Addressing pressures on health services in Belo Horizonte, Brazil through community-based care for poor older people: a qualitative study.

Background: In low and middle-income countries, there is growing interest in managing pressures on health services through community interventions for older people. Evidence on the effects of such interventions is scarce. We draw on qualitative data to examine these effects for a specific scheme, Programa Maior Cuidado (PMC) in the Brazilian city of Belo Horizonte. Methods: Building on quantitative findings reported elsewhere, we use qualitative data to develop and test theories of change. These include data from 50 meetings with policymakers, managers and staff in 30 health centres and social assistance posts. Data collection was embedded in key informant interaction and knowledge coproduction. Data include participant and non-participant observation, focus groups and semi-structured interviews with key informants, as well as older people and carers from seven families. Findings: The data reveal three theories of change. Theory 1 is PMC maintains older people's health which reduces their need for inpatient or outpatient care. We find strong evidence to support this, through effects on use of medication, chronic disease management and risk prevention. Theory 2 is PMC promotes timely intervention by anticipating health problems, thus reducing demand for emergency and acute care. We find some evidence for this, but it was limited by limited availability of timely treatment or referral beyond PMC. Theory 3 is PMC facilitates hospital discharge. We find limited evidence for this, reflecting a lack of formal liaison between PMC and hospitals. Interpretation: Schemes like PMC have potential to reduce pressures on health service utilisation by older people, if they are well articulated with wider health services. Funding: Medical Research Council, Newton Fund and Brazilian Council of State Funding Agencies.

Juvenile handling rescues autism-related effects of prenatal exposure to valproic acid.

Environmental factors acting on young animals affect neurodevelopmental trajectories and impact adult brain function and behavior. Psychiatric disorders may be caused or worsen by environmental factors, but early interventions can improve performance. Understanding the possible mechanisms acting upon the developing brain could help identify etiological factors of psychiatric disorders and enable advancement of effective therapies. Research has focused on the long-lasting effects of environmental factors acting during the perinatal period, therefore little is known about the impact of these factors at later ages when neurodevelopmental pathologies such as autism spectrum disorder (ASD) are usually diagnosed. Here we show that handling mice during the juvenile period can rescue a range of behavioral and cellular effects of prenatal valproic acid (VPA) exposure. VPA-exposed animals show reduced sociability and increased repetitive behaviors, along with other autism-related endophenotypes such as increased immobility in the forced swim test and increased neuronal activity in the piriform cortex (Pir). Our results demonstrate that briefly handling mice every other day between postnatal days 22 and 34 can largely rescue these phenotypes. This effect can also be observed when animals are analyzed across tests using an "autism" factor, which also discriminates between animals with high and low Pir neuron activity. Thus, we identified a juvenile developmental window when environmental factors can determine adult autism-related behavior. In addition, our results have broader implications on behavioral neuroscience, as they highlight the importance of adequate experimental design and control of behavioral experiments involving treating or testing young animals.

The effects of an innovative integrated care intervention in Brazil on local health service use by dependent older people.

BACKGROUND: Since 2011, the Brazilian city of Belo Horizonte has been operating an innovative scheme to support care-dependent older people in disadvantaged communities: Programa Maior Cuidado (PMC - Older Person's Care Program). This paper examines two potential associations between inclusion in PMC on types of outpatient health service utilization by dependent older people. The first is that being in PMC is associated with a higher frequency of outpatient visits for physical rehabilitation. The second is that being in PMC is associated with a higher frequency of planned versus unplanned outpatient visits. METHODS: We apply a quasi-experimental design to a unique set of health administrative data recording visits to outpatient health services. We focus on comparisons of the universe of visits, transformed to ratios of planned/unplanned visits and rehabilitation/other reasons for visiting the outpatient service. First, we preprocess our sample through different matching techniques such as 'coarsened exact matching' (CEM), 'nearest neighbor' based on logit scores (NN), 'optimal pair' (OP) and 'optimal full' (OF) methods. Second, we estimate marginal effects of being in PMC on our outcomes of interest. We use Poisson regressions controlling for individual and community factors and use robust standard errors. Our results are presented as the comparative incidence ratio of PMC on rehabilitation and planned visits. RESULTS: We find significant positive incidence rates for belonging to PMC for both outcomes of interest under all matching specifications. Poisson models using CEM shows a higher incidence rate for planned visits in comparison to unplanned visits, 1.3 (95% CI 1.1-1.4), by PMC patients compared to the non-PMC controls, and a higher proportion of visits for rehabilitation, 3.4 (95% CI 1.7-6.8). Similar positive results are found across other matching methods and models. CONCLUSIONS: Our analysis reveals significant positive associations between older people included in PMC and a matched set of controls for a greater ratio of making outpatient visits that were planned, rather than unplanned. We find similar associations for the proportion of visits made for rehabilitation, as opposed to other reasons. These findings indicate that PMC influences some elements of outpatient health service utilization by dependent older people.

Estimation of all-cause excess mortality by age-specific mortality patterns for countries with incomplete vital statistics: a population-based study of the case of Peru during the first wave of the COVID-19 pandemic.

BACKGROUND: All-cause excess mortality is a comprehensive measure of the combined direct and indirect effects of COVID-19 on mortality. Estimates are usually derived from Civil Registration and Vital Statistics (CRVS) systems, but these do not include non-registered deaths, which may be affected by changes in vital registration coverage over time. METHODS: Our analytical framework and empirical strategy account for registered mortality and under-registration. This provides a better estimate of the actual mortality impact of the first wave of the COVID-19 pandemic in Peru. We use population and crude mortality rate projections from Peru's National Institute of Statistics and Information (INEI, in Spanish), individual-level registered COVID-19 deaths from the Ministry of Health (MoH), and individual-level registered deaths by region and age since 2017 from the National Electronic Deaths Register (SINADEF, in Spanish).We develop a novel framework combining different estimates and using quasi-Poisson models to estimate total excess mortality across regions and age groups. Also, we use logistic mixed-effects models to estimate the coverage of the new SINADEF system. FINDINGS: We estimate that registered mortality underestimates national mortality by 37•1% (95% CI 23% - 48•5%) across 26 regions and nine age groups. We estimate total all-cause excess mortality during the period of analysis at 173,099 (95% CI 153,669 - 187,488) of which 108,943 (95% CI 96,507 - 118,261) were captured by the vital registration system. Deaths at age 60 and over accounted for 74•1% (95% CI 73•9% - 74•7%) of total excess deaths, and there were fewer deaths than expected in younger age groups. Lima region, on the Pacific coast and including the national capital, accounts for the highest share of excess deaths, 87,781 (95% CI 82,294 - 92,504), while in the opposite side regions of Apurimac and Huancavelica account for less than 300 excess deaths. INTERPRETATION: Estimating excess mortality in low- and middle-income countries (LMICs) such as Peru must take under-registration of mortality into account. Combining demographic trends with data from administrative registries reduces uncertainty and measurement errors. In countries like Peru, this is likely to produce significantly higher estimates of excess mortality than studies that do not take these effects into account. FUNDING: None.

Building the capacity of community health workers to support health and social care for dependent older people in Latin America: a pilot study in Fortaleza, Brazil.

BACKGROUND: Brazil is seeing rapid population ageing, which is leading to new demands on primary health care services. There is a need to develop and assess the effectiveness of new interventions to build the capacity of staff, including community health workers, to meet the needs of groups such as care-dependent older people and their care-givers. This study examines the feasibility of a small training intervention piloted in the Brazilian city of Fortaleza. METHODS: The study evaluated participants' own assessments of key knowledge and skills related to the needs of care-dependent older people, both before and after the training intervention. It also assessed their capacity to implement a simple screening tool of geriatric risk factors. RESULTS: The participant self-assessments indicate significant improvements in their perceived knowledge and capacity in responding to the health needs of care-dependent older people. Additionally, participants were able to successfully conduct the home visits and screening for risk factors. CONCLUSIONS: The study demonstrates the feasibility of developing interventions to enhance the capacity of community health workers to meet the needs of dependent older people in countries like Brazil. The evidence of effectiveness, though limited and subjective, provides justification for a larger, formally evaluated intervention. The experience of Fortaleza provides valuable lessons for other cities and countries in the region which are facing similar challenges.

Meeting the complex challenge of health and social care provision for rapidly-ageing populations: introducing the concept of "avoidable displacement from home".

The increasing numbers of people at very old ages pose specific policy challenges for health and social care and highlight the need to rethink established models of service provision. The main objective of this paper is to introduce the concept of "avoidable displacement from home" (ADH). The study argues that ADH builds on and adds value to existing concepts, offering a holistic, person-centered framework for integrated health and social care provision for older people. It also demonstrates that this framework can be applied across different levels, ranging from macro policymaking to organizational and individual decision-making. The paper pays attention to the Brazilian context but argues that ADH is a universally applicable concept.

Meeting the complex challenge of health and social care provision for rapidly-ageing populations: introducing the concept of "avoidable displacement from home" / O enfrentamento do desafio complexo da prestação de serviços de saúde e sociais para populações com envelhecimento rápido: a introdução do conceito de "deslocamento residencial evitável" / Resolver el complejo desafío para la salud y atención social en poblaciones que envejecen rápidamente: introduciendo el concepto de "desplazamiento evitable desde el hogar"

Abstract: The increasing numbers of people at very old ages pose specific policy challenges for health and social care and highlight the need to rethink established models of service provision. The main objective of this paper is to introduce the concept of "avoidable displacement from home" (ADH). The study argues that ADH builds on and adds value to existing concepts, offering a holistic, person-centered framework for integrated health and social care provision for older people. It also demonstrates that this framework can be applied across different levels, ranging from macro policymaking to organizational and individual decision-making. The paper pays attention to the Brazilian context but argues that ADH is a universally applicable concept.

Resumo: O número crescente de indivíduos muito idosos cria desafios específicos para as políticas de assistência social e de saúde. Os desafios incluem a necessidade de repensar os modelos assistenciais atuais. O artigo tem como objetivo principal introduzir o conceito de "deslocamento residencial evitável" (DRE). Argumentamos que o conceito de DRE elabora e contribui para os conceitos existentes, oferecendo um arcabouço holístico e centrado na pessoa para a assistência de saúde e social para os idosos. Demonstramos que esse arcabouço pode ser aplicado em diversos níveis, desde a formulação de políticas macro até as decisões organizacionais e individuais. O artigo aborda particularmente o contexto, mas sustenta que o DRE é um conceito universalmente aplicável.

Resumen: Un número creciente de personas con edad muy avanzada plantea desafíos específicos para las políticas de salud y atención social. Esto implica la necesidad de repensar los modelos establecidos de provisión de servicios. El objetivo principal de este artículo es introducir el concepto de "desplazamiento evitable del hogar" (DEH). Nosotros planteamos que el DEH se basa y añade valor a conceptos existentes, ofreciendo un marco de trabajo holístico, centrado en la persona para la provisión integrada de salud y atención social a personas mayores. Demostramos que este marco de trabajo se puede aplicar a través de diferentes niveles, que van desde la elaboración de políticas macro a la adopción de decisiones por parte de organizaciones e individuos. Este trabajo fija su atención en particular sobre el contexto brasileño, pero plantea que el DEH es un concepto aplicable universalmente.