sensíveis à atenção primária (17,10%) e relativa importância no atendimento de não residentes (26%). Os hospitais grandes realizam os atendimentos de alta complexidade, têm taxa de ocupação média de 64,73% e apresentam maior abrangência geográfica. CONCLUSÕES Os indicadores apontam três perfis de hospitais, caracterizados principalmente pela escala de produção. Os hospitais de pequeno porte apresentam baixa performance, sugerindo a necessidade de reorganização da oferta do cuidado hospitalar, principalmente no nível municipal. O conjunto dos indicadores propostos inclui as principais dimensões do cuidado hospitalar, fornecendo uma ferramenta que pode ser utilizada no planejamento e monitoramento contínuo da rede hospitalar do Sistema Único de Saúde.

Desejo por filhos entre mulheres de alta escolaridade: conflitos, mudanças e permanências / Desire for motherhood among women with higher education: conflict, change and permanence / Deseo de hijos entre mujeres con educación superior: conflictos, cambios y permanencias

Este trabalho analisa as percepções e os significados da maternidade para um grupo de mulheres de alta escolaridade, casadas ou em união consensual, com no máximo um filho, residentes em um município mineiro de porte médio. Os dados provêm de 16 entrevistas semiestruturadas, realizadas em 2018 no município de Governador Valadares, MG. Os resultados indicam que, embora a maternidade seja um acontecimento desejado e valorizado, a decisão dessas mulheres não é isenta de dúvidas em relação às dificuldades para conciliar um filho com o desejo de liberdade e crescimento profissional. Essas dúvidas decorrem do fato de a maternidade ainda ter um lugar de destaque na vida das mulheres, mesmo entre um grupo de vanguarda, e se tornar mãe permanece tendo um efeito expressivo em suas vidas. Os conflitos gerados pela concomitância entre a permanência do desejo relacionado à maternidade e a emergência de novos projetos individuais apresentados às mulheres desafiam a lógica tradicional que relaciona escolaridade e projetos reprodutivos.

This paper analyzes the perceptions and meanings of motherhood for a group of women with high education, married or in consensual union, with no more than one child, residents of a mid-size city. Data come from sixteen semi-structured interviews conducted in 2018 in the municipality of Governador Valadares, MG. Results show that although motherhood is a desired and valued event, the decision is loaded with doubts regarding the difficulties to reconcile raising a child with the desire for freedom and professional growth. Doubts emerge as motherhood continues to have a prominent place in women's lives, even within a rather avant-garde group. Becoming a mother remains a significant event in their lives. Conflicts generated by the simultaneous existence of the desire to be a mother and the new individual projects unveiled to women defies the common perception that links schooling to reproductive intentions.

Este artículo analiza las percepciones y los significados de la maternidad para un grupo de mujeres con educación superior, casadas o en unión consensual sin hijos o, como máximo, un hijo, residentes de una ciudad de tamaño mediano. Los datos provienen de 16 entrevistas semiestructuradas hechas en Governador Valadares, Minas Gerais, en 2018. Los resultados indican que, aunque la maternidad es un evento deseado y valorado, la decisión de estas mujeres educadas no es indudable en relación con las dificultades para conciliar a un niño con el deseo de libertad y crecimiento profesional porque la maternidad todavía tiene un lugar destacado en la vida de las mujeres y convertirse en madre sigue teniendo un efecto significativo en sus vidas. Los conflictos generados por la concomitancia entre la persistencia del deseo relacionado con la maternidad y la aparición de nuevos proyectos individuales para las mujeres desafían la lógica tradicional que relaciona los proyectos escolares y reproductivos.

Pandemia por COVID-19 no Brasil: análise da demanda e da oferta de leitos hospitalares e equipamentos de ventilação assistida segundo diferentes cenários / Pandemia por COVID-19 en Brasil: análisis de la demanda y oferta de camas hospitalarias, así como equipamientos de ventilación asistida, según diferentes escenarios / The COVID-19 pandemic in Brazil: analysis of supply and demand of hospital and ICU beds and mechanical ventilators under different scenarios

O objetivo deste estudo é analisar a pressão sobre o sistema de saúde no Brasil decorrente da demanda adicional gerada pela COVID-19. Para tanto, foi realizado um conjunto de simulações para estimar a demanda de leitos gerais (microrregiões de saúde), leitos de UTI e equipamentos de ventilação assistida (macrorregiões de saúde) em diferentes cenários, para intensidade (taxas de infecção equivalentes a 0,01, 0,1 e 1 caso por 100 habitantes) e horizontes temporais (1, 3 e 6 meses). Os resultados evidenciam uma situação crítica do sistema para atender essa demanda potencial, uma vez que diversas microrregiões e macrorregiões de saúde operariam além de sua capacidade, comprometendo o atendimento a pacientes principalmente aqueles com sintomas mais severos. O estudo apresenta três mensagens relevantes. Em primeiro lugar, é necessário reduzir a velocidade de propagação da COVID-19 na população brasileira, permitindo um tempo maior para a reorganização da oferta e aliviando a pressão sobre o sistema de saúde. Segundo, é necessário expandir o número de leitos disponíveis. Ainda que o setor privado contribua para amortecer o déficit de demanda, a oferta conjunta dos dois setores não seria suficiente em várias macrorregiões. A construção de hospitais de campanha é importante, tanto em locais onde historicamente há vazios assistenciais como também naqueles onde já se observa uma pressão do lado da demanda. A terceira mensagem diz respeito à organização regionalizada dos serviços de saúde que, apesar de adequada em situações de demanda usual, em momentos de pandemia este desenho implica desafios adicionais, especialmente se a distância que o paciente tiver de percorrer for muito grande.

El objetivo de este estudio es analizar la presión sobre el sistema de salud brasileño, ocasionada por la demanda adicional de camas hospitalarias y equipos de ventilación mecánica, generada por el COVID-19. Para tal fin, se realizó un conjunto de simulaciones, con el fin de estimar la demanda de camas generales (microrregiones de salud), camas de UTI y equipamientos de ventilación asistida (macrorregiones de salud) en diferentes escenarios, según la intensidad (tasas de infección equivalentes a 0,01, 0,1 y 1 caso por 100 habitantes) y horizontes temporales (1, 3 y 6 meses). Los resultados evidencian una situación crítica del sistema para atender esa demanda potencial, ya que diversas microrregiones y macrorregiones de salud operarían más allá de su capacidad, comprometiendo la atención a pacientes principalmente aquellos con los síntomas más graves. El estudio presenta tres mensajes relevantes. En primer lugar, es necesario reducir la velocidad de propagación del COVID-19 en la población brasileña, permitiendo un tiempo mayor para la reorganización de la oferta y aliviando la presión sobre el sistema de salud. En segundo lugar, es necesario expandir el número de camas disponibles. A pesar de que el sector privado contribuya a amortiguar el déficit de demanda, la oferta conjunta de los dos sectores no sería suficiente en varias macrorregiones. La construcción de hospitales de campaña es importante, tanto en lugares donde históricamente existen lagunas asistenciales, como también en aquellos donde ya se observa una presión por parte de la demanda. El tercer mensaje se refiere a la organización por regiones de los servicios de salud que, a pesar de ser adecuada en situaciones de demanda habitual, en momentos de pandemia, este diseño implica desafíos adicionales, especialmente si la distancia que el paciente tuviera que recorrer fuera muy lejana.

This study aims to analyze the pressure on the Brazilian health system from the additional demand created by COVID-19. The authors performed a series of simulations to estimate the demand for hospital beds (health micro-regions) as well as to ICU beds, and mechanical ventilators (health macro-regions) under different scenarios of intensity (infection rates equivalent to 0.01, 0.1, and 1 case por 100 inhabitants) and time horizons (1, 3, and 6 months). The results reveal a critical situation in the system for meeting this potential demand, with numerous health micro-regions and macro-regions operating beyond their capacity, compromising the care for patients, especially those with more severe symptoms. The study presents three relevant messages. First, it is necessary to slow the spread of COVID-19 in the Brazilian population, allowing more time for the reorganization of the supply and relieve the pressure on the health system. Second, the expansion of the number of available beds will be the key. Even if the private sector helps offset the deficit, the combined supply from the two sectors (public and private) would be insufficient in various macro-regions. The construction of field hospitals is important, both in places with a history of "hospital deserts" and in those already pressured by demand. The third message involves the regionalized organization of health services, whose design may be adequate in situations of routine demand, but which suffer additional challenges during pandemics, especially if patients have to travel long distances to receive care.

Signifying Zika: heterogeneity in the representations of the virus by history of infection.

Despite having been broadly advertised by the mass media, many negative consequences of the Zika virus have been less significant than originally predicted. It is likely that after a few months from the epidemic's onset, personal experience with the virus has altered the person's way to deal with the disease. This study explores the relation between exposure to Zika virus and the social representation of the epidemic. More specifically, one analyzes if increased exposure to the risk of Zika infection changes the characteristics of the web of meanings surrounding the epidemic. Between August and November of 2016, 150 interviews were conducted in the municipality of Governador Valadares, Minas Gerais State, Brazil. Based on the Free Words Association Technique, data on evocations related to the Zika virus were modeled by social network analysis, allowing the characterization of the web of meanings by level of exposure to the risk of Zika infection. The analysis performed here suggests that those never infected by any disease transmitted by the Aedes aegypti mosquito have a lesser representation, incorporating information from the media through lay thinking. In contrast to those with low levels of exposure, the social representation of people infected by Zika is associated with meanings related to the most common symptoms, such as pain, rash, and itching. Personal experience seems to shape the social representation of the disease, increasing the focus on its proximate consequences. Public campaigns designed to foster protective behavior should take into consideration the heterogeneity in the representations of this epidemic to improve adherence to preventive behavior.

Signifying Zika: heterogeneity in the representations of the virus by history of infection / Dando significado ao vírus Zika: heterogeneidade nas representações sociais do vírus de acordo com a história de infecção / Dando significado al virus Zika: heterogeneidad en las representaciones del virus por el historial de infección

Abstract: Despite having been broadly advertised by the mass media, many negative consequences of the Zika virus have been less significant than originally predicted. It is likely that after a few months from the epidemic's onset, personal experience with the virus has altered the person's way to deal with the disease. This study explores the relation between exposure to Zika virus and the social representation of the epidemic. More specifically, one analyzes if increased exposure to the risk of Zika infection changes the characteristics of the web of meanings surrounding the epidemic. Between August and November of 2016, 150 interviews were conducted in the municipality of Governador Valadares, Minas Gerais State, Brazil. Based on the Free Words Association Technique, data on evocations related to the Zika virus were modeled by social network analysis, allowing the characterization of the web of meanings by level of exposure to the risk of Zika infection. The analysis performed here suggests that those never infected by any disease transmitted by the Aedes aegypti mosquito have a lesser representation, incorporating information from the media through lay thinking. In contrast to those with low levels of exposure, the social representation of people infected by Zika is associated with meanings related to the most common symptoms, such as pain, rash, and itching. Personal experience seems to shape the social representation of the disease, increasing the focus on its proximate consequences. Public campaigns designed to foster protective behavior should take into consideration the heterogeneity in the representations of this epidemic to improve adherence to preventive behavior.

Resumo: Apesar de amplamente noticiadas pela grande mídia, muitas das consequências negativas do vírus Zika foram menos significativas em relação às previsões originais. É provável que depois de alguns meses de epidemia, a experiência pessoal com o vírus já tenha alterado a maneira individual de lidar com a doença. Este estudo explora a relação entre a exposição ao vírus Zika e as representações sociais da epidemia. Mais especificamente, analisamos se o aumento da exposição ao risco de infecção pelo vírus Zika altera as características da teia de significados em torno da epidemia. Entre agosto e novembro de 2016, foram realizadas 150 entrevistas no Município de Governador Valadares, Minas Gerais, Brasil. Com base na técnica do Teste de Associação de Palavras, os dados de citações relacionadas ao vírus Zika foram modelados através da análise de redes sociais, permitindo a caracterização da teia de significados de acordo com o nível de exposição ao risco de infecção. A análise feita aqui sugere que pessoas que nunca foram infectadas por qualquer vírus transmitido pelo Aedes aegypti têm uma representação menos completa, incorporando informações da mídia através do pensamento leigo. Ao contrário daquelas com baixos níveis de exposição, a representação social feita por pessoas infectadas com o vírus Zika está associada aos significados relacionados aos sintomas mais comuns, como dor, exantema e prurido. A experiência pessoal parece moldar a representação social da doença, aumentando o foco nas consequências mais próximas. As campanhas públicas para promover o comportamento preventivo devem levar em conta a heterogeneidade das representações dessa epidemia para poder melhorar a aderência.

Resumen: A pesar de haber sido divulgado ampliamente por los medios de comunicación, muchas de las consecuencias negativas del virus del Zika han sido menos significativas de lo que se predijo originalmente. Parece que tras unos cuantos meses desde el inicio de la epidemia, la experiencia personal con el virus ha alterado la percepción personal sobre cómo lidiar con la enfermedad. Este estudio investiga la relación entre la exposición al virus Zika y la representación social de la epidemia. Más específicamente, este estudio analiza si una mayor exposición al riesgo de infección debida al Zika, modifica las características de la red de significados sobre epidemias. Entre agosto y noviembre de 2016, se realizaron 150 entrevistas en el municipio de Governador Valadares, Minas Gerais, Brasil. Basado en la Free Words Association Technique, la información sobre referencias relacionadas con el virus del Zika se modelaron mediante un análisis del entorno social, permitiendo la caracterización de la red de significados por el nivel de exposición al riesgo de la infección debida al Zika. El análisis realizado aquí sugiere que quienes nunca fueron infectados por ninguna enfermedad transmitida por el mosquito Aedes aegypti tienen una menor representación, incorporando información de los medios de comunicación, a través de un pensamiento generalista. En contraposición con quienes tuvieron un bajo nivel de exposición, la representación social de la gente infectada por Zika está asociada con significados relacionados con los síntomas más comunes, como dolor, sarpullido, y picores. La experiencia personal parece configurar la representación social de la enfermedad, aumentando centro de atención en sus consecuencias más próximas. Las campañas públicas diseñadas para fomentar comportamientos de protección deberían tener en consideración la heterogeneidad en las representaciones sociales de esta epidemia para mejorar la adhesión al tratamiento de la misma.