Vivências de gordofobia médica em serviços de saúde no Brasil / Experiences of medical fatphobia in health services in Brazil / Experiencias de gordofobia médica en servicios de salud en Brasil

Objetivo: categorizar as vivências de gordofobia médica em serviços de saúde no Brasil. Método: estudo retrospectivo e misto, com abordagem exploratório sequencial, realizado entre janeiro de 2021 e janeiro de 2022. Os dados foram coletados manualmente, por meio da ferramenta de busca avançada e através da hashtag "gordofobia médica", no Twitter e no Instagram, respectivamente. E foram analisados por meio de análise temática. Resultados: encontrou-se 476 registros e 75 foram selecionados. Teve-se como categorias temáticas, estímulo não solicitado a medidas cirúrgicas para o emagrecimento; falta de atenção às queixas principais dos pacientes; violências psicológicas, verbais e/ou físicas associadas ao excesso de peso; e gordofobia como barreira para o acesso à saúde. Além disso, foram relatadas percepções de consequências à saúde como, abandono de tratamento, prejuízos à saúde mental e prejuízos à saúde materno-infantil. Conclusão: as características dos relatos evidenciam a sub-representação dos homens em debates relacionados à obesidade, hegemonia do saber biomédico perante questões sociais, estreitamento do acesso à saúde e contribuição negativa para a saúde física e mental das pessoas.

Objective: to categorize experiences of medical fatphobia in health services in Brazil. Method: retrospective and mixed study, with a sequential exploratory approach, carried out between January 2021 and January 2022. Data were collected manually, through the advanced search tool and through the hashtag "medical fatphobia", on Twitter and Instagram, respectively. And they were analyzed through thematic analysis. Results: 476 records were found and 75 were selected. Thematic categories were: unsolicited stimulus to surgical measures for weight loss; lack of attention to patients' main complaints; psychological, verbal and/or physical violence associated with being overweight; and fatphobia as a barrier to access to health. In addition, perceptions of health consequences were reported, such as treatment abandonment, damage to mental health and consequences for maternal and child health. Conclusion: the characteristics of the reports show the underrepresentation of men in debates related to obesity, hegemony of biomedical knowledge in the face of social issues, narrowing of access to health and negative contribution to people's physical and mental health.

Relationship between polyvictimization and overweight among adolescents from São Paulo city, Brazil.

This study is to identify victimization patterns and analyze the association between the experience of polyvictimization and overweight or obesity among adolescent girls and boys. The sample consisted of 2680 Brazilian ninth-graders enrolled in public and private schools, taken from the São Paulo Project for the social development of children and adolescents (SP-PROSO). Victimization was explored in two ways: (i) as per Finkelhor and (ii) by latent class analysis (LCA). The interest outcomes were overweight and obesity. Multinomial logistic regression models were used to study the relationship between victimization and overweight or obesity, controlling for confounders. LCA grouped boys and girls adolescents into three classes. These classes received the same labels, but the patterns differed between sexes. Class 1 was characterized by fewer types of victimization suffered and lower endorsement values in the analyzed items and was named bullying and indirect victimization (♀: 42.7%, n = 546; ♂: 21.6%, n = 293). Class 2 included more victimization types than Class 1 and less than Class 3. This class was labeled family violence and peer victimization (♀: 29.1%, n = 356; ♂: 47.9%, n = 652). Class 3 was named high polyvictimization (♀: 28.2%, n = 345; ♂: 30.5%, n = 418). According to Finkelhor, polyvictimization was not associated with overweight or obesity in both sexes. Only the class of high polyvictimization was associated with being overweight (ORadj: 1.60, 95%CI: 1.01-2.54) in girls. In this study, polyvictimization was associated with being overweight only among adolescent girls. Longitudinal studies in different contexts and populations are needed to understand this relationship.

Community violence and internalizing mental health symptoms in adolescents: A systematic review.

PURPOSES: Mental disorders are responsible for 16% of the global burden of disease in adolescents. This review focuses on one contextual factor called community violence that can contribute to the development of mental disorders OBJECTIVE: To evaluate the impact of community violence on internalizing mental health symptoms in adolescents, to investigate whether different proximity to community violence (witness or victim) is associated with different risks and to identify whether gender, age, and race moderate this association. METHODS: systematic review of observational studies. The population includes adolescents (10-24 years), exposition involves individuals exposed to community violence and outcomes consist of internalizing mental health symptoms. Selection, extraction and quality assessment were performed independently by two researchers. RESULTS: A total of 2987 works were identified; after selection and extraction, 42 works remained. Higher exposure to community violence was positively associated with internalizing mental health symptoms. Being a witnessing is less harmful for mental health than being a victim. Age and race did not appear in the results as modifiers, but male gender and family support appear to be protective factors in some studies. CONCLUSION: This review confirms the positive relationship between community violence and internalizing mental health symptoms in adolescents and provides relevant information that can direct public efforts to build policies in the prevention of both problems.

Violência familiar na infância, violência no namoro e saúde mental na adolescência / Family violence against children, dating violence and adolescent mental health

O objetivo geral desta tese foi conhecer as magnitudes e os padrões das violências no namoro na adolescência (VNA) e das violências familiares na infância (VFI), as repercussões da VFI nos diferentes padrões de VNA, bem como as relações entre os padrões de VFI e a saúde mental na adolescência. O objetivo geral suscitou três objetivos específicos, cada um explorado em um manuscrito. Os dados usados na tese derivaram da pesquisa "Estupro de vulnerável e outras violências contra adolescentes e jovens do sexo feminino", desenvolvida em 2017 e 2018 que contou com a participação de 721 estudantes de escolas públicas e privadas da IX Região Administrativa (RA) do Rio de Janeiro. Para identificar a VNA, a VFI e estimar a saúde mental, usou-se respectivamente as versões brasileiras do instrumento Conflict in Adolescent Dating Relationships Inventory (CADRI), do Childhood Trauma Questionnaire (CTQ) e do General Health Questionnaire (GHQ-12). As estratégias de análise de dados variaram em função dos diferentes objetivos/manuscritos. O manuscrito 1 estimou as magnitudes de exposição e perpetração das VNA entre os escolares da IX RA do município do Rio de Janeiro. A prevalência de vitimização variou de 16,7% (sexual) a 94,6% (emocional). A prevalência de perpetração variou entre 9,9% (sexual) e 94,6% (emocional). Os adolescentes que relataram serem vítimas de violência na infância, os que vivem em áreas violentas e os que consomem bebidas alcoólicas com maior frequência tiveram maior prevalência de VNA. Os manuscritos 2 e 3 utilizaram análises de classes latentes (ACL) para identificar os padrões de VNA (manuscrito 2) e o padrão de VFI (manuscrito 3) com base na agregação de indivíduos em classes, caracterizadas em função da probabilidade de endosso aos diferentes itens dos instrumentos CADRI e CTQ. Além da identificação destes padrões, buscou-se utilizar as classes estimadas em modelos causais aferindo os efeitos das dimensões de VFI para os padrões de VNA (manuscrito 2) e das classes de VFI para a saúde mental dos adolescentes (manuscrito 3). No manuscrito 2, identificou-se três classes latentes de VNA entre meninas e meninos. O abuso sexual na infância aumentou a chance de pertencer à classe mais grave de vitimização de VNA entre as meninas (OR = 5,72; IC 95% = 2,51-13,06). Os abusos emocionais (OR=5,97; IC 95% = 1,95-18,30) e físicos (OR=3,16; IC 95%=1,07-9,34) aumentaram as chances de classificar os meninos na classe mais grave de perpetração de VNA. A ACL do manuscrito 3 também identificou três classes de violência familiar na infância, tanto em meninas, como em meninos. Apesar de várias semelhanças entre as classes dos dois sexos, as meninas foram mais vítimas de abuso sexual e os meninos de punição corporal (castigo físico). Pertencer à classe mais grave de VFI aumentou os escores do GHQ-12 em 2 a 3 pontos quando comparados às classes mais brandas de violência. A partir destes resultados e com as discussões trazidas pelos três manuscritos, espera-se que esta tese tenha contribuído tanto com as discussões temáticas das violências, como apresentado alguns avanços metodológicos no campo da análise epidemiológica. Com relação aos primeiros aspectos, mais uma vez, evidenciou-se que a violência entre pais e filhos é um problema de saúde pública, por sua alta frequência e relações diretas e especificas com a violência no namoro de adolescentes; ampliou-se também os debates sobre a relação entre as violências e o gênero, na medida em que tanto as prevalências como os padrões de violência diferem entre meninos e meninas desde a infância; identificou-se padrões de violência que mostram que a vivência de diferentes tipos de abuso é a situação mais frequente entre crianças e adolescentes; percebeu-se que as repercussões das violências contra crianças na saúde mental de adolescentes dependem do padrão de coocorrência das diferentes formas de vitimização infantil. Com relação aos avanços metodológicos, a tese é inovadora por propor, pela primeira vez no Brasil, a utilização de ACL para caracterizar as violências contra crianças e em relacionamentos amorosos de adolescentes. Ademais, a tese avança ao articular a identificação de padrões de violência via análise de classes latentes com seus fatores de risco e consequências, ampliando as possibilidades de inferência dos modelos.

The main objective of this thesis was to know the magnitudes and patterns of dating violence in adolescence (DV) and family violence against children (VAC), the repercussions of on different DV patterns, and the relationship of VAC patterns to health mentality in adolescence. The general objective raised three specific goals. Each one was explored in one manuscript. The data used in the thesis were derived from the research "Rape of the vulnerable and other violence against female adolescents and young people", developed in 2017 and 2018, with 721 students from public and private schools in the IX Administrative Region (AR) of Rio de Janeiro. The Brazilian versions of the Conflict in Adolescent Dating Relationships Inventory (CADRI) instrument, the Childhood Trauma Questionnaire (CTQ) and the General Health Questionnaire (GHQ-12) were used to identify DV, VAC and to estimate mental health trends respectively. Data analysis strategies varied according to different objectives/manuscripts. Manuscript 1 estimated the magnitudes of exposure and perpetration of DV among students from the IX AR in Rio de Janeiro. The estimated victimization prevalence ranged from 16.7% (sexual) to 94.6% (emotional). The prevalence of perpetration ranged from 9.9% (sexual) to 94.6% (emotional). Adolescents who reported child abuse, those living in violent areas, and those who consumed alcohol more frequently had a higher prevalence of DV. Manuscripts 2 and 3 used latent classes analysis (LCA) to identify the DV patterns (manuscript 2) and the VAC pattern (manuscript 3) based on the aggregation of individuals into classes, characterized according to the probability of endorsement to the different items from the CADRI and CTQ instruments. In addition to identifying these patterns, we sought to use the estimated classes in causal models, assessing the effects of the VAC dimensions for the DV patterns (manuscript 2) and the VAC classes for adolescents' mental health (manuscript 3). In manuscript 2, three latent classes of DV were identified among girls and boys. Childhood sexual abuse increased the chance of belonging to the most severe class of DV victimization among girls (OR = 5.72; 95% CI = 2.51-13.06). Emotional (OR=5.97; 95% CI = 1.95-18.30) and physical (OR=3.16; 95% CI=1.07-9.34) abuse increased the chances of classifying boys in the most severe class of DV perpetration. The LCA of manuscript 3 also identified three classes of VAC, both in girls and boys. Despite several similarities between the classes of the two sexes, girls suffered more with sexual abuse and boys with corporal punishment (physical punishment). Belonging to the most severe class of VAC increased the GHQ-12 scores by 2 to 3 points compared to the milder classes of violence. Based on these results and with the discussions brought by the three manuscripts, it is expected that this thesis has contributed both to the thematic discussions of violence and presented some methodological advances in the field of epidemiological analysis. Regarding the first aspect, once again, it is evident that violence between parents and children is a public health problem due to its high frequency and direct and specific relationship with violence in adolescents' dating. Debates on the relationship between violence and gender have expanded, as both the prevalence and patterns of violence differ between boys and girls since childhood; patterns of violence were identified that indicate that experiencing different types of abuse is the most frequent situation among children and adolescents, and it was noticed that the repercussions of violence against children on the mental health of adolescents depend on the pattern of co-occurrence of different forms of child victimization. Regarding methodological advances, the thesis is innovative as it proposes the use of LCA to characterize VAC and DV for the first time in Brazil. Furthermore, the thesis advances by articulating the identification of patterns of violence via the analysis of latent classes with their risk factors and consequences, expanding the possibilities of inference from the models.

Childhood abuse and community violence: Risk factors for youth violence.

OBJECTIVE: To investigate the joint effect of child abuse and neglect (CAN) and community violence (CV) on adolescents with peers that commit youth violence (YV). METHODS: This is a school-based cross-sectional study of 699 students enrolled in four public and nine private schools in the municipality of Rio de Janeiro, Brazil. Participants were selected through a complex cluster sampling procedure. CAN was identified using the Childhood Trauma Questionnaire (CTQ). Exposure to CV was assessed by asking students if they have witnessed cases of lethal violence in the community. YV was measured indirectly through questions about having friends who have committed acts of crime. Multivariate logistic models were used to study the effects of emotional, physical, and sexual abuse and emotional and physical neglect in childhood on YV, controlled for confounders, according to different levels of CV. RESULTS: Emotional abuse OR = 3.32 (CI 95%: 1.79-6.17), sexual abuse OR = 2.33 (CI 95%: 1.20-4.54), and physical neglect OR = 1.81 (CI 95%: 1.02-3.20) increased the odds of YV in adolescents, whether cooccurring with CV or not. Physical abuse OR = 3.95 (CI 95%: 2.29 - 6.80) and emotional neglect OR = 2.93 (CI 95%: 1.83-4.72) are only risk factors for YV involvement when associated with CV. CONCLUSIONS: These findings highlight the relevance of CAN and CV as risk factors for YV and the potential increase in adolescents' vulnerability when exposed to both. Policies aiming at preventing and dealing with CAN are essential strategies to reduce YV, especially in areas with high levels of CV.

Association between psychiatric hospitalizations, coverage of psychosocial care centers (CAPS) and primary health care (PHC) in metropolitan regions of Rio de Janeiro (RJ) and São Paulo (SP), Brazil. / Associação entre Internações psiquiátricas, cobertura de CAPS e atenção básica em regiões metropolitanas do RJ e SP, Brasil.

To analyze the association between the coverage of psychosocial care centers (CAPS) and Primary Health Care (PHC) and the number of psychiatric hospitalizations in the metropolitan regions of the capitals of Rio de Janeiro (RJ) and São Paulo (SP) states. This is an ecological time-series study with population consisting of dwellers of metropolitan areas of the municipalities of RJ and SP hospitalized in the Unified Health System (SUS). Secondary data were collected from DATASUS and IBGE portal and indicators calculated (CAPS supply, PHC coverage, provision of psychiatric beds and psychiatric hospitalization rates). Indicators' time trends and the association between CAPS and PHC coverage and hospitalization rates were calculated. Reduced psychiatric hospitalizations rates and psychiatric beds and increased CAPS and PHC coverage were observed in the two location under study, with inverse and statistically significant association. Results confirmed the hypothesis of association between increasing CAPS and PHC supply with decreased psychiatric hospitalization rates, in the study's period and regions. This finding reinforces the importance of continuous and improved health and psychiatric reform-related policies.

CONCLUSÕES: O objetivo deste artigo é analisar a associação entre a cobertura de Centros de Atenção Psicossocial (CAPS) e a Atenção Básica (AB) e o número de internações psiquiátricas, nas regiões metropolitanas das capitais dos Estados de Rio de Janeiro (RJ) e São Paulo (SP). Estudo ecológico de séries temporais com população composta por residentes das regiões metropolitanas dos municípios do RJ e de SP internados no âmbito do SUS. Dados secundários foram coletados (portal do DATASUS e IBGE) e calculados indicadores (oferta de CAPS, cobertura da AB, oferta de leitos psiquiátricos e taxa de internações psiquiátricas). Foram calculadas as tendências temporais dos indicadores e a associação entre as coberturas de CAPS e AB e as taxas de internação. Observou-se redução das taxas de internações psiquiátricas e oferta de leitos e aumento da cobertura de CAPS e AB nas duas localidades estudadas, com associação inversa e estatisticamente significativa. : os resultados confirmaram a hipótese de associação entre as tendências crescentes de oferta de CAPS e AB e diminuição das taxas de internação psiquiátrica no período e regiões do estudo. Este achado reforça a importância da continuidade e aprimoramento das políticas relacionadas às reformas psiquiátrica e sanitária.

Associação entre Internações psiquiátricas, cobertura de CAPS e atenção básica em regiões metropolitanas do RJ e SP, Brasil / Association between psychiatric hospitalizations, coverage of psychosocial care centers (CAPS) and primary health care (PHC) in metropolitan regions of Rio de Janeiro (RJ) and São Paulo (SP), Brazil

Resumo Conclusões O objetivo deste artigo é analisar a associação entre a cobertura de Centros de Atenção Psicossocial (CAPS) e a Atenção Básica (AB) e o número de internações psiquiátricas, nas regiões metropolitanas das capitais dos Estados de Rio de Janeiro (RJ) e São Paulo (SP). Estudo ecológico de séries temporais com população composta por residentes das regiões metropolitanas dos municípios do RJ e de SP internados no âmbito do SUS. Dados secundários foram coletados (portal do DATASUS e IBGE) e calculados indicadores (oferta de CAPS, cobertura da AB, oferta de leitos psiquiátricos e taxa de internações psiquiátricas). Foram calculadas as tendências temporais dos indicadores e a associação entre as coberturas de CAPS e AB e as taxas de internação. Observou-se redução das taxas de internações psiquiátricas e oferta de leitos e aumento da cobertura de CAPS e AB nas duas localidades estudadas, com associação inversa e estatisticamente significativa. : os resultados confirmaram a hipótese de associação entre as tendências crescentes de oferta de CAPS e AB e diminuição das taxas de internação psiquiátrica no período e regiões do estudo. Este achado reforça a importância da continuidade e aprimoramento das políticas relacionadas às reformas psiquiátrica e sanitária.

Abstract To analyze the association between the coverage of psychosocial care centers (CAPS) and Primary Health Care (PHC) and the number of psychiatric hospitalizations in the metropolitan regions of the capitals of Rio de Janeiro (RJ) and São Paulo (SP) states. This is an ecological time-series study with population consisting of dwellers of metropolitan areas of the municipalities of RJ and SP hospitalized in the Unified Health System (SUS). Secondary data were collected from DATASUS and IBGE portal and indicators calculated (CAPS supply, PHC coverage, provision of psychiatric beds and psychiatric hospitalization rates). Indicators' time trends and the association between CAPS and PHC coverage and hospitalization rates were calculated. Reduced psychiatric hospitalizations rates and psychiatric beds and increased CAPS and PHC coverage were observed in the two location under study, with inverse and statistically significant association. Results confirmed the hypothesis of association between increasing CAPS and PHC supply with decreased psychiatric hospitalization rates, in the study's period and regions. This finding reinforces the importance of continuous and improved health and psychiatric reform-related policies.