Abrir gavetas, tramar redes: dos impactos ressonantes da educação pelo trabalho na saúde / Open drawers, weave networks: the resonant impacts of education through work on health

Objetivo: Este artigo objetiva trazer a cena uma pesquisa relativa ao impacto do Programa de Educação pelo Trabalho na Saúde, o qual estabelece uma trama entre ensino universitário, política pública e demandas sociais em saúde. Método: O tema do impacto, tão frequente nas discussões envolvendo avaliação e monitoramento em políticas e ações em educação e saúde, foi tomado em consideração, não apenas como uma pergunta a responder, mas como uma construção de pensamento sobre o que uma política pública "faz" na realidade (como uma política pública "impacta" uma realidade) e como uma prática de ensino e aprendizagem é afetada por esta. Antes de avaliá-lo, medi-lo, primeiramente, foi necessário tematizá-lo, em diálogo aberto com quem participou do Programa. Resultados: o impacto que ressoou tem a ver com a convocação ao movimento; o borramento de fronteiras disciplinares; a produção de outras possibilidades aos saberes e fazeres, e no deslocamentos nos modos de ser profissional, docente e discente. O impacto se mostrou no entre, nos novos pactos postos a funcionar. Nesta perspectiva, foi necessário apurar os sentidos para encontrá-lo, para perceber o que ressoa como efeito do encontro. Conclusões: Uma vez assim, uma "pesquisa de impacto" não atesta este ou qualquer programa, ou política, ela cartografa movimentos. O impacto seria relativo àquilo que resta inacabado: não o que aconteceu, mas aquilo que entrou em acontecimento, em construção de realidades possíveis, imprevisíveis, invisíveis e inaudíveis, que ao entrarem em movimento produzem realidades, impactos.

Motivation and adherence to psychosocial treatment for alcohol and drug use-related problems / Motivação e adesão ao tratamento psicossocial entre usuários de substâncias químicas

This is a prospective cohort study of 150 individuals attending a specialized health service for substance-related disorders. The study investigated the association between motivation to remain in treatment and treatment adherence. All service users were interviewed soon after admission to the treatment program and were followed-up during the first two months of treatment. A Cox Regression Model was used to estimate the hazard ratios for dropout during the two months following the admission interview. The results indicated that individuals with a primary-school education, lack of income, and low motivation toward treatment at the admission interview presented a higher risk of treatment dropout. This study showed the importance of motivation in changing addictive behavior and in adherence to treatment as essential factors for recovery.

A associação entre a motivação para manter-se em tratamento e a respectiva adesão foi estudada em uma coorte prospectiva de 150 usuários de um Centro de Atenção Psicossocial-Álcool e Drogas. Modelo de Regressão de Cox foi usado para estimar as razões de risco para o abandono do tratamento durante os dois primeiros meses após a entrevista de admissão. Os resultados sugerem que a pouca escolaridade (até a 9ª série), a ausência ou insuficiência de renda, bem como a baixa motivação no momento da entrevista de admissão são fatores de risco para o abandono do tratamento. As motivações para mudar o comportamento aditivo e para aderir ao tratamento foram identificadas como um dos fatores importantes para a recuperação de indivíduos com problemas relacionados ao uso de substâncias químicas.

Factors associated with post-diagnosis pregnancies in women living with HIV in the south of Brazil.

OBJECTIVES: To analyze the factors associated with the occurrence of pregnancies after the diagnosis of infection by HIV. METHODS: Cross-sectional study with women of a reproductive age living with HIV/AIDS cared for in the public services of the city of Porto Alegre, in southern Brazil. The data was analyzed from a comparison between two groups: women with and women without pregnancies after the diagnosis of HIV. Poisson regression models were used to estimate the reasons of prevalence (RP). RESULTS: The occurrence of pregnancies after the diagnosis of HIV is associated with a lower level of education (RP adjusted = 1.31; IC95%: 1.03-1.66), non-use of condoms in the first sexual intercourse (RP = 1.32; IC95%: 1.02-1.70), being 20 years old or less when diagnosed with HIV (RP = 3.48; IC95%: 2.02-6.01), and experience of violence related to the diagnosis of HIV (RP = 1.28; IC95%: 1.06-1.56). CONCLUSIONS: The occurrence of pregnancies after the diagnosis of infection by HIV does not indicate the exercise of the reproductive rights of the women living with HIV/AIDS because these pregnancies occurred in contexts of great vulnerability.

Socioeconomic and regional inequalities of pap smear coverage. / Desigualdades socioeconômicas e regionais na cobertura de exames citopatológicos do colo do útero.

Objectives To identify socioeconomic and regional inequalities of pap smear coverage in the state of Rio Grande do Sul. Methods An ecological study based on data of the 2011-2012 national health information system to estimate the annual coverage of pap smears for the overall female population of the state and for women without private health insurance. We estimated annual pap smear coverage according to the Municipal Social Vulnerability Index and health macro-regions and regions of the state. Results The percentage of women without private health insurance ranged from 38.1% to 94.2% in the health regions. Pap smear coverage was 17.3% for the overall female population and 23.8% for women without private health insurance. Pap smear coverage was higher in more socially vulnerable municipalities and regions with a higher percentage of women with private health insurance. Conclusions The prevalence of private health insurance should be considered in studies that address the coverage of the Brazilian Unified Health System (SUS).

The Scale of Self-Efficacy Expectations of Adherence to Antiretroviral Treatment: A Tool for Identifying Risk for Non-Adherence to Treatment for HIV.

BACKGROUND: Identification of risk for non-adherence to treatment is a challenge for personalized care for people living with HIV. Standardized questionnaires of patients' expectations of their capability to overcome obstacles for treatment adherence may be used as a pre-screening for risk identification. A scale of self-efficacy expectations of adherence to antiretroviral treatment (SEA-ART scale) was previously developed. This study assesses the scale validity in predicting non-adherence to ART in adults living with HIV. METHODS AND FINDINGS: A prospective cohort study applied a 21-item SEA-ART scale to 275 adults in ART treatment at an outpatient public service for HIV in Southern Brazil. ART medications taken were assessed at one-month follow-up; ART adherence was devised as an intake of 95% and more of the prescribed medication. A SEA-ART score was calculated by adding up the scores of all items. Multivariable logistic regression and the Area Under the Receiver-Operating-Characteristic Curve (AUROC) were applied to examine the ability of the SEA-ART score to predict non-adherence at follow-up. The SEA-ART score varied from 21 to 105; mean 93.9; median 103.0. Non-adherence was 30.3% (n = 81/267). The odds of non-adherence was 8% lower for each unit increase of the SEA-ART score; after adjustment for age, sex, formal education and time in treatment (OR = 0.92; 95%CI 0.90-0.95; LRT for linear trend, p = 0.002). The AUROC was 0.80 (95%CI 0.73-0.87; p<0.001). The SEA-ART optimal cut-off value was 101, providing a sensitivity of 76.5%, a specificity of 73.1%, a positive predictive value of 55.4% and a negative predictive value of 87.7%. There was no evidence of difference in sensitivity, and specificity among groups organized by age, gender, formal education and time in treatment. CONCLUSIONS: The SEA-ART scale appears to have a good capacity to discriminate between adherents and non-adherents at one-month follow-up. Further studies should confirm these results in other populations.

Desigualdades socioeconômicas e regionais na cobertura de exames citopatológicos do colo do útero / Desigualdades socioeconómicas y regionales en la cobertura de exámenes citopatológicos del cuello uterino / Socioeconomic and regional inequalities of pap smear coverage

RESUMO Objetivos Identificar desigualdades socioeconômicas e regionais na cobertura de exames citopatológicos do colo do útero no Rio Grande do Sul. Métodos Estudo ecológico utilizou dados dos sistemas de informação em saúde de 2011-2012 para estimar coberturas anuais de exames para todas as mulheres residentes e para as não beneficiárias de planos privados de saúde. Desigualdades na cobertura foram estimadas conforme o Índice de Vulnerabilidade Social Municipal, macrorregiões e regiões de saúde. Resultados A prevalência de mulheres não beneficiarias de planos privados de saúde variou de 38,1% a 94,2% entre regiões de saúde. A cobertura estadual foi 17,3% para todas as residentes e 23,8% para as não beneficiárias de planos privados. As maiores coberturas ocorreram nos municípios em maior vulnerabilidade social e nas regiões com maior prevalência de planos privados. Conclusões A prevalência de planos privados de saúde deve ser considerada em estudos da cobertura de serviços pelo Sistema Único de Saúde.

RESUMEN Objetivos Identificar desigualdades socioeconómicas y regionales en la cobertura de exámenes citopatológicos del cuello uterino en Rio Grande do Sul. Métodos Estudio ecológico utilizó datos de los sistemas de información en salud de 2011-2012 para estimar coberturas anuales de exámenes para la totalidad de mujeres residentes y para no beneficiarias de planes privados de salud. Se estimaron las desigualdades según el Índice de Vulnerabilidad Social Municipal, las macroregiones y las regiones de salud. Resultados La prevalencia de mujeres no beneficiarias de planes privados de salud tuvo una variación de 38.1% a 94.2% entre las regiones de salud. La cobertura del estado fue de 17.3% para la totalidad de residentes y el 23.8% para no beneficiarias de planes privados. Las mayores coberturas sucedieron en los municipios de mayor vulnerabilidad social y regiones con mayor prevalencia de planes privados. Conclusiones La prevalencia de los planes privados de salud debe ser considerada en los estudios de cobertura de servicios del Sistema Único de Salud (SUS).

ABSTRACT Objectives To identify socioeconomic and regional inequalities of pap smear coverage in the state of Rio Grande do Sul. Methods An ecological study based on data of the 2011-2012 national health information system to estimate the annual coverage of pap smears for the overall female population of the state and for women without private health insurance. We estimated annual pap smear coverage according to the Municipal Social Vulnerability Index and health macro-regions and regions of the state. Results The percentage of women without private health insurance ranged from 38.1% to 94.2% in the health regions. Pap smear coverage was 17.3% for the overall female population and 23.8% for women without private health insurance. Pap smear coverage was higher in more socially vulnerable municipalities and regions with a higher percentage of women with private health insurance. Conclusions The prevalence of private health insurance should be considered in studies that address the coverage of the Brazilian Unified Health System (SUS).

Tematizar o impacto na educação pelo trabalho em saúde: abrir gavetas, enunciar perguntas, escrever / Thematizing the impact of health work on education: opening drawers, enunciating questions, and writing / Tematizar el impacto en la educación en el trabajo para la salud: abrir gavetas, enunciar preguntas, escribir

O tema do impacto, frequente na discussão envolvendo políticas públicas de saúde, foi tomado em consideração. Ponderou-se o Programa de Educação pelo Trabalho para a Saúde, incentivo político-financeiro do Ministério da Saúde, para questionar o dimensionamento da integração ensino-serviço. Pretendeu-se instigar ao pensamento, não apresentar métodos e técnicas, entretanto, usou-se um programa orientado pela ação das redes de atenção e objeto de um estudo de impacto. O objetivo foi contribuir com uma espécie de diálogo aberto, levantando questões e apontando a importância de uma rede de pensamento. O impacto, tornado uma pergunta, foi o impulsionador, concluindo-se que faz-se necessário: abrir gavetas (problematizar concepções de base), enunciar perguntas (acolher desafios inovadores) e escrever (elaborar raciocínios disruptores), de modo que uma pesquisa, análise, ou avaliação lance problemas, desafios e disrupturas quando se quer novos arranjos de conhecimentos e práticas.

The impactof health work on education involving health public policies was investigated. The study was focused on the Education by Work for Health Program, sponsored by the Ministry of Health, to develop questions concerning the teaching-service integration. The study aims to fuel thinking, contribute to an open dialog, raise questions, and point out the importance of a network of thinking, instead of providing readymade questions, methods, and techniques. It suggests that the development of questions requires opening of drawers by discussing basic concepts to enunciate questions that invite innovative challenges and to deduce a disruptive reasoning. This is likely to provide the research study, analysis, or program evaluation with the basis to raise issues, challenges, and disruptions potentially useful for new arrangements of knowledge and practices.

El tema del impacto, frecuente en la discusión envolviendo políticas públicas de salud, fue tomado en consideración. Se ponderó el Programa de Educación en el Trabajo para la Salud, incentivo político-financiero del Ministerio de la Salud, para cuestionar el dimensionamiento de la integración enseñanza-servicio. Se pretendió instigar al pensamiento, no presentar métodos y técnicas, a través de un Programa orientado por la acción de las redes de atención y objeto de un estudio de impacto. El objetivo fue contribuir con una especie de diálogo abierto, levantando cuestiones y apuntando la importancia de una red de pensamiento. El impacto, como pregunta, fue el impulsor, concluyéndose que se hace necesario abrir gavetas (problematizar concepciones de base), enunciar preguntas (acoger desafíos innovadores) y escribir (elaborar raciocinios separadores), de modo que una investigación, análisis o evaluación propongan nuevos arreglos de conocimientos y prácticas.

[Development and validation of a social vulnerability index applied to public policies of the Unified Health System (SUS)]. / Desenvolvimento e validação de um índice de vulnerabilidade social aplicado a políticas públicas do SUS.

The article outlines the development and initial validation of a Social Vulnerability Index (SVI) including five social determinants of risk to health and demonstrates its application in the financing of primary care by the Unified Health System (SUS) in the State of Rio Grande do Sul. Municipal indicators of vulnerability relating to poverty and population dispersion were obtained from the 2010 population census of the Brazilian Institute of Geography and Statistics. Both exploratory and confirmatory factor analysis suggests that the five items can constitute a reliable and acceptable measurement scale. The SVI-5 was then generated based on the first main component, measuring municipal inequalities in social vulnerability relating to poverty and population in the territory in Z-scores. The external validity of SVI-5 was examined in relation to health outcomes using DATASUS 2007-2011 data, revealing that infant mortality and hospitalizations for conditions treatable by primary care are greater in more vulnerable municipalities The results suggest that the SVI-5 is a valid measure of inequalities in social vulnerability between municipalities, applicable to socially equitable policies in health.

Desenvolvimento e validação de um índice de vulnerabilidade social aplicado a políticas públicas do SUS / Development and validation of a social vulnerability index applied to public policies of the Unified Health System (SUS)

O artigo apresenta o desenvolvimento e a validação inicial de um Índice de Vulnerabilidade Social - IVS-5, incluindo cinco determinantes sociais de risco à saúde, e exemplifica sua aplicação no financiamento da atenção básica pelo Sistema Único de Saúde no Rio Grande do Sul. Indicadores municipais de vulnerabilidade relativa à pobreza e dispersão populacional foram obtidos do Censo do IBGE-2010. A análise fatorial exploratória e a análise fatorial confirmatória sugerem que os cinco itens podem constituir uma escala de medida cuja confiabilidade é aceitável. O IVS-5 foi então gerado a partir do primeiro componente principal, medindo, em escores Z, desigualdades municipais na vulnerabilidade social relativa à pobreza e dispersão populacional no território. A validade externa do IVS-5 foi examinada em relação a desfechos de saúde, usando dados do Datasus 2007-2011, mostrando que a mortalidade infantil e as hospitalizações por condições sensíveis à atenção básica são maiores em municípios mais vulneráveis. Os resultados sugerem que o IVS-5 é medida válida de desigualdades na vulnerabilidade social entre municípios, aplicável a políticas de equidade social e em saúde.

The article outlines the development and initial validation of a Social Vulnerability Index (SVI) including five social determinants of risk to health and demonstrates its application in the financing of primary care by the Unified Health System (SUS) in the State of Rio Grande do Sul. Municipal indicators of vulnerability relating to poverty and population dispersion were obtained from the 2010 population census of the Brazilian Institute of Geography and Statistics. Both exploratory and confirmatory factor analysis suggests that the five items can constitute a reliable and acceptable measurement scale. The SVI-5 was then generated based on the first main component, measuring municipal inequalities in social vulnerability relating to poverty and population in the territory in Z-scores. The external validity of SVI-5 was examined in relation to health outcomes using DATASUS 2007-2011 data, revealing that infant mortality and hospitalizations for conditions treatable by primary care are greater in more vulnerable municipalities The results suggest that the SVI-5 is a valid measure of inequalities in social vulnerability between municipalities, applicable to socially equitable policies in health.

Percepção e atitudes maternas em relação às orientações de profissionais de saúde referentes a práticas alimentares no primeiro ano de vida / Maternal perception and attitudes regarding healthcare professionals' guidelines on feeding practices in the child's first year of life

OBJETIVO: Avaliar a percepção e as atitudes maternas relacionadas à adesão às orientações de profissionais de saúde sobre aleitamento materno e alimentação complementar e fatores associados. MÉTODOS: Análise transversal de dados de ensaio de campo randomizado, em que foram sorteadas 20 Unidades de Saúde (US) de Porto Alegre-RS das oito gerências distritais de saúde do município. Gestantes atendidas nestas US foram selecionadas e, aos 6-9 meses de idade das crianças, foram obtidos, em visitas domiciliares, dados quanto à percepção materna de adesão às orientações dos profissionais e de consequências das práticas alimentares na saúde da criança. Análises de associação foram realizadas por meio de Regressão de Poisson. RESULTADOS: Foram obtidos dados de 631 binômios mãe-criança. Conforme a percepção das mães, 47% relataram não seguir orientações recebidas nas US. Dentre essas, 45,7% não reconhecem a importância da alimentação para a saúde da criança. A percepção de adesão às orientações dos profissionais foi associada com maiores prevalências de aleitamento materno exclusivo (AME), introdução de alimentos sólidos (IAS) após quatro meses e introdução de alimentos não recomendados após seis meses, além de maior renda familiar. Observaram-se maiores prevalências de AME e IAS após quatro meses (p < 0,05) entre as mães que acreditam na importância da alimentação para a saúde da criança. CONCLUSÃO: Houve elevada prevalência de mães que não seguem as orientações dos profissionais de saúde e a percepção de que a alimentação não influencia a saúde da criança pode ser uma barreira para melhorias nas práticas alimentares na infância.

OBJECTIVE: To evaluate the maternal perceptions and attitudes related to adherence to healthcare professionals' guidelines on breastfeeding and complementary feeding, and associated factors. METHODS:A cross-sectional analysis of data from a randomized field trial was performed, in which 20 health centers (HCs) were selected in the city of Porto Alegre, state of Rio Grande do Sul, from eight Health Management Districts of the city. Pregnant women were selected from these HCs, and when the children were aged between six and nine months, data regarding the maternal perception of adherence to professional advice and consequences of feeding practices on child health were obtained during home visits. Association analyses were performed using Poisson regression. RESULTS: Data were collected from 631 mother-child binomials. According to the mothers' perception, 47% reported not following instructions received in the HC. Among these, 45.7% did not recognize the importance of eating habits for the child's health. The perception of adherence to professional advice was associated with higher prevalence of exclusive breastfeeding (EBF), introduction of solid food (ISF) after four months, introduction of non-recommended foods after six months, and higher family income. A higher prevalence of EBF and ISF was observed after four months (p < 0.05) among mothers who believed in the importance of feeding habits for the child's health. CONCLUSION: There was a high prevalence of mothers who did not follow the advice of health professionals; the perception that food does not affect the child's health can be a barrier to the improvement of eating habits in childhood.

Maternal perception and attitudes regarding healthcare professionals' guidelines on feeding practices in the child's first year of life.

OBJECTIVE: To evaluate the maternal perceptions and attitudes related to adherence to healthcare professionals' guidelines on breastfeeding and complementary feeding, and associated factors. METHODS: A cross-sectional analysis of data from a randomized field trial was performed, in which 20 health centers (HCs) were selected in the city of Porto Alegre, state of Rio Grande do Sul, from eight Health Management Districts of the city. Pregnant women were selected from these HCs, and when the children were aged between six and nine months, data regarding the maternal perception of adherence to professional advice and consequences of feeding practices on child health were obtained during home visits. Association analyses were performed using Poisson regression. RESULTS: Data were collected from 631 mother-child binomials. According to the mothers' perception, 47% reported not following instructions received in the HU. Among these, 45.7% did not recognize the importance of eating habits for the child's health. The perception of adherence to professional advice was associated with higher prevalence of exclusive breastfeeding (EBF), introduction of solid food (ISF) after four months, introduction of non-recommended foods after six months, and higher family income. A higher prevalence of EBF and ISF was observed after four months (p < 0.05) among mothers who believed in the importance of feeding habits for the child's health. CONCLUSION: There was a high prevalence of mothers who did not follow the advice of health professionals; the perception that food does not affect the child's health can be a barrier to the improvement of eating habits in childhood.

A Disease Register for ME/CFS: Report of a Pilot Study.

BACKGROUND: The ME/CFS Disease Register is one of six subprojects within the National ME/CFS Observatory, a research programme funded by the Big Lottery Fund and sponsored by Action for ME. A pilot study in East Anglia, East Yorkshire, and London aimed to address the problem of identifying representative groups of subjects for research, in order to be able to draw conclusions applicable to the whole ME/CFS population.While not aiming for comprehensive population coverage, this pilot register sought to recruit participants with ME/CFS in an unbiased way from a large population base. Those recruited are constituting a cohort for long-term follow-up to shed light on prognosis, and a sampling frame for other studies. FINDINGS: Patients with unidentified chronic fatigue were identified in GP databases using a READ-code based algorithm, and conformity to certain case definitions for ME/CFS determined. 29 practices, covering a population aged 18 to 64 of 143,153, participated.510 patients with unexplained chronic fatigue were identified. 265 of these conformed to one or more case definitions. 216 were invited to join the register; 160 agreed. 96.9% of participants conformed to the CDC 1994 (Fukuda) definition; the Canadian definition defined more precisely a subset of these. The addition of an epidemiological case definition increased case ascertainment by approximately 4%. A small-scale study in a specialist referral service in East Anglia was also undertaken.There was little difference in pattern of conformity to case definitions, age or sex among disease register participants compared with subjects in a parallel epidemiological study who declined to participate.One-year follow-up of 50 subjects showed little change in pain or fatigue scores. There were some changes in conformity to case definitions. CONCLUSIONS: Objective evaluation indicated that the aim of recruiting participants with ME/CFS to a Disease Register had been fulfilled, and confirmed the feasibility of our approach to case identification, data processing, transmission, storage, and analysis. Future developments should include expansion of the ME/CFS Register and its linkage to a tissue sample bank and post mortem tissue archive, to facilitate support for further research studies.

Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) in adults: a qualitative study of perspectives from professional practice.

BACKGROUND: Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) can cause profound and prolonged illness and disability, and poses significant problems of uncertainty for healthcare professionals in its diagnosis and management. The aim of this qualitative study was to explore the nature of professional 'best practice' in working with people with CFS/ME. METHODS: The views and experiences of health care practitioners (HCPs) were sought, who had been judged by people with CFS/ME themselves to have been particularly helpful and effective. Qualitative semi-structured interviews following a topic guide were carried out with six health care practitioners. Interviews were audio-recorded, transcribed and subject to thematic analysis. RESULTS: Five main themes were developed: 1) Diagnosis; 2) Professional perspectives on living with CFS/ME; 3) Interventions for treatment and management; 4) Professional values and support for people with CFS/ME and their families; 5) Health professional roles and working practices. Key findings related to: the diagnostic process, especially the degree of uncertainty which may be shared by primary care physicians and patients alike; the continued denial in some quarters of the existence of CFS/ME as a condition; the variability, complexity, and serious impact of the condition on life and living; the onus on the person with CFS/ME to manage their condition, supported by HCPs; the wealth of often conflicting and confusing information on the condition and options for treatment; and the vital role of extended listening and trustful relationships with patients. CONCLUSIONS: While professional frustrations were clearly expressed about the variability of services both in primary and specialist care and continuing equivocal attitudes to CFS/ME as a condition, there were also strong positive messages for people with CFS/ME where the right services are in place. Many of the findings from these practitioners seen by their patients as helping them more effectively, accord with the existing literature identifying the particular importance of listening skills, respect and trust for establishing a therapeutic relationship which recognises key features of the patient trajectory and promotes effective person-centred management of this complex condition. These findings indicate the need to build such skills and knowledge more systematically into professional training informed by the experience of specialist services and those living with the condition.

Long-term effectiveness of a nutritional program in reducing early childhood caries: a randomized trial.

OBJECTIVES: To investigate the effectiveness of home visits advising mothers about healthy feeding practices during the first year of life on the occurrence of early childhood caries and severe early childhood caries at 4 years of age. METHODS: We conducted a parallel randomized trial of mothers of single, full-term children with birthweight > or = 2500g in São Leopoldo, Brazil. The intervention group received monthly advice up to 6 months and then at 8, 10 and 12 months by undergraduate nutrition students, based on the "Ten Steps for Healthy Feeding'', a Brazilian national health policy for primary care based on World Health Organization guidelines. The primary outcome was the occurrence of early childhood caries at age four. Secondary outcomes included the occurrence of severe early childhood caries and the number of affected teeth: decayed (white spots and cavities), missing and filled teeth (d(1+)mft). Blinded observers ascertained feeding habits in the home and one blinded dentist performed dental examinations in a municipal clinic. This study is registered with ClinicalTrials.gov, number NCT00629629. RESULTS: Of 500 mother-child pairs (200 intervention, 300 control) enrolled, 340 (141 intervention, 199 control) completed 4 year follow-up. As 138 (69.3%) controls but only 76 (53.9%) intervention children had early childhood caries, home counseling reduced incidence by 22% (RR 0.78; 95% CI 0.65-0.93). Severe early childhood caries incidence was reduced by 32% (RR 0.68; 95% CI 050-0.92). The mean number of affected teeth was lower for the intervention group (3.25) compared with the control group (4.15) (Mann Whitney U-test; p=0.023). No adverse effects were noted. CONCLUSIONS: Home nutritional advice during the first year of life decreases caries incidence and severity at four years of age in a low income community.

The expressed needs of people with chronic fatigue syndrome/myalgic encephalomyelitis: a systematic review.

BACKGROUND: We aimed to review systematically the needs for support in managing illness and maintaining social inclusion expressed by people with chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) METHODS: We carried out a systematic review of primary research and personal ('own') stories expressing the needs of people with CFS/ME. Structured searches were carried out on Medline, AMED, CINAHL, EMBASE, ASSIA, CENTRAL, and other health, social and legal databases from inception to November 2007. Study inclusion, data extraction and risk of bias were assessed independently in duplicate. Expressed needs were tabulated and a conceptual framework developed through an iterative process. RESULTS: Thirty two quantitative and qualitative studies, including the views of over 2500 people with CFS/ME with mainly moderate or severe illness severity, met the inclusion criteria. The following major support needs emerged: 1) The need to make sense of symptoms and gain diagnosis, 2) for respect and empathy from service providers, 3) for positive attitudes and support from family and friends, 4) for information on CFS/ME, 5) to adjust views and priorities, 6) to develop strategies to manage impairments and activity limitations, and 7) to develop strategies to maintain/regain social participation. CONCLUSIONS: Although the studies were heterogeneous, there was consistent evidence that substantial support is needed to rebuild lives. Gaining support depends - most importantly - on the ability of providers of health and social care, colleagues, friends and relatives, and those providing educational and leisure services, to understand and respond to those needs.

Inequalities in cesarean delivery rates by ethnicity and hospital accessibility in Brazil.

OBJECTIVE: To investigate inequalities in cesarean delivery rates in Brazil according to ethnic group and level of access to hospital delivery. METHODS: Cross-sectional analysis of data for primiparous women with singleton deliveries between 2003 and 2004 from the National Information System of Live-Births (6,064,799 live births). Robust Poisson regression modeling was applied to estimate prevalence ratios of cesarean deliveries for ethnic group and level of access to hospital delivery according to residence. RESULTS: There were 2,438,180 primiparous deliveries and the cesarean rate was 45.8%. Ethnic inequalities in cesarean delivery rates showed lower rates for all ethnic groups compared with white women, with the lowest rates recorded for indigenous women. The association between ethnicity and cesarean delivery was higher in states with lower access to hospital (P<0.001). Multiple regression models showed that this association was, in part, explained by older maternal age and higher levels of education and prenatal care. CONCLUSIONS: Overuse of cesarean delivery and strong evidence of ethnic inequalities in cesarean rates exist in Brazil. The inequalities are greater in states with lower access to hospital and were partially explained by socioeconomic factors and prenatal care, suggesting a misuse of medical technology at birth.

Motivação de pacientes hospitalizados para evitar o consumo excessivo de bebidas alcoólicas / Motivación de pacientes hospitalizados para evitar el consumo excesivo de bebidas alcohólicas / Motivation of hospitalized patients to avoid excessive consumption of alcoholic beverages

Esta pesquisa visou a determinar as variáveis associadas à motivação de pacientes hospitalizados para evitar o consumo excessivo de bebidas alcoólicas. Trata-se de um estudo transversal, do qual participaram 1.050 pacientes do sexo masculino com idade entre 21 e 70 anos, internados em três hospitais da cidade de Pelotas, no período de 1° de novembro de 2000 a 15 de junho de 2001. A coleta dos dados foi realizada através da aplicação de questionários. Os achados revelaram que 180 pacientes eram bebedores excessivos, predominando, entre eles, as pessoas com menor poder aquisitivo e elevada faixa etária. Já os mais jovens mostraram-se pouco motivados para evitar tal hábito; por esse motivo, tal grupo deve ser considerado alvo prioritário das intervenções realizadas pelos profissionais de saúde, a fim de possibilitar sua sensibilização quanto aos transtornos ocasionados pelo abuso do álcool.

This research aimed to determine the variables associated to the motivation of inpatients to avoid excessive consumption of alcoholic beverages. This is a cross-sectional study in which participated 1.050 male patients aged between 21 and 70 years, hospitalized in three hospitals of the city of Pelotas, in the period from November 1st, 2000 to June 15th, 2001. Data collection was performed by the application of questionnaires. The findings revealed that 180 patients were excessive drinkers, predominating, among them, people with less economic power and higher age group. By the other hand, the younger group presented itself less motivated to avoid such habits. Therefore, that group must be considered a priority target from interventions performed by health professionals, in order to enable their awareness about the inconvenience caused by the abuse of alcohol.

Esta investigación tuvo como objetivo determinar las variables asociadas a la motivación de pacientes hospitalizados a fin de evitar el consumo excesivo de bebidas alcohólicas. Se trata de un estudio transversal, en el cual participaron 1.050 pacientes de sexo masculino con edades entre 21 y 70 años, hospitalizados en tres hospitales de la ciudad de Pelotas, en el período de 1 de noviembre de 2000 al 15 de junio de 2001. La colecta de datos fue realizada mediante la aplicación de cuestionarios. Los hallazgos revelaron que 180 pacientes fueron bebedores excesivos, predominando, entre ellos, las personas con menos poder adquisitivo y de alta faja etaria. Ya, los más jóvenes se mostraron poco motivados para evitar tal hábito, por ese motivo, ese grupo debe ser considerado meta prioritaria de las intervenciones realizadas por los profesionales de la salud, a fin de posibilitar su sensibilización acerca de los trastornos causadas por el abuso del alcohol.

Some risk factors associated with overweight, stunting and wasting among children under 5 years old.

OBJECTIVE: To explore whether socioeconomic and sanitary conditions, maternal and child factors are associated with overweight, stunting, and wasting in children under five year old in the city of São Leopoldo, southern Brazil. METHODS: Cross-sectional study of 3,957 children aged 1 month to 5 years conducted in all primary care services of the city during the National Children's Vaccination Day in 2002. Maternal and child factors were assessed by a questionnaire. Children's height and weight were measured. Cluster analysis was used to group the areas served by the primary care services according to socioeconomic and sanitary conditions of the census tracts assessed by the 2001 National Census. RESULTS: Wasting was observed in 2.6% of children, stunting in 9.1% and overweight in 9.8%. The multivariable logistic regression model suggests that overweight was associated with higher socioeconomic status and better sanitation of the area (OR = 1.47; 95%CI 1.09-1.96), single child (OR = 1.44; 95%CI 1.00-2.07) and birth weight >or= 2,500 g (OR = 2.21; 95%CI 1.27-3.83). Wasting was associated with low birth weight (OR = 3.46; 95%CI 2.06-5.80) and mother's age < 20 years (OR = 1.99; 95%CI 1.09-3.62). Stunting was associated with low socioeconomic status and poor sanitation of the area (OR = 2.36; 95%CI 1.51-3.69), three or more siblings (OR = 3.12; 95%CI 2.18-4.47), low birth weight < 2,500 g (OR = 3.49; 95%CI 2.53-4.80), child age < 36 months (OR = 1.77; 95%CI 1.37-2.29) and mother's age < 20 years (OR = 1.60; 95%CI 1.09-2.35). CONCLUSIONS: Overweight and stunting were the major anthropometric problems and therefore should be a priority for public policies.

Alguns fatores associados a excesso de peso, baixa estatura e déficit de peso em menores de 5 anos / Some risk factors associated with overweight, stunting and wasting among children under 5 years old

OBJETIVO: Examinar fatores socioeconômicos e outras condições de vida familiar associadas a excesso de peso, baixa estatura e baixo peso para a estatura em menores de 5 anos. MÉTODOS: Estudo transversal avaliou 3.957 crianças entre 1 mês e 5 anos de idade durante campanha nacional de imunização no município de São Leopoldo (RS) em 2002. As condições socioeconômicas e de saneamento das áreas de abrangência das unidades de saúde foram agrupadas por análise de cluster dos setores do censo populacional de 2001. RESULTADOS: Déficit de peso para estatura ocorreu em 2,6 por cento das crianças, baixa estatura em 9,1 por cento e excesso de peso em 9,8 por cento. A regressão logística multivariada sugere que os fatores associados à chance de excesso de peso foram: área de condições socioeconômicas alta (RC = 1,47; IC95 por cento 1,09-1,96), filhos únicos (RC = 1,44; IC95 por cento 1,00-2,07) e peso ao nascer ≥ 2.500 g (RC = 2,21; IC95 por cento1,27-3,83). A chance de déficit de peso associou-se ao baixo peso ao nascer (RC = 3,46; IC95 por cento 2,06-5,80) e idade da mãe < 20 anos (RC = 1,99; IC95 por cento 1,09-3,62). A baixa estatura associou-se à área de condições socioeconômicas baixas (RC = 2,36; IC95 por cento 1,51-3,69), três ou mais irmãos (RC = 3,12; IC95 por cento 2,18-4,47), peso ao nascer < 2.500 g (RC = 3,49; IC95 por cento 2,53-4,80), idade < 36 meses (RC = 1,77; IC95 por cento 1,37-2,29) e idade materna < 20 anos (RC = 1,60; IC95 por cento1,09-2,35). CONCLUSÕES: Excesso de peso e baixa estatura foram os principais desvios antropométricos observados neste estudo, constituindo prioridades que devem ser consideradas nas políticas públicas atuais.

OBJECTIVE: To explore whether socioeconomic and sanitary conditions, maternal and child factors are associated with overweight, stunting, and wasting in children under five year old in the city of São Leopoldo, southern Brazil. METHODS: Cross-sectional study of 3,957 children aged 1 month to 5 years conducted in all primary care services of the city during the National Children's Vaccination Day in 2002. Maternal and child factors were assessed by a questionnaire. Children's height and weight were measured. Cluster analysis was used to group the areas served by the primary care services according to socioeconomic and sanitary conditions of the census tracts assessed by the 2001 National Census. RESULTS: Wasting was observed in 2.6 percent of children, stunting in 9.1 percent and overweight in 9.8 percent. The multivariable logistic regression model suggests that overweight was associated with higher socioeconomic status and better sanitation of the area (OR = 1.47; 95 percentCI 1.09-1.96), single child (OR = 1.44; 95 percentCI 1.00-2.07) and birth weight ≥ 2,500 g (OR = 2.21; 95 percentCI 1.27-3.83). Wasting was associated with low birth weight (OR = 3.46; 95 percentCI 2.06-5.80) and mother's age < 20 years (OR = 1.99; 95 percentCI 1.09-3.62). Stunting was associated with low socioeconomic status and poor sanitation of the area (OR = 2.36; 95 percentCI 1.51-3.69), three or more siblings (OR = 3.12; 95 percentCI 2.18-4.47), low birth weight < 2,500 g (OR = 3.49; 95 percentCI 2.53-4.80), child age < 36 months (OR = 1.77; 95 percentCI 1.37-2.29) and mother's age < 20 years (OR = 1.60; 95 percentCI 1.09-2.35). CONCLUSIONS: Overweight and stunting were the major anthropometric problems and therefore should be a priority for public policies.