Atenção primária à saúde infantil: a maior avaliação de base populacional da história do SUS / Primary child health care: the largest population-based assessment in the history of Brazilian National Health System

Resumo Desde 2019, o IBGE vem ocupando no cenário da avaliação de políticas públicas no Brasil um local de protagonismo. Após a Pesquisa Nacional de Saúde (PNS) avaliar os serviços de atenção primária no Sistema Único de Saúde (SUS) prestados aos adultos, em 2022 a Pesquisa Nacional por Amostra de Domicílios Contínua (PNAD-C) investigou o cuidado infantil. Para isso, utilizou uma das versões do Primary Care Assessment Tool (PCAT), desenvolvido e disseminado por Starfield e Shi para avaliar a existência e extensão dos atributos dos serviços de atenção primária à saúde (APS). O público-alvo pesquisado incluiu crianças menores de 13 anos, e os questionários foram respondidos por seus responsáveis/cuidadores. Contemplou todas as 27 unidades da federação do país, em amostras aleatórias probabilísticas, desdobrando-se ainda pelas regiões metropolitanas e capitais do Brasil. Trata-se do maior inquérito domiciliar sobre avaliação da saúde infantil já realizado no Brasil. A partir da PNS-2019 e da PNAD-C em 2022, o IBGE inaugura seu maior legado para a atenção primária à saúde no Brasil no que se refere à avaliação dos usuários do SUS, com todas as unidades da federação (re)conhecendo como a sociedade brasileira avalia os serviços de saúde no primeiro nível de atenção.

Abstract The IBGE has been playing a leading role in the public policy evaluation in Brazil since 2019. After the National Health Survey (PNS) evaluated primary care services in the Unified Health System (SUS) provided to adults, in 2022, the Continuous National Household Sample Survey (PNAD-C) investigated child health. To this end, it adopted one version of the Primary Care Assessment Tool (PCAT), developed and disseminated by Starfield and Shi to assess the existence and extent of the attributes of PHC services. The target audience surveyed included children under 13 years of age, and the questionnaires were answered by their guardians/caregivers. It included all the 27 federative units of the country in random probabilistic samples, also unfolding in the Brazilian metropolitan regions and capitals. This is the largest household survey on child health assessment ever conducted in Brazil. With the PNS-2019 and the PNAD-C in 2022, IBGE inaugurates its greatest legacy for Brazilian primary health care regarding the evaluation of SUS users, with all federative units recognizing and understanding how Brazilian society evaluates health services at the first level of care.

Addressing recall bias in (post-)conflict data collection and analysis: lessons from a large-scale health survey in Colombia.

BACKGROUND: Much applied research on the consequences of conflicts for health suffers from data limitations, particularly the absence of longitudinal data spanning pre-, during- and post-conflict periods for affected individuals. Such limitations often hinder reliable measurement of the causal effects of conflict and their pathways, hampering also the design of effective post-conflict health policies. Researchers have sought to overcome these data limitations by conducting ex-post surveys, asking participants to recall their health and living standards before (or during) conflict. These questions may introduce important analytical biases due to recall error and misreporting. METHODS: We investigate how to implement ex-post health surveys that collect recall data, for conflict-affected populations, which is reliable for empirical analysis via standard quantitative methods. We propose two complementary strategies based on methods developed in the psychology and psychometric literatures-the Flashbulb and test-retest approaches-to identify and address recall bias in ex-post health survey data. We apply these strategies to the case study of a large-scale health survey which we implemented in Colombia in the post-peace agreement period, but that included recall questions referring to the conflict period. RESULTS: We demonstrate how adapted versions of the Flashbulb and test-retest strategies can be used to test for recall bias in (post-)conflict survey responses. We also show how these test strategies can be incorporated into post-conflict health surveys in their design phase, accompanied by further ex-ante mitigation strategies for recall bias, to increase the reliability of survey data analysis-including by identifying the survey modules, and sub-populations, for which empirical analysis is likely to yield more reliable causal inference about the health consequences of conflict. CONCLUSIONS: Our study makes a novel contribution to the field of applied health research in humanitarian settings, by providing practical methodological guidance for the implementation of data collection efforts in humanitarian contexts where recall information, collected from primary surveys, is required to allow assessments of changes in health and wellbeing. Key lessons include the importance of embedding appropriate strategies to test and address recall bias into the design of any relevant data collection tools in post-conflict or humanitarian contexts.

Primary Care Asssement Tool: diferenças regionais a partir da Pesquisa Nacional de Saúde do Instituto Brasileiro de Geografia e Estatística / Primary Care Assessment Tool: regional differences based on the National Health Survey from Instituto Brasileiro de Geografia e Estatística

Resumo Em 2019, o Instituto Brasileiro de Geografia e Estatística (IBGE) de forma inédita entre os institutos oficiais de estatística em todo o mundo, incluiu um módulo especial sobre avaliação da atenção primária à saúde em seu principal inquérito populacional de base domiciliar, a Pesquisa Nacional de Saúde (PNS). O inquérito considerou a versão reduzida do instrumento Primary Care Assessment Tool (PCAT), desenvolvida e disseminada por Starfield e Shi para avaliar a existência e extensão das características de estrutura e processos dos serviços de atenção primária em saúde. Trata-se da maior amostra probabilística com o uso desse instrumento já realizada em um único país do mundo que entrevistou usuários com 18 anos ou mais (n = 9.677). Os resultados dos escores gerais do PCAT do Brasil (5,9 [5,8; 5,9]) apontam grandes contrastes regionais e intraregionais, com a região Sul do país destacando-se com as melhores avaliações dos serviços de atenção primária (escore geral = 6,3 [6,2; 6,5]) e a região norte, por outro lado, com as menores (escore geral = 5,5 [5,3; 5,7]). Foram também observadas diferenças estatisticamente significantes e mais favoráveis entre os moradores de domicílios cadastrados pelas equipes de saúde da família, entre os mais idosos e entre que mais utilizam os serviços de saúde (adultos com morbidades referidas).

Abstract In 2019, unprecedentedly among the official statistical institutes worldwide, the IBGE included a particular module on evaluating primary health care in its central population-based population survey, the National Health Survey (PNS-2019). The survey considered the reduced version of the Primary Care Assessment Tool (PCAT), developed and disseminated by Starfield and Shi, to assess the existence and extent of the structure and process characteristics of PHC services. It is the most significant probabilistic sample using this instrument ever conducted in a single country in the world that interviewed users aged 18 or over (n=9,677). The results of the Brazilian overall PCAT scores (5.9 [5.8; 5.9]) point to significant regional and intraregional contrasts, with the South of the country standing out with the best evaluations of primary care services (overall score = 6.3 [6.2; 6.5]) and the North with the worse (overall score = 5,5 [5,3; 5,7]). There were also statistically significant and more favorable differences between residents of households registered by family health teams, among older adults, and those using health services the most (adults with reported morbidities).

Primary Care Asssement Tool (PCAT): a construção de uma nova linha de base para avaliação dos serviços de saúde no Brasil / Primary Care Assessment Tool (PCAT): developing a new baseline for evaluating Brazilian health services

Resumo No Brasil, no âmbito do SUS, a APS ganhou relevância a partir da estruturação da Estratégia Saúde da Família entre as décadas de 1990/2000. Existem inúmeros instrumentos para a avaliação desses serviços no mundo. Dentre eles, destaca-se a família de instrumentos do Primary Care Assessment Tool (PCAT), desenvolvida e disseminada por Starfield e Shi para avaliar a existência e extensão das características dos serviços de atenção primária em saúde. Reforçando a importância do uso desse instrumento no Brasil, o Ministério da Saúde publicou em 2020, uma nova edição da versão brasileira que informa a metodologia utilizada, resgatando o papel do IBGE como grande avaliador externo do SUS. O IBGE incluiu de forma pioneira em seu principal inquérito amostral domiciliar, a Pesquisa Nacional de Saúde, um módulo de perguntas da versão reduzida do PCAT para usuários adultos. Os principais resultados globais encontrados (escore geral=5,9) informam que aqueles que mais utilizam os serviços de APS (adultos com morbidades referidas), são também os que avaliam mais positivamente tais serviços. Também foram observadas diferenças entre os moradores de domicílios cadastrados pelas equipes de Saúde da Família, entre os que recebem visitas de agentes comunitários e agentes de endemias e, por faixa etária (os mais idosos avaliam de forma mais positiva os serviços).

Abstract In Brazil, within the SUS, Primary Health Care (PHC) gained relevance from the Family Health Strategy's structuring from the 1990s to the 2000s. Several instruments are available in the world to evaluate PHC services, including the family of instruments of the Primary Care Assessment Tool (PCAT), developed and disseminated by Starfield & Shi to assess the existence and extent of the features of primary health care services. Reinforcing the importance of using this instrument in Brazil, the Ministry of Health published in 2020 a new edition of the Brazilian version that informs the methodology used for such instruments, reviving the role of IBGE as a significant external evaluator of the SUS. The IBGE pioneered in its primary household random sample survey, the National Health Survey, a question-based module of the reduced version of the PCAT for adult users. The leading global results found for Brazil (overall PCAT score=5.9) inform that those who use PHC services (adults with referred morbidities) the most are also those who evaluate these services most positively. Differences were also observed among the residents of households registered by the family health teams, those receiving visits from the community and endemic workers, and age groups (older people evaluate services more positively).

Geospatial estimation of reproductive, maternal, newborn and child health indicators: a systematic review of methodological aspects of studies based on household surveys.

BACKGROUND: Geospatial approaches are increasingly used to produce fine spatial scale estimates of reproductive, maternal, newborn and child health (RMNCH) indicators in low- and middle-income countries (LMICs). This study aims to describe important methodological aspects and specificities of geospatial approaches applied to RMNCH coverage and impact outcomes and enable non-specialist readers to critically evaluate and interpret these studies. METHODS: Two independent searches were carried out using Medline, Web of Science, Scopus, SCIELO and LILACS electronic databases. Studies based on survey data using geospatial approaches on RMNCH in LMICs were considered eligible. Studies whose outcomes were not measures of occurrence were excluded. RESULTS: We identified 82 studies focused on over 30 different RMNCH outcomes. Bayesian hierarchical models were the predominant modeling approach found in 62 studies. 5 × 5 km estimates were the most common resolution and the main source of information was Demographic and Health Surveys. Model validation was under reported, with the out-of-sample method being reported in only 56% of the studies and 13% of the studies did not present a single validation metric. Uncertainty assessment and reporting lacked standardization, and more than a quarter of the studies failed to report any uncertainty measure. CONCLUSIONS: The field of geospatial estimation focused on RMNCH outcomes is clearly expanding. However, despite the adoption of a standardized conceptual modeling framework for generating finer spatial scale estimates, methodological aspects such as model validation and uncertainty demand further attention as they are both essential in assisting the reader to evaluate the estimates that are being presented.

Nutritional Deprivation Index is negatively associated with socio-economic factors in Paraguayan households.

The present study aimed to examine the nutritional deprivation of Paraguayan households (measured as households' access to diverse diets) and investigate the association between nutritional deprivation and socio-economic characteristics in a large sample. An extension of Alkire-Foster methodology, a technique widely employed in multidimensional poverty measurement, was used to calculate both the incidence and intensity of nutritional deprivation. The resulting Nutritional Deprivation Index allows us to consider minimum food group requirements that vary by food groups as well as by individual characteristics such as age, sex and activity level. Applying the methodology to a nationally representative sample of households from the 2011-2012 Income and Expenditures Household Survey, the study found that about two in every three Paraguayan households (67 %) were inadequately nourished in at least four (of the total of six) food groups. Although no significant differences were found between rural and urban households, the incidence of multi-dimensionally deprived households generally decreased as income increased. Logistic regression results showed that nutritional deprivation decreased as household income and mother's education increased and increased with household size. Our study concludes that the majority of Paraguayan households is significantly nutritionally deprived across most food groups and suggests that strategies are needed to improve their access to diverse diets, especially among its lower- and middle-income segments.

Estimating access to drinking water and sanitation: The need to account for uncertainty in trend analysis.

Nationally representative household surveys are the main source of data for tracking drinking water, sanitation and hygiene (WASH) coverage. However, all survey point estimates have a certain degree of error that must be considered when interpreting survey results for policy and decision making. In this article, we develop an approach to characterize and quantify uncertainty around WASH estimates. We apply it to four countries - Bolivia, Gambia, Morocco and India - representing different regions, number of data points available and types of trajectories, in order to illustrate the importance of communicating uncertainty for temporal estimates, as well as taking into account both the compositional nature and non-linearity of JMP data. The approach is found to be versatile and particularly useful in the WASH sector, where the dissemination and analysis of standard errors lag behind. While it only considers the uncertainty arising from sampling, the proposed approach can help improve the interpretation of WASH data when evaluating trends in coverage and informing decision making.

Antenatal care as a means to increase participation in the continuum of maternal and child healthcare: an analysis of the poorest regions of four Mesoamérican countries.

BACKGROUND: Antenatal care (ANC) is a means to identify high-risk pregnancies and educate women so that they might experience a healthier delivery and outcome. There is a lack of evidence about whether receipt of ANC is an effective strategy for keeping women in the system so they partake in other maternal and child interventions, particularly for poor women. The present analysis examines whether ANC uptake is associated with other maternal and child health behaviors in poor mothers in Guatemala, Honduras, Nicaragua, and Mexico (Chiapas). METHODS: We conducted a cross-sectional survey of women regarding their uptake of ANC for their most recent delivery in the last two years and their uptake of selected services and healthy behaviors along a continuity of maternal and child healthcare. We conducted logistic regressions on a sample of 4844 births, controlling for demographic, household, and maternal characteristics to understand the relationship between uptake of ANC and later participation in the continuum of care. RESULTS: Uptake of four ANC visits varied by country from 17.0% uptake in Guatemala to 81.4% in Nicaragua. In all countries but Nicaragua, ANC was significantly associated with in-facility delivery (IFD) (Guatemala odds ratio [OR] = 5.28 [95% confidence interval [CI] 3.62-7.69]; Mexico OR = 5.00 [95% CI: 3.41-7.32]; Honduras OR = 2.60 [95% CI: 1.42-4.78]) and postnatal care (Guatemala OR = 4.82 [95% CI: 3.21-7.23]; Mexico OR = 4.02 [95% CI: 2.77-5.82]; Honduras OR = 2.14 [95% CI: 1.26-3.64]), but did not appear to have any positive relationship with exclusive breastfeeding habits or family planning methods, which may be more strongly determined by cultural influences. CONCLUSIONS: Our results demonstrate that uptake of the WHO-recommended four ANC visits has limited effectiveness on uptake of services in some poor populations in Mesoamérica. Our study highlights the need for continued and varied efforts in these populations to increase both the uptake and the effectiveness of ANC in encouraging positive and lasting effects on women's uptake of health care services.

Análisis de factores asociados a la asistencia a citas médicas preventivas. El caso de Bogotá, Colombia 2014

bjetivo: analizar los factores asociados a la asistencia a citas médicas preventivas en la ciudad de Bogotá en el año 2014.Métodos: se ajustaron dos modelos de Ecuaciones de Estimación Generalizadas (GEE) con función de enlace Bernoulli y estructuras de correlación independiente y simétrica compuesta para la variable de asistencia a citas médicas preventivas.Resultados: el nivel de ingreso, el estrato socioeconómico y el nivel educativo alcanzado por el jefe de hogar generan un aumento en la probabilidad de asistir a citas médicas preventivas: la razón de probabilidad de asistencia y no asistencia es por lo menos 1,5 veces mayor en miembros de hogares de estratos distintos al 1 y por cada 100 mil pesos adicionales en el ingreso mensual del hogar dicha razón se incrementa en 1 %. Aquellos miembros pertenecientes a hogares, cuyo jefe alcanzó un nivel educativo superior a primaria tienen una razón de probabilidad de asistencia y no asistencia a citas preventivas hasta 2,3 veces mayor.Conclusiones: los resultados coinciden con los de Grossman (1972) y Kenkel (1990); sin embargo, aspectos como el nivel educativo individual, la presencia de adultos mayores e infantes o inclusive de un cónyuge en el hogar no están relacionados con la asistencia a citas médicas preventivas.

bjective: Analyze factors involved in preventive medical appointments attendance in Bogota year 2014.Methods: two models were adjusted under GEE using a Bernoulli link function with independent and exchangeable correlation structures for preventive medical appointments attendance.Results: Income and socioeconomic stratum increase probability of preventive appointments attendance: Odds ratio of attendance and not attendance is at least 1,5 times higher in stratum 2 or higher households. Also, for every $100.000 additional pesos in monthly household income the reason increases by 1%. Household members which head reached an educational level higher than primary have an odds ratio of attendance and not attendance up to 2,3 times higher.Conclusions: Results are similar to Grossman (1972) and Kenkel (1990) nevertheless, individual educational level, presence in household of elder people or children and even presence of spouse are not related with preventive medical appointments attendance.

Incidencia del gasto catastrófico en salud de los hogares costarricenses 2004 y 2013

bjetivo: identificar el porcentaje de hogares cuyos desembolsos por concepto del gasto de bolsillo pueden llegar a constituirse en una catástrofe financiera (30 o 40%del ingreso familiar).Métodos:se utiliza el módulo de Equidad y Protección Financiera del software ADePT, del Grupo de Investigación y Desarrollo del Banco Mundial, así como una serie de rutinas programables que replican la metodología de análisis del gasto catastrófico del estudio desarrollado por Knaul, Wong, y Arreola-Ornelas (2012).Resultados: la incidencia de gasto catastrófico se incrementó levemente al pasar de un 0.6 % de los hogares en el año 2004 a un 0.8 % en el 2013.Conclusiones:la incidencia del gasto catastrófico en salud de los hogares costarricenses no representa un problema para el sistema de salud costarricense, pero es un aspecto que debe focalizarse a sus características estructurales.

bjetive: Identify the percentage of households whose out-of-pocket expenditures turn out to be a financial catastrophe (thirty to forty percent of household income).Methods: The World Bank's Research and Development Group Equity and Financial Protection module ADePT software is used along with a series of programmable routines that replicate the catastrophic expenditure analysis methodology of the study developed by Knaul, Wong, and Arreola-Ornelas (2012).Results: The incidence of catastrophic expenditure increased slightly from 0.6 percent of households in 2004 to 0.8 percent in 2013.Conclusions: The incidence of catastrophic health expenditure in Costa Rican households is not a problem for the Costa Rican health system, but the concern should be issue targeted.

Coverage and timing of antenatal care among poor women in 6 Mesoamerican countries.

BACKGROUND: Poor women in the developing world have a heightened need for antenatal care (ANC) but are often the least likely to attend it. This study examines factors associated with the number and timing of ANC visits for poor women in Guatemala, Honduras, Mexico, Nicaragua, Panama, and El Salvador. METHODS: We surveyed 8366 women regarding the ANC they attended for their most recent birth in the past two years. We conducted logistic regressions to examine demographic, household, and health characteristics associated with attending at least one skilled ANC visit, four skilled visits, and a skilled visit in the first trimester. RESULTS: Across countries, 78 % of women attended at least one skilled ANC visit, 62 % attended at least four skilled visits, and 56 % attended a skilled visit in the first trimester. The proportion of women attending four skilled visits was highest in Nicaragua (81 %) and lowest in Guatemala (18 %) and Panama (38 %). In multiple countries, women who were unmarried, less-educated, adolescent, indigenous, had not wanted to conceive, and lacked media exposure were less likely to meet international ANC guidelines. In countries with health insurance programs, coverage was associated with attending skilled ANC, but not the timeliness. CONCLUSIONS: Despite significant policy reforms and initiatives targeting the poor, many women living in the poorest regions of Mesoamérica are not meeting ANC guidelines. Both supply and demand interventions are needed to prioritize vulnerable groups, reduce unplanned pregnancies, and reach populations not exposed to common forms of media. Top performing municipalities can inform effective practices across the region.

A distribuição de renda nas pesquisas domiciliares brasileiras: harmonização e comparação entre Censos, PNADs e POFs / /Income distribution according to Brazilian household surveys: harmonization and comparison of Census, PNAD and POF data / /La distribución del ingreso en las encuestas de hogares brasileñas: armonización y comparación entre los censos, las PNAD y las POF

O objetivo deste trabalho é documentar e explicar as diferenças nas distribuições de renda do Censo Demográfico, da Pesquisa Nacional por Amostra de Domicílios (PNAD) e da Pesquisa de Orçamentos Familiares (POF). A principal hipótese é a de que é possível promover grande convergência dos resultados entre as três pesquisas com procedimentos de harmonização ex post, que compatibilizam, na medida do possível, diferenças amostrais, conceituais e de coleta e tratamento dos dados. Os resultados confirmam, em boa medida, esta hipótese: de modo geral, a harmonização aproxima as três pesquisas e reduz significativamente as maiores discrepâncias entre as distribuições de renda, em especial na comparação entre Censo e PNAD. Embora persistam em alguns casos diferenças quanto aos níveis de renda, desigualdade e pobreza, sua evolução ao longo do tempo torna-se muito semelhante nas três pesquisas. Por fim, observa-se também que as discrepâncias remanescentes seguem um padrão, ou seja, mesmo após a harmonização, a distribuição de renda na PNAD tende a ser um pouco mais igualitária do que no Censo e na POF: os rendimentos dos mais pobres são mais altos e os dos mais ricos, mais baixos...

The aim of this paper is to document and explain the differences in income distribution in three Brazilian household surveys: the Demographic Census, the National Household Sample Survey (PNAD - Pesquisa Nacional por Amostra de Domicílios) and the Family Budgets Survey (POF - Pesquisa de Orçamentos Familiares). The main hypothesis is that it is possible to achieve great convergence of results in the aforementioned surveys with ex post harmonization procedures that minimize, as far as possible, discrepancies in sampling design, in concepts, and in data collection and treatment. The results confirm, to a large extent, this hypothesis: in general, harmonization approximates the three surveys and significantly reduces the major discrepancies between income distributions, in particular concerning Census vs. PNAD comparisons. Although, in some cases, differences persist in the levels of income, inequality and poverty, their tendencies over time become remarkably similar in the three surveys. Finally, it is observed that the remaining discrepancies follow a pattern: even after harmonization, income distribution in PNADs tends to be a little more egalitarian than in Censuses and in POFs, that is, the poorest families have higher incomes and the richest families have lower incomes...

El objetivo de este trabajo es documentar y explicar las diferencias en la distribución del ingreso que surgen del censo demográfico, la Pesquisa Nacional por Amostra de Domicílios (PNAD) y la Pesquisa de Orçamentos Familiares (POF). La hipótesis principal que se propone es que es posible promover una gran convergencia de los resultados entre las tres encuestas con los procedimientos de armonización ex post, que compatibilizan, en la medida de lo posible, las diferencias muestrales, conceptuales y de recogida y tratamiento de los datos. Los resultados confirman en buena medida esta hipótesis: de modo general, la armonización aproxima las tres encuestas y reduce significativamente las mayores discrepancias entre las distribuciones del ingreso, especialmente cuando se comparan el censo y la PNAD. Aunque en algunos casos persisten las diferencias en los niveles del ingreso, la desigualdad y la pobreza, su evolución en el tiempo llega a ser muy similar en las tres encuestas. Por último, también se observó que las discrepancias remanentes siguen un patrón, es decir, incluso después de la armonización, la distribución del ingreso en la PNAD tiende a ser un poco más igualitaria que en el censo y en la POF: en ese instrumento, los ingresos de los más pobres son más altos y los de los más ricos, más bajos...

Epidemiological investigation on envenomation: from theory to practice

A better understanding of the epidemiology of envenoming would improve care, provided that the survey is representative, reliable and accurate. Several types of surveys could help to clarify the incidence, severity, circumstances, factors and determinants of envenomations. The relevant information may be collected and analyzed from hospital records or case report forms (for retrospective studies) or established from a protocol of longitudinal observation of cases attended at health facilities during a given period (prospective study). The household survey includes interviewing all or part of the population of a locality with a standardized questionnaire to obtain information on the circumstances of the accident. Finally, standardized questionnaires can be administered to health workers in order to ascertain the circumstances and procedures of care, the availability and use of treatment and the level of knowledge of agents. Correctly performed, these surveys should promote the organization of the management of snakebites or scorpion stings because they identify the location of envenomation and quantify the needs. However, the surveyed localities should be chosen for relevance to be representative of the territory, just as methodology and analysis should be rigorous in order to give useful results.

Epidemiological investigation on envenomation: from theory to practice

A better understanding of the epidemiology of envenoming would improve care, provided that the survey is representative, reliable and accurate. Several types of surveys could help to clarify the incidence, severity, circumstances, factors and determinants of envenomations. The relevant information may be collected and analyzed from hospital records or case report forms (for retrospective studies) or established from a protocol of longitudinal observation of cases attended at health facilities during a given period (prospective study). The household survey includes interviewing all or part of the population of a locality with a standardized questionnaire to obtain information on the circumstances of the accident. Finally, standardized questionnaires can be administered to health workers in order to ascertain the circumstances and procedures of care, the availability and use of treatment and the level of knowledge of agents. Correctly performed, these surveys should promote the organization of the management of snakebites or scorpion stings because they identify the location of envenomation and quantify the needs. However, the surveyed localities should be chosen for relevance to be representative of the territory, just as methodology and analysis should be rigorous in order to give useful results.

Tendencias del consumo de drogas de 1998 a 2005 en tres ciudades de la zona norte de México: Ciudad Juárez, Monterrey y Tijuana / Trends of drug use 1998 to 2005 in three cities in the northern zone of Mexico: Ciudad Juarez, Monterrey and Tijuana

Drug use in Mexico has been on the rise since the 1970s. Nonetheless, this problem has exhibited important variations in the different regions of Mexico. To document these trends, the National Institute of Psychiatry Ramón de la Fuente (INP) has performed household surveys on addictions in different Mexican cities. In the 1970s and early 1980s surveys were conducted in the following cities: Mexico City, La Paz, Baja California Sur; Mexicali, Baja California Norte; Monterrey, Nuevo León; San Luis Potosí, San Luis Potosí; and Puebla, Puebla, among others. The first national survey in urban population was carried out in 1 988, and was repeated in 1993 and 1998, while the first national survey to included rural population was conducted in 2002, which is being followed by another study currently in the field. The student population has also been extensively studied, and has been included in three national drug surveys and studies performed in different entities. Antecedents Results from these surveys show that drug use has not increased in a uniform fashion throughout the Mexican Republic and both student and household surveys have demonstrated higher rates in the northwestern region of the country comprising the states of Baja California, Sonora and Chihuahua, which have exhibited above-average drug use on comparison with the remaining regions of the country. The most frequently consumed drug by the population is marihuana. The 1988 national household survey registered a rising prevalence in use of 2.9% in Mexican population aged 12-65 years of individuals who had used drugs at some time during their lifetime; in 1993 this prevalence increased to 3.32% and in 1998 to 4.70%; while in 2002 the percentage demonstrated a slight decrease to 3.48%. In 1988, the second place in drug preferences of the population was inhalants with a prevalence of drug use at some time during their lifetime of 0.76%; by 1993, the second place was occupied by cocaine. Prevalence of use of the latter was 0.33% in 1988; by 1993, cocaine increased to 0.56% and to 1.45% in 1998, presenting a slight decrease in use in 2002 (1.23%). From 1988-2002 non-prescribed medical drugs consumed were found in the third place in population preference. Objective This article compared drug use rates observed in three cities on or near Mexico's northern border with the U. S.: Ciudad Juarez, Chihuahua; Tijuana, Baja California Norte, and Monterrey, Nuevo León, were studied as part of the 1 998 national survey on addictions by selecting independent representative samples of these localities and with a new survey of these entities in 2005. Method The 1998 national survey of addictions was carried out in a representative sample of Mexican urban population (in localities of 2500 inhabitants). Independent samples were drawn from inhabitants living in several cities throughout Mexico. In this article we report the drug-use trends for three of these cities (Ciudad Juarez, Monterrey and Tijuana) by comparing the rates observed in 1998 with the results of a new wave of household surveys conducted in 2005 in the same cities using comparable methodology. Samples in both periods included population 12-65 years of age residing in households. Sample design was stratified by means of the following: several stages with localities (Áreas Geoestadísticas Básicas, AGEBS, its acronym in Spanish, census tracts); blocks of houses within the selected localities; segments of houses within sample blocks, and one individual per household as the selection unit in each stage. Sample size in Tijuana was 466 and 553 in 1998 and 2005, respectively, while sample sizes for Ciudad Juarez were 472 in 1998 and 606 in 2005, and for Monterrey this was 637 in 1998 and 675 in 2005, and the non-response rate was 23% in 1 998 and 20.3% in 2005. Instruments for obtaining information employed in both time frames considered were similar. Two types of questionnaires were administered: a household questionnaire that included sociodemographic information on all household inhabitants in the sample and their housing conditions and an standardized individual questionnaire administered in a face-to-face interview that collected information on the following: prevalence and use patterns of tobacco, alcohol, five types of illegal drugs (marihuana, cocaine, heroin, hallucinogens, amphetamine-type stimulants and other drugs); four types of medical pharmaceuticals utilized without a prescription (narcotics, stimulants, tranquilizers and sedatives), determining consequences and services utilization. In this article tobacco and alcohol use is not reported. This questionnaire has been extensively tested and used in previous surveys. Interviewers were persons academically prepared in the Social Sciences and trained in the logistics of the several survey stages and extensively supervised during field work. Results Highest rates of use were observed in Tijuana and Ciudad Juarez in contrast with Monterrey, which had lower rates. When use of any drug was considered, an increase in lifetime use from 1998-2005 was observed in all three cities; when use during the past year was contemplated, an increase was observed from 1998-2005 from 2.8-4.8% in the case of Ciudad Juarez and in Monterrey from 1.3%-2.0%, while these rates for Tijuana decreased from 5.4%-4.01%. Reports of use during the previous month fell in Tijuana from 4.4%-2.81 % and in Monterrey this decreased from 1.1 %-0.71 %, while in Ciudad Juarez drug use rates during the previous month increased from 2.4%-3.24%. It is important to mention that there was no statistical significance in any of the different prevalences types. Lifetime use of medical drugs without prescription increased in Tijuana and in Monterrey, while in Ciudad Juarez this remained stable from 1998-2005. In 2005, use of medical drugs decreased in Ciudad Juarez from 1.2%-0.88% and in Tijuana from 1.3%-1 .28%, while in Monterrey no use was detected in 1998, but 0.48% of interviewees did reported drug use in 2005. Previous-month use increased in Tijuana from 0.7%-1 .28% and in Monterrey this ranged from no use in 1998 to 0.48% by contrast in Ciudad Juarez previous-month drug use fell from 1.2-0.88%. In referring only to use of any illegal drug (excluding medical pharmaceutical), lifetime use increased in all three cities from 1998-2005; lifetime use doubled in Monterrey and Ciudad Juarez, while use during the previous year decreased in Tijuana from 4.4%-3.25% and increased in Ciudad Juarez from 1.6%-3.98% and in Monterrey from 1.3%-1 .52%. Prior-month increased in Ciudad Juarez from 1.2%-2.42%, while this exhibited a decrease in Tijuana from 3.9%-2.05% and in Monterrey from 1.1%-0.23%. Data also indicate that a high proportion of individuals in Monterrey have used only one drug; these percentages rose in the 1998-2005 period from 3.7%-8.96% numbers of the poly-drug users doubled in Tijuana from 4%-8.44% and in Ciudad Juarez from 3.2%-7.43%; in Tijuana this was due to an increase among males, and in Ciudad Juarez the number of poly-drug users increased in both genders.

El consumo de drogas en México ha ido en aumento. En la década de 1970, el Instituto Nacional de Psiquiatría realizó las primeras encuestas de hogares sobre el tema de las adicciones en población de distintas ciudades del país: la Ciudad de México, La Paz, B.C.S.; Mexicali, B.C.; Monterrey, N.L.; San Luis Potosí, S.L.P., y Puebla, Pue, entre otras y ha documentado las tendencias del problema y sus variaciones regionales. A nivel nacional se han realizado en hogares cuatro encuestas en 1988, en 1993, en 1998 y en 2002, denominadas <>. Asimismo se han levantado tres encuestas nacionales sobre drogas entre la población estudiantil, las cuales han dado cuenta de que el consumo de drogas no se ha incrementado de manera uniforme en el país, sino que tanto en las encuestas estudiantiles como entre las de adicciones ha resaltado la zona noroccidental, conformada por estados como Baja California, Sonora y Chihuahua, donde se tienen las mayores cifras de consumo de drogas en la República Mexicana. Las encuestas de adicciones indican que la droga que más ha consumido alguna vez en la vida la población urbana de 12 a 65 años es la mariguana, con los siguientes porcentajes: en 1988, 2.99%; en 1993, 3.32%; en 1998, 4.70%; y en la medición de 2002 disminuyó ligeramente a 3.48%. En 1988, el segundo lugar lo ocupaban los inhalables con 0.76%, pero en las demás mediciones ocupa este lugar la cocaína, con 0.56% en 1 993; 1.45% en 1998 y en 2002, 1.23%. En el tercer lugar se encuentran las drogas médicas consumidas sin prescripción desde 1988 hasta 2002. Este artículo presenta una comparación de las prevalencias de uso de drogas en tres ciudades de la Encuesta Nacional de Adicciones de 1998 con respecto a la Encuesta de ciudades de 2005 de las tres ciudades siguientes: Ciudad Juárez, Monterrey y Tijuana. La Encuesta Nacional de Adicciones de 1998 se realizó en una muestra representativa de la población urbana de todo el país (en localidades de más de 2500 habitantes). En esta encuesta, las 32 entidades del país se dividieron en tres regiones y también se obtuvieron muestras en ciudades fronterizas que fueron: Tijuana, Ciudad Juárez y Matamoros y en tres zonas metropolitanas que fueron: La ciudad de México, Guadalajara y Monterrey. La muestra fue de 12015 entrevistas completas. La encuesta de ciudades de 2005 se realizó en cuatro ciudades que fueron: Querétaro, Monterrey, Ciudad Juárez y Tijuana. Sin embargo, para efectos de este trabajo, solamente se comparan las tres últimas. Las dos encuestas tuvieron como objetivo a la población de 12 a 65 años de edad. En ambas se aplicaron dos cuestionarios: el de hogar con datos socioeconómicos y otro individual, cuyas secciones de consumo de drogas fueron iguales. El muestreo en ambas encuestas fue multietápico, probabilístico y estratificado, y en la última etapa se seleccionó a un individuo de cada hogar con un rango de edad de 12 a 65 años. Se obtuvo una no respuesta de 23% en 1998 y de 20.3% en 2005.

Os Suplementos Saúde na Pesquisa Nacional por Amostra de Domicílios (PNAD) no Brasil / Health supplements in the Brazilian National Household Survey - PNAD

As mudanças socioeconômicas, demográficas e tecnológicas e suas implicações nas políticas públicas demandam dos órgãos governamentais a produção de informações. As informações atualizadas de base populacional e de âmbito nacional são essenciais ao processo de planejamento e ao acompanhamento pela sociedade do cumprimento dos princípios constitucionais da saúde, como direito ao acesso igualitário aos serviços de saúde. A Pesquisa Nacional por Amostra de Domicílios (PNAD) é uma fonte de dados importante para o conhecimento e monitoramento de aspectos relevantes da situação de saúde da população brasileira e do acesso, utilização e financiamento de serviços de saúde. Neste artigo, faz-se um breve histórico da evolução dos objetivos, da periodicidade e da abrangência geográfica ao longo de quatro décadas da PNAD no Brasil, enfatizando-se os principais aspectos incluídos nos suplementos de saúde em 1981, 1986, 1998 e 2003. A produção de textos técnicos e acadêmicos, gerados a partir desses suplementos, tem permitido conhecer aspectos importantes da saúde da população brasileira e monitorar, em diferentes recortes geográficos e socioeconômicos, as políticas voltadas para o acesso e uso de serviços de saúde. Argumenta-se sobre a necessidade de iniciar uma discussão mais profunda sobre a continuidade da série histórica iniciada em 1998, frente à implantação, em futuro próximo, do Sistema Integrado de Pesquisas Domiciliares (SIPD) pelo IBGE.

Inequalities in health in Latin America and the Caribbean: descriptive and exploratory results for self-reported health problems and health care in twelve countries / Desigualdades de salud en América Latina y el Caribe: resultados descriptivos y exploratorios basados en la autonotificación de problemas de salud y atención de salud en doce países

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

Objetivo. Explorar y describir las desigualdades detectadas a partir de la autonotificación de problemas de salud y de la búsqueda de atención sanitaria en 12 países de América Latina y el Caribe. Métodos. Se analizan las preguntas sobre los problemas de salud y la búsqueda de atención en encuestas de hogares de tipo general y se describen las desigualdades correspondientes de acuerdo con quintiles de gasto (o ingreso) doméstico per cápita, sexo, grupo de edad (niños, adultos y adultos mayores) y área urbana o rural. En el caso de las personas que buscaron atención de salud, se aplica la técnica de pulimiento de medianas por nivel económico y sexo para los tres grupos de edad. Resultados. Aun cuando el trabajo es exploratorio y descriptivo, los resultados muestran en los países estudiados la existencia de importantes gradientes en la utilización de servicios de salud según nivel económico, y la presencia de diferencias generalmente pequeñas entre hombres y mujeres, con algunas excepciones en los estratos económicos más bajos en áreas urbanas. Conclusiones. Las desigualdades detectadas a partir de la autonotificación de problemas de salud son muy pequeñas entre personas de diferente nivel económico y los problemas suelen ser más frecuentes entre las mujeres que entre los hombres. Esto se debe posiblemente a diferencias culturales y sociales en la percepción de la salud. Las desigualdades en la búsqueda de atención son grandes en la mayoría de los países estudiados. Es muy importante que se desarrollen proyectos regionales encaminados a mejorar las preguntas para la autonotificación de problemas de salud con el fin de poder estudiar a fondo los factores que determinan las desigualdades en el ámbito sanitario. Los autores concluyen que debido a que los gradientes económicos muestran patrones diferentes en los distintos grupos de edad y en hombres y mujeres, los datos no deben estandarizarse a la hora de derivar curvas de concentración y calcular los índices de concentración. Al final hay una lista de recomendaciones sobre cómo mejorar estas fuentes de datos. Pese a sus deficiencias, las encuestas de hogares nos ayudan a entender las complejidades de las desigualdades de salud en estos países.