Factors Associated with HIV and Vulnerability Contexts for Women in Brazil.

The purpose of this study was to identify factors associated with HIV and vulnerability contexts for women in Porto Alegre, Brazil. The participants were 1326 women recruited by complex sampling design, divided into two groups: 640 women with HIV (WLH) and 686 women who did not have HIV (WNLH). Gross and weighted statistical analyses were performed. Logistic regression models were used to estimate the odds ratio (OR) for 12 variables. The main results demonstrated that WLH had lower income (p < .001) and poorer education (p = .038), and few used condoms during their first sexual intercourse (p < .001). The occurrence of HIV was higher among the black population (p < .001). Sex in exchange for money (p < .001) and sexually transmitted infections (p < .001) were more frequent among WLH than among WNLH. The age of sexual debut and age difference from the partner at first sexual intercourse (FSI) were not associated with the outcome. The high percentage of non-use of condoms during the FSI shows how vulnerable individuals are right at the beginning of their sexual lives. More effective prevention strategies can be developed by nurses in view of the contexts of vulnerability surrounding women.

Survival and predictors of death in tuberculosis/HIV coinfection cases in Porto Alegre, Brazil: A historical cohort from 2009 to 2013.

BACKGROUND: Tuberculosis is a curable disease, which remains the leading cause of death among infectious diseases worldwide, and it is the leading cause of death in people living with HIV. The purpose is to examine survival and predictors of death in Tuberculosis/HIV coinfection cases from 2009 to 2013. METHODS: We estimated the survival of 2,417 TB/HIV coinfection cases in Porto Alegre, from diagnosis up to 85 months of follow-up. We estimated hazard ratios and survival curves. RESULTS: The adjusted risk ratio (aRR) for death, by age, hospitalization, and Directly Observed Treatment was 4.58 for new cases (95% CI: 1.14-18.4), 4.51 for recurrence (95% CI: 1.11-18.4) and 4.53 for return after abandonment (95% CI: 1.12-18.4). The average survival time was 72.56 ± 1.57 months for those who underwent Directly Observed Treatment and 62.61 ± 0.77 for those who did not. CONCLUSIONS: Case classification, age, and hospitalization are predictors of death. The occurrence of Directly Observed Treatment was a protective factor that increased the probability of survival. Policies aimed at reducing the mortality of patients with TB/HIV coinfection are needed.

Factors associated with directly observed treatment in tuberculosis/HIV coinfection cases in Porto Alegre, 2009-2013: A retrospective cohort.

BACKGROUND: TB/HIV coinfection is a serious public health issue in Brazil, and patients with coinfection have difficulty adhering to treatments. Directly observed treatment (DOT) has been recommended by the World Health Organization, considering the vulnerability of those affected. The purpose is to investigate the occurrence of DOT and associated factors compared to conventional treatment in Porto Alegre, Brazil. METHODS: A retrospective cohort study was carried out with all patients with coinfection from 2009 to 2013 in the city of Porto Alegre, Brazil, the state capital with the highest rate of coinfection in Brazil. The data came from national health information systems. The dependent variable was the performance of DOT. Bivariate and multivariable models were used to determine factors associated with DOT. The percentage of cure and death was verified in a period of two years, comparing patients who received and did not receive DOT. RESULTS: 2,400 cases of coinfection were reported, with 1,574 males and 826 females and a mean age of 38 years ± 9.91 years. The occurrence of DOT was 16.9%. In the multivariable analysis, factors independently associated to DOT were the year (with greater chances of being received in 2012 and 2013), place of origin, non-white race (OR = 1.29, 95% CI = 1.08-1.54), cases of relapse (OR = 1.33; 95% CI = 1.03-1.73), readmission after abandonment (OR = 1.48, 95% CI = 1.20-1.83), transfer (OR = 2.04; 95% CI = 1.40-2.98), acid-fast bacilli (AFB) test with positive result in first sample (OR = 1.73, 95% CI = 1.24-2.42), alcohol abuse (OR = 1.39; 95% CI = 1.16-1.67), and mental disorders (OR = 1.83; 95% CI = 1.38-2.44.) Of the 532 cases of death, occurring in two years, 10.2% were in patients who underwent DOT and 89.8% in patients who did not undergo DOT (p<0.001). O percentual de óbitos em pessoas que receberam DOT foi de 13% e o percentual de óbitos para pessoas que receberam tratamento convencional foi de 24%. CONCLUSIONS: There was an increase in the percentage of DOT over the years in the scenario studied, and the predictors for DOT were related to social vulnerability. In relation to death within two years, a lower proportion was found in patients who underwent DOT, suggesting a protective effect of the strategy.

Epidemiological profile of tuberculosis cases with HIV coinfection in Porto Alegre city, Brazil / Perfil epidemiológico de los casos de tuberculosis con coinfección VIH en Porto Alegre / Perfil epidemiológico dos casos de tuberculose com coinfecção HIV em Porto Alegre, Brasil

ABSTRACT Objective: To describe and compare the epidemiological profile of cases of tuberculosis and HIV coinfection of the District Administration Health Units of Porto Alegre, Brazil, from 2009 to 2013. Method: Retrospective cohort with data from national health information systems. Sociodemographic, clinical and follow-up variables were investigated through association tests. Results: 2,419 cases of tuberculosis and HIV coinfection were reported, with a mean age of 38 ± 9.91 years, predominantly white and with up to 7 years of study. The comparison between the District Administration Health Units was significant in terms of race/color (p<0.001), gender (p<0.001), schooling (p<0.004), age (p<0.003), place of origin (p<0.001), (p<0.001), alcoholism (p<0.001), indication and performance of Directly Observed Therapy (p<0.001), closure (p<0.001). Conclusion: Socioeconomic and treatment variables influence the occurrence of coinfection in different areas of Porto Alegre, reinforcing that the sum of different factors explains the indicators of the disease.

RESUMEN Objetivo: Describir y comparar el perfil epidemiológico de los casos de coinfección por Tuberculosis y VIH, por la Gerencia Distrital de Porto Alegre, en el período de 2009 a 2013. Método: Cohorte, retrospectiva, con datos de sistemas nacionales de información en salud. Se investigaron variables sociodemográficas, clínicas y de seguimiento, por medio de pruebas de asociación. Resultados: Se notificaron 2.419 casos de coinfección Tuberculosis y VIH, con una media de edad de 38 ± 9,91 años, predominantemente blancos y con hasta 7 años de estudio. La comparación entre las Gerencias Distritales fue significativa como raza/color (p <0,001), sexo (p <0,001), escolaridad (p <0,004), edad (p <0,003), lugar de origen (p <0,001), situación de origen (p <0,001), alcoholismo (p <0,001), indicación y realización de tratamiento directamente observado (p <0,001), situación de cierre (p <0,001). Conclusión: Las variables socioeconómicas y de realización del tratamiento influencian la ocurrencia de la coinfección en diferentes áreas de Porto Alegre, reforzando que la suma de diferentes factores explica los indicadores de la enfermedad.

RESUMO Objetivo: Descrever e comparar o perfil epidemiológico dos casos de coinfecção por Tuberculose e HIV, pela Gerência Distrital de Porto Alegre, no período de 2009 a 2013. Método: Coorte retrospectivo, com dados de sistemas nacionais de informação em saúde. Foram investigadas variáveis sociodemográficas, clínicas e de acompanhamento, por meio de testes de associação. Resultados: Foram notificados 2.419 casos de coinfecção Tuberculose e HIV, com média de idade de 38 ±9,91 anos, predominantemente brancos e com até 7 anos de estudo. A comparação entre as Gerências Distritais foi significativa quanto raça/cor (p<0,001), sexo (p<0,001), escolaridade (p<0,004), idade (p<0,003), local de origem (p<0,001), situação de entrada (p<0,001), alcoolismo (p<0,001), indicação e realização de Tratamento Diretamente Observado (p<0,001), situação de encerramento (p<0,001). Conclusão: Variáveis socioeconômicas e de realização do tratamento influenciam a ocorrência da coinfecção em diferentes áreas de Porto Alegre, reforçando que a soma de diferentes fatores explica os indicadores da doença.

Epidemiological profile of tuberculosis cases with HIV coinfection in Porto Alegre city, Brazil.

OBJECTIVE: To describe and compare the epidemiological profile of cases of tuberculosis and HIV coinfection of the District Administration Health Units of Porto Alegre, Brazil, from 2009 to 2013. METHOD: Retrospective cohort with data from national health information systems. Sociodemographic, clinical and follow-up variables were investigated through association tests. RESULTS: 2,419 cases of tuberculosis and HIV coinfection were reported, with a mean age of 38 ± 9.91 years, predominantly white and with up to 7 years of study. The comparison between the District Administration Health Units was significant in terms of race/color (p<0.001), gender (p<0.001), schooling (p<0.004), age (p<0.003), place of origin (p<0.001), (p<0.001), alcoholism (p<0.001), indication and performance of Directly Observed Therapy (p<0.001), closure (p<0.001). CONCLUSION: Socioeconomic and treatment variables influence the occurrence of coinfection in different areas of Porto Alegre, reinforcing that the sum of different factors explains the indicators of the disease.

Factors associated with hospitalization and death among TB/HIV co-infected persons in Porto Alegre, Brazil.

In locations with a high rate of tuberculosis (TB) and HIV infection, there are a number of strategies to prevent negative outcomes such as opportunistic infections, hospitalizations and death, and this article investigates risk factors for the occurrence of hospitalization and death in cases of TB/HIV co-infection in the south of Brazil. The data are taken from a population-based retrospective cohort study on cases of TB/HIV co-infection from 2009 to 2013 in Porto Alegre, Brazil. Sociodemographic, epidemiological and clinical variables were analyzed. Relative risk (RR) estimates for hospitalization and death were determined by regression models. There were 2,419 co-infection cases, of which 1,527 (63.1%) corresponded to hospitalizations, and 662 (27.4%) to death. The occurrence of hospitalization was associated with ≤ 7 years of schooling (RR = 3.47, 95%CI: 1.97-6.29), 8-11 years of schooling (RR = 2.56, 95%CI: 1.44-4.69), place of origin-district health authorities Northwest/Humaitá/Navegantes/Ilhas (RR = 2.01, 95%CI: 1.44-2.82), type of entry into the surveillance system as in cases of reentry after withdrawal (RR = 1,35, 95%CI: 1.07-1.70), closure in surveillance as in withdrawal of treatment (RR = 1.47, 95%CI: 1.18-1.83) and multidrug-resistant tuberculosis (RR = 3.94, 95%CI: 1.97-8.81). The occurrence of death was associated with age (RR = 1.07, 95%CI: 1,01-1,14), ≤ 7 years of schooling (RR = 3.94, 95%CI: 2.26-7.09), 8-11 years of schooling (RR = 2.84, 95%CI: 1.61-5.16), place of origin-district health authorities Baltazar (RR = 2.05, 95%CI: 1.48-2.86), type of entry in the surveillance system as cases of re-entry after withdrawal (RR = 1.53, 95%CI: 1.22-1.91), relapse (RR = 1.33, 95%CI: 1.03-1.73). The occurrence of hospitalizations and deaths is high among co-infected patients. Our estimation approach is important in order to identify, from the surveillance data, the risk factors for hospitalization and death in co-infected patients, so that they may receive more attention from the Brazilian national healthcare system.

Atenção à Saúde dos Usuários com Hipertensão Arterial Sistêmica, no Rio Grande Do Sul e Nas Demais Unidades Federativas do Brasil, Na Atenção Básica / Care For Users With Systemic Arterial Hypertension, In The Rio Grande do Sul And In Other Federal Units Of Brazil, In The Primary Health Care

Objetivo: comparar a atenção à saúde dos usuários com hipertensão arterial sistêmica ofertada no Rio Grande do Sul com aquela ofertada nas demais unidades federativas do país. Método: Trata-se de um estudo epidemiológico, observacional e analítico, de cunho ecológico, com dados oriundos do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB), ano 2012. A amostra nacional foi composta por 65.391 usuários, dos quais 36,5% possuía hipertensão arterial sistêmica. Comparações foram realizadas quanto à atenção a saúde dos 23.797 hipertensos residentes no Rio Grande do Sul (RS) e nas demais UFs. Resultados: A prevalência de HAS no RS foi de 35,9% (n = 1.156). Observou-se diferença estatística entre RS e demais UFs quanto à ocorrência de consulta nos últimos 6 meses (p<0,001), realização de exames (p<0,001), agendamento de consulta (p<0,001), e local de retirada de medicamentos (p<0,001). Conclusões: Apesar do RS ser apontado como uma das UFs com maior prevalência de HAS, as comparações apontam melhores resultados nas demais UFs quanto à atenção à saúde do hipertenso na atenção básica. Os resultados permitem discutir melhorias de acesso e qualidade da atenção básica. Sugere-se que o PMAQ-AB inclua questões relativas à adesão ao tratamento e questões sobre o tratamento não medicamentoso para a avaliação da qualidade da atenção à saúde do hipertenso.(AU)

Objective: To compare the health care provided for users who suffer from systemic arterial hypertension in Rio Grande do Sul and other states of Brazil. Method: This is an epidemiological, observational and analytic ecological study with data from the National Program for Access and Quality Improvement in Primary Care (PMAQAB) - 2012. The sample consisted of 65,391 users, 36.5% of whom suffered from systemic arterial hypertension (SAH) and answered questions regarding health care for hypertensive patients in primary care facilities. The service provided in Rio Grande do Sul was compared to that of other states. Results: The prevalence of SAH in the national sample was 36.5% (n = 23,797), whereas in Rio Grande do Sul it was 35.9% (n = 1,156). Statistical differences were found related to consultations in the last six months (p <0.001), medical examinations (p <0.001), appointments schedule (p <0.001) and medication deliverance sites (p <0.001). Conclusions: Although Rio Grande do Sul is regarded as one of the states with the highest prevalence rates of SAH, comparison shows other states have better results as far as care for hypertensive patients in primary health care is concerned. Results can support the debate about improving the quality of primary care, for which PMAQ was intended. It is suggested that PMAQ includes both adherence to treatment and non-drug treatments as factors to evaluate the quality of the care provided for hipertensive patients.(AU)

Disponibilidade do teste rápido para sífilis e anti-HIV nas Unidades de Atenção Básica do Brasil, no ano de 2012 / Availability of rapid tests for syphilis and HIV at Primary Health Care Units of Brasil in 2012

Objetivo: verificar e comparar a disponibilidade dos testes rápidos, nas cinco regiões do Brasil. Método: trata-se de um estudo epidemiológico ecológico, que analisou dados secundários provenientes do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica, coletados no ano de 2012. Resultados: em 96,6% e 86% dos estabelecimentos, respectivamente, o teste para sífilis e anti-HIV não estavam disponíveis. Teste para sífilis sempre disponível foi encontrado com maior frequência na região centro-oeste (6,1%; p<0,01) e teste anti-HIV na região sudeste (30,5%; p<0,01). Conclusões: foram evidenciadas desigualdades regionais na disponibilidade dos testes rápidos na atenção básica no Brasil. Considerando os elevados índices de sífilis e Aids no país, acredita-se que a disponibilidade dos testes rápidos constitui-se como uma relevante estratégia de enfrentamento. Portanto, frente às recentes recomendações das políticas públicas que incentivam a testagem na atenção básica, tornam-se necessárias ações de saúde para garantir que os testes rápidos estejam sempre disponíveis. (AU)

Objective: To check and compare the availability of rapid tests for syphilis and HIV in the five regions of Brazil. Method: This is an ecological epidemiological study, which analyzed secondary data from the National Program for Access and Quality Improvement in Primary Care (PMAQ-AB) - 2012. Results: Syphilis and HIV tests were not available in respectively 96.6% and 86% of the facilities. Syphilis tests were found more frequently in the Central-West Region (6.1%, p <0.01) and HIV tests in the Southeast Region (30.5%; p <0.01). Conclusions: Regional inequalities were evidenced in the availability of rapid tests in primary health care in Brazil. Given the high levels of syphilis and AIDS in Brazil, the availability of rapid tests constitutes a relevant coping strategy. Therefore, in the face of recent public policy recommendations that encourage testing in primary care, health actions are needed to ensure that rapid tests are always available. (AU)

Vulnerabilidade e direitos humanos na compreensão de trajetórias de internação por tuberculose / Vulnerability and human rights in the understanding of trajectories of tuberculosis hospitalization

Resumo O objetivo foi compreender como desigualdades e violações de direitos humanos se articulam em trajetórias de vulnerabilidade à internação por tuberculose. Foram realizadas entrevistas com pessoas internadas para tratamento da tuberculose em um hospital localizado em Porto Alegre, região sul do Brasil, no ano de 2014. Coinfecção tuberculose-HIV/aids, uso nocivo de drogas (especialmente o crack) e estar em situação de rua foram os acontecimentos mais expressivos nas trajetórias estudadas. A análise, orientada pelo quadro da vulnerabilidade e dos direitos humanos, e pelo construcionismo social como uma de suas bases teóricas, fez emergir a reflexão sobre marcadores sociais da diferença - gênero, raça, classe social e estigma relacionado à aids e ao uso de drogas - e suas intersecções na constituição das situações associadas ao adoecimento. A expressividade desses marcadores e seus efeitos na produção de desigualdades, discriminação, exploração e opressão permitiu desvelar o cenário sociocultural em que as trajetórias de internação por tuberculose são construídas. Esse conhecimento pode contribuir com a resposta que a tuberculose demanda, especialmente, ao reconhecer que as propostas em saúde precisam buscar mitigar vulnerabilidades sem negligenciar o enfrentamento às desigualdades sociais e à proteção aos direitos humanos.

Abstract The goal was to understand how inequality and violation of human rights were articulated in trajectories of vulnerability in tuberculosis hospitalization. Interviews were conducted with people hospitalized for tuberculosis treatment in a hospital located in Porto Alegre, southern region of Brazil, in 2014. Tuberculosis-HIV/AIDS co-infection, harmful use of drugs (especially crack), and life on the streets were the most significant events on the trajectories studied. The analysis, guided by the framework of vulnerability and human rights, and by the social constructionism as one of its theoretical basis, brought up the reflection about social markers of difference - genre, race, social class and stigma related to AIDS and use of drugs - and its intersections in building situations associated with illness. The expressiveness of these markers and their effects on the production of inequalities, discrimination, exploitation and oppression allowed revealing the social and cultural scenarios in which trajectories of tuberculosis hospitalization are built. These findings may contribute to the response that tuberculosis demands, especially by recognizing that health proposals must seek to mitigate vulnerabilities without neglecting the need to confront social inequalities and protect human rights.

The silences framework: metodologia para pesquisas de temas sensíveis e perspectivas marginalizadas na saúde / The silences framework: metodología para investigaciones de temas sensibles y perspectivas marginalizadas en la salud / The silences framework: method for research of sensitive themes and marginalized health perspectives

RESUMO Objetivo: descrever a utilização da metodologia The Silences Framework em uma pesquisa na área da saúde, envolvendo a temática da coinfecção tuberculose/HIV/aids. Método: a metodologia foi originalmente utilizada para estudar decisões e silêncios de homens negros do Caribe que viviam na Inglaterra, problematizando-se os temas 'saúde sexual' e 'etnicidade' e resultando em uma teoria para a pesquisa de questões sensíveis e de cuidados de saúde de populações marginalizadas. The Silences Framework define áreas de pesquisa e experiências que são pouco estudadas, compreendidas ou silenciadas. Resultados: os "silêncios" podem refletir aspectos não compartilhados sobre como crenças, valores e experiências de alguns grupos influenciam sua saúde. Esse referencial prevê a aplicação de quatro estágios complementares: trabalhando os silêncios, ouvindo os silêncios, dando voz aos silêncios e trabalhando com os silêncios. A análise ocorre de modo cíclico e pode ser repetida enquanto os silêncios não forem desvelados. Conclusão: este artigo apresenta a noção de "sons do silêncio", mapeando um quadro teórico antiessencialista para sua utilização em pesquisas sensíveis na area da saúde e da enfermagem, podendo ser referência para outros investigadores em estudos envolvendo populações marginalizadas.

RESUMEN Objetivo: describir la utilización de la metodología The Silences Framework en una investigación en el área de la salud, involucrando la temática de la co-infección Tuberculosis/VIH/SIDA. Método: la metodología fue originalmente utilizada para estudiar decisiones y silencios de hombres negros del Caribe que vivían en Inglaterra, problematizándose los temas 'salud sexual' y 'etnicidad' y resultando en una teoría para la investigación de cuestiones sensibles y de cuidados de la salud de las poblaciones marginadas. The Silences Framework define áreas de investigación y experiencias que son poco investigadas, comprendidas o silenciadas. Resultados: los "silencios" pueden reflejar aspectos no compartidos de cómo las creencias, valores y experiencias de algunos grupos influencian su salud. Este referencial prevé la aplicación de cuatro etapas complementarias: trabajando los silencios, oyendo los silencios, dando voz a los silencios y trabajando con los silencios. El análisis ocurre de modo cíclico y puede ser repetido mientras los silencios no se desvelan. Conclusión: este artículo presenta la noción de "sonidos del silencio", mapeando un cuadro teórico anti-esencialista para su utilización en investigaciones sensibles en el área de la salud y de la enfermería, pudiendo ser referencia para otros investigadores en estudios involucrando poblaciones marginadas.

ABSTRACT Objective: to describe the experience of applying of The Silences Framework to underpin health research investigating Tuberculosis/HIV/AIDS coinfection. Method: the Silences Framework originally developed following a study exploring the decisions and silences surrounding black Caribbean men living in England, discussing the themes 'sexual health' and 'ethnicity'. Following this study, a conceptual theory for research on sensitive issues and health care of marginalized populations was developed called 'Screaming Silences', which forms the foundation of The Silences Framework. 'Screaming Silences' define research areas and experiences that are poorly studied, little understood or silenced. Results: the Silences Framework supports researchers in revealing "silences" in the subjects they study - as such, results may reflect how beliefs, values, and experiences of some groups influence their health. This framework provides the application of four complementary stages: working the silences, hearing silences, voicing silences and working with the silences. The analysis occurs cyclically and can be repeated as long as the silences inherent in a study are not revealed. Conclusion: this article presents The Silences Framework and the application of the notion of "sounds of silence", mapping an antiessentialist theoretical framework for its use in sensitive research in health and nursing areas, being a reference for other researchers in studies involving marginalized populations.

Proposta de ações em saúde para a terceira idade: um relato de experiência a partir da atuação do sanitarista / Proposal of health activities for elderly: a report based on the experience of a collective health professional

Objetivo: Apresentar a construção de um projeto de intervenção para a terceira idade, com ações cujas ênfases foram a promoção de uma vida mais saudável, e o reconhecimento do idoso como um cidadão ativo no processo do cuidado com a saúde e do envelhecimento. Métodos: Realizou-se o mapeamento de unidades de saúde que realizam grupos de idosos em Porto Alegre. Algumas destas unidades foram visitadas. Como técnica de coleta de informações utilizou-se a observação participante e a condução de entrevistas. Paralelamente a isso, foram realizadas leituras sobre envelhecimento saudável e técnicas de condução de grupos de convivência para idosos. Resultados: Planejou-se uma lista de atividades que foram desenvolvidas num grupo de idosos. Foram contatados voluntários para a condução de atividades, as quais necessitavam de habilidades artísticas especificas. As demais técnicas e atividades foram desenvolvidas pelas autoras e equipe de saúde. Todas as atividades foram discutidas com a equipe de saúde e com os participantes antes de serem implementadas. As atividades foram avaliadas, posteriormente, pelos profissionais e pelos idosos participantes. Considerações finais: Nesta experiência, os espaços de grupos deixaram de ser um encontro para resolver problemas relacionados ao adoecimento, consolidando-se como um espaço de produção de saúde e de formação de vínculo profissional/usuário e entre os participantes. Recomenda-se a realização de atividades como as apresentadas nessa proposta, tendo em vista a necessidade de transformação dos espaços tradicionais de saúde e a necessidade de espaços de produção de saúde fora dos serviços tradicionais. (AU)

Objective: To present a project designed for elderly consisting of activities that emphasized the promotion of a healthier life and the recognition of them as active players in the process of health care. Methods: After the health care facilities that held groups of elderly people in Porto Alegre had been mapped, some of them were visited. Interviews were carried out and participatory observation was performed to collect data. Simultaneously, healthy aging and interaction techniques for elderly groups were researched. Results: A list of activities was planned and performed in a group of elderly people. Volunteers were invited to perform activities that required specific artistic skills, whereas the authors and the health care team performed those that didn't. All activities were not only discussed with health care teams and participants before taking place, but also evaluated after that. Final considerations: In this experience, group meetings moved on from being mere occasions to solve problems related to illness to become opportunities to promote health and bonds between professionals and users, as well as among the users themselves. Activities such as those presented in this article are highly recommended in order to improve the conventional health care services as well as to create situations to promote health outside conventional facilities.(AU)