Dificuldades com amamentação e sua relação com a prática alimentar na alta hospitalar / Breastfeeding difficulties and their relationship with eating habits at hospital discharge / Dificultades con la lactancia y su relación con la práctica alimentaria en el alta hospitalaria

Objetivo: descrever as frequências das dificuldades com aleitamento materno durante a internação em alojamento conjunto e sua relação com a prática alimentar na alta hospitalar. Método: estudo transversal conduzido a partir de dados de uma coorte, realizada entre março de 2017 e abril de 2018, mediante entrevistas face a face e coleta de dados de prontuários hospitalares de um hospital de referência nacional para alto risco fetal e infantil. Utilizou-se a estatística descritiva por meio de frequências absolutas, relativas e teste qui-quadrado em todas as análises. Resultados: de 686 mães e seus recém-nascidos, 50,6% das mulheres apresentaram dificuldades com aleitamento materno, com destaque para: pega, sucção, tipo de mamilo, trauma mamilar. Dentre os recém-nascidos que receberam aleitamento materno exclusivo na alta hospitalar, 51,3% não apresentaram dificuldades com amamentação durante a internação. Conclusão: apesar da dificuldade apresentada em metade da amostra estudada, ressalta-se a necessidade do suporte precoce ao aleitamento materno exclusivo ainda no ambiente hospitalar.

Objective: to describe the frequencies of breastfeeding difficulties during hospitalization in rooming-in and their relationship with eating habits at hospital discharge. Method: cross-sectional study conducted from data from a cohort, carried out between March 2017 and April 2018, through face-to-face interviews and data collection from hospital records of a national reference hospital for high fetal and infant risk. Descriptive statistics were used through absolute and relative frequencies and the chi-square test in all analyses. Results: of 686 mothers and their newborns, 50.6% of the women had difficulties with breastfeeding, with emphasis on: attachment, suction, type of nipple, nipple trauma. Among newborns who were exclusively breastfed at hospital discharge, 51.3% had no breastfeeding difficulties during hospitalization. Conclusion: despite the difficulty presented by half of the studied sample, the need for early support for exclusive breastfeeding is highlighted, even in the hospital environment.

Objetivo: describir las frecuencias de dificultades para amamantar durante la hospitalización en alojamiento conjunto y su relación con los hábitos alimentarios al alta hospitalaria. Método: estudio transversal realizado a partir de datos de una cohorte, realizada entre marzo de 2017 y abril de 2018, a través de entrevistas cara a cara y recolección de datos de registros hospitalarios de un hospital de referencia nacional de alto riesgo fetal e infantil. Se utilizó estadística descriptiva a través de frecuencias absolutas y relativas y la prueba de chi-cuadrado en todos los análisis. Resultados: de 686 madres y sus recién nacidos, el 50,6% de las mujeres presentaron dificultades para amamantar, con énfasis en: agarre, succión, tipo de pezón, traumatismo en el pezón. Entre los recién nacidos que recibieron lactancia materna exclusiva al alta hospitalaria, el 51,3% no tuvo dificultades para amamantar durante la hospitalización. Conclusión: a pesar de la dificultad presentada por la mitad de la muestra estudiada, se destaca la necesidad de apoyo temprano para la lactancia materna exclusiva, incluso en el ámbito hospitalario.

The first year of the COVID-19 pandemic in an indigenous population in Brazil: an epidemiological study.

This cross-sectional observational study that describes the epidemiological data of the first year of the COVID-19 pandemic in the Mato Grosso do Sul State, aimed to demonstrate the differences between indigenous and non-indigenous populations, characterize confirmed cases of COVID-19 according to risk factors related to ethnicity, comorbidities and their evolution and to verify the challenges in facing the disease in Brazil. SIVEP-Gripe and E-SUS-VE, a nationwide surveillance database in Brazil, from March 2020 to March 2021 in Mato Grosso do Sul state, were used to compare survivors and non-survivors from indigenous and non-indigenous populations and the epidemiological incidence curves of these populations. A total of 176,478, including 5,299 indigenous people, were confirmed. Among the indigenous population, 52.5% (confidence interval [CI] 51.2-53.9) were women, 38% (CI 36.7-39.4) were 20-39 years old, 56.7% were diagnosed by rapid antibody tests, 12.3% (CI 95%:11.5-13.2) had at least one comorbidity, and 5.3% (CI 95%:4.7-5.9) were hospitalized. In the non-indigenous patients, 56.8% were confirmed using RT-PCR, 4.4% (CI 95%:4.3-4.5) had at least one comorbidity, and 8.0% (CI 95%:7.9-8.2) were hospitalized. The majority of non-survivors were ≥60 years old (65.1% indigenous vs. 74.1% non-indigenous). The mortality in indigenous people was more than three times higher (11% vs. 2.9%). Indigenous people had a lower proportion of RT-PCR diagnoses; deaths were more frequent in younger patients and were less likely to be admitted to hospital. Mass vaccination may have controlled the incidence and mortality associated with COVID-19 in this population during the period of increased viral circulation.

Is work-family conflict a pathway between job strain components and binge eating? A cross-sectional analysis from the ELSA-Brasil study.

BACKGROUND: Job strain has been reported as a trigger for binge eating, yet the underlying mechanisms have been unclear. The aim of this study was to evaluate whether work-family conflict is a pathway in the association between job strain and binge eating, considering the possible effect-modifying influence of body mass index (BMI). METHODS: This cross-sectional analysis included 12,084 active civil servants from the multicenter Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Job strain was assessed using the Demand-Control-Support Questionnaire. Work-family conflict was considered as a latent variable comprising three items. Binge eating was defined as eating a large amount of food in less than 2 h at least twice a week in the last six months with a sense of lack of control over what and how much was eaten. Structural equation modelling was used to test the role of work-family conflict in the association between job strain and binge eating, stratifying for BMI. RESULTS: For individuals of normal weight, positive associations were found between skill discretion and binge eating (standardized coefficient [SC] = 0.209, 95%CI = 0.022-0.396), and between psychological job demands and work-family conflict (SC = 0.571, 95%CI = 0.520-0.622), but no statistically significant indirect effect was found. In overweight individuals, psychological job demands, skill discretion, and work-family conflict were positively associated with binge eating (SC = 0.099, 95%CI = 0.005-0.193; SC = 0.175, 95%CI = 0.062-0.288; and SC = 0.141, 95%CI = 0.077-0.206, respectively). Also, work-family conflict was observed to be a pathway on the associations of psychological job demands and decision authority with binge eating (SC = 0.084, 95%CI = 0.045-0.122; and SC = - 0.008, 95%CI = - 0.015- - 0.001, respectively). CONCLUSIONS: Work-family conflict partly explains effects of high levels of psychological job demands and low levels of decision authority on binge eating among overweight individuals. Moreover, skill discretion is positively associated with binge eating, regardless of BMI category.

Recent studies have found work-family conflict (i.e., incompatible work and family demands) to link between work issues and physical and mental health. Accordingly, this study investigated whether the relationship between job strain and binge eating is explained by work-family conflict, by body mass index (BMI), in a large sample of Brazilian civil servants. Overall, this study demonstrated that, among overweight individuals, excessive job demands and low decision authority (over what to do at work and how) contribute to binge eating by increasing work-family conflict. Also, excessive skill discretion at work, including opportunities to acquire and use specific job skills, is related to binge eating, regardless of BMI, which deserves further investigation. In conclusion, the results indicate that work-family conflict is a potential mechanism through which job strain can affect eating behavior among overweight individuals.

The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil): Factors Related to Smoking Cessation.

BACKGROUND: Smoking cessation is not an easy accomplishment. However, the benefits are several for those who do it, such as cardiovascular risk reduction 1 year after quitting smoking. This study aimed to verify the factors related to smoking cessation in civil servants of The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). METHODS: This study had a longitudinal design using data from a prospective cohort of civil servants (ELSA-Brasil). Our variable of interest was smoking cessation. The relationship between socio-demographic characteristics, job stress, health-related variables, legislation, and smoking cessation was analyzed by Cox proportional hazard models. The analyses were stratified by gender. Second-hand smoke exposure, age, education, excessive alcohol consumption, common mental disorder, and smoking control law were the variables considered in the final model. RESULTS: Information of 2020 women and 2429 men was analyzed. Individuals without second-hand smoke exposure, with up to 49 years of age, with higher education, without excessive alcohol consumption, without common mental disorders, and who initiated smoking in 1989 or after the smoking control law had a higher risk of stopping smoking. The risks magnitudes were higher for women. CONCLUSIONS: Our study reinforces the necessity of alcohol consumption regulation, the relevance of Public Health Policies, and the need for more smoking cessation measures focused on men, on people with mental disorders, alcoholism, and older adults. Also, our results did not show significant risks regarding the psychosocial working environment.

Estresse no trabalho e níveis de hemoglobina glicada: o papel da escolaridade. Dados da linha de base do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil) / Job stress and glycated hemoglobin levels: the role of educational attainment. Baseline data from the Longitudinal Study of Adult Health (ELSA-Brasil)

Resumo Introdução: as condições estressantes do trabalho estão associadas ao aumento dos níveis glicêmicos, mas pouco se conhece sobre o papel da escolaridade neste contexto. Objetivos: analisar a associação entre o estresse psicossocial no trabalho e os níveis de hemoglobina glicada (HbA1c) e a influência da escolaridade como modificador de efeito. Métodos: estudo transversal com dados de 11.922 trabalhadores ativos da linha de base do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). O estresse psicossocial no trabalho foi avaliado pelo modelo demanda-controle. Foram empregadas a regressão logística multinomial e interações multiplicativas. Resultados: em trabalhadoras do sexo feminino com baixa escolaridade, observou-se associação entre baixo uso de habilidades no trabalho (OR 1,56; IC95% 1,09-2,24) e HbA1c elevada. A baixa autonomia no trabalho foi relacionada à HbA1c limítrofe (OR 1,21; IC95% 1,01-1,45) e elevada (OR 1,73; IC95% 1,19-2,51). Entre trabalhadores do sexo masculino com baixa escolaridade, o trabalho de alto desgaste (OR 1,94; IC95% 1,18-3,21), o baixo uso de habilidades (OR 2,00; IC95% 1,41-2,83) e a baixa autonomia no trabalho (OR 1,58; IC95% 1,13-2,21) foram associados à HbA1c elevada. Conclusão: o estresse psicossocial no trabalho foi associado a níveis limítrofes e elevados de HbAlc para trabalhadores com baixa escolaridade de ambos os sexos. Assim, ações para modificar as relações de trabalho e prevenir doenças crônicas devem ser priorizadas.

Abstract Introduction: stressful work conditions are associated to increased glycemic levels, but little is known about the role of educational attainment in this association. Objectives: to analyze the association between psychosocial stress at work, levels of glycated hemoglobin (HbA1c), and the role of educational attainment as an effect modifier. Methods: a cross-sectional study with baseline data from 11,922 active workers who participated in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Psychosocial stress at work was measured via the Demand-Control model. Multinomial logistic regression and multiplicative interactions were performed. Results: among female workers with low educational attainment, there was an association of low skill discretion and elevated HbA1c (OR 1.56; 95% CI 1.09-2.24). Low decision authority was associated to borderline (OR 1.21; 95% CI 1.01-1.45) and high (OR 1.73; 95% CI 1.19-2.51) HbA1c. Among male workers with low educational attainment, high strain (OR 1.94; 95% CI 1.18-3.21), low skill discretion (OR 2.0; 95% CI 1.41-2.83), and low decision authority (OR 1.58; 95% CI 1.13-2.21) were associated to high HbA1c. Conclusion: Stress at work was associated to high and borderline levels of HbAlc in workers from both genders with low educational attainment. Actions to modify work relations and to prevent chronic diseases should be prioritized for this group.

The first year of the COVID-19 pandemic in an indigenous population in Brazil: an epidemiological study

ABSTRACT This cross-sectional observational study that describes the epidemiological data of the first year of the COVID-19 pandemic in the Mato Grosso do Sul State, aimed to demonstrate the differences between indigenous and non-indigenous populations, characterize confirmed cases of COVID-19 according to risk factors related to ethnicity, comorbidities and their evolution and to verify the challenges in facing the disease in Brazil. SIVEP-Gripe and E-SUS-VE, a nationwide surveillance database in Brazil, from March 2020 to March 2021 in Mato Grosso do Sul state, were used to compare survivors and non-survivors from indigenous and non-indigenous populations and the epidemiological incidence curves of these populations. A total of 176,478, including 5,299 indigenous people, were confirmed. Among the indigenous population, 52.5% (confidence interval [CI] 51.2-53.9) were women, 38% (CI 36.7-39.4) were 20-39 years old, 56.7% were diagnosed by rapid antibody tests, 12.3% (CI 95%:11.5-13.2) had at least one comorbidity, and 5.3% (CI 95%:4.7-5.9) were hospitalized. In the non-indigenous patients, 56.8% were confirmed using RT-PCR, 4.4% (CI 95%:4.3-4.5) had at least one comorbidity, and 8.0% (CI 95%:7.9-8.2) were hospitalized. The majority of non-survivors were ≥60 years old (65.1% indigenous vs. 74.1% non-indigenous). The mortality in indigenous people was more than three times higher (11% vs. 2.9%). Indigenous people had a lower proportion of RT-PCR diagnoses; deaths were more frequent in younger patients and were less likely to be admitted to hospital. Mass vaccination may have controlled the incidence and mortality associated with COVID-19 in this population during the period of increased viral circulation.

The effect of risk at birth on breastfeeding duration and exclusivity: A cohort study at a Brazilian referral center for high-risk neonates and infants.

BACKGROUND AND AIM: Both breastfeeding and the use of human milk are strategies that provide better conformation to health throughout an individual's life and bring countless short- and long- term benefits, which are well established in the scientific literature. For at-risk newborns (NBs), these strategies are crucial interventions to enable neonatal survival with better quality of life due to the distinctive and complex composition of human milk, which serves as personalized food-medicine-protection. However, there is limited knowledge about breastfeeding practices in high-risk NBs. The aim was to estimate the duration of EBF and to investigate the effect of risk at birth on EBF discontinuity in the first six months of life'. METHODS: This cohort study included 1,003 NBs from a high-risk referral center, followed up from birth to the sixth month of life, between 2017 and 2018. Correspondence and cluster analysis was used to identify neonatal risk clusters as the main exposure. The object of interest was the time until EBF discontinuity. The Kaplan-Meier methods and the Cox proportional hazards model were used to estimate the hazard ratio and 95% confidence intervals. RESULTS: The prevalence and median duration of EBF decreased proportionally in the three groups. The multiple model revealed a gradient in EBF discontinuity, which was 40% higher in risk group 1 and 111% higher in risk group 2 compared to healthy full-term NBs. Additionally, EBF during hospitalization predicted a longer median duration of this practice for high-risk NBs. CONCLUSION: This study confirms a high proportion of high-risk NBs who have EBF discontinued before six months of life. The risk of EBF discontinuity is higher in risk groups, with a gradual effect even when adjusted by several factors. Effective interventions are needed to promote, protect, and support breastfeeding in different profiles of risk-at-birth groups.

Ultra-processed foods, changes in blood pressure and incidence of hypertension: the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

OBJECTIVE: To estimate changes in blood pressure and the incidence of hypertension associated with consumption of ultra-processed foods (UPF) by Brazilian civil servants at a 4-year follow-up. DESIGN: Longitudinal analysis of the ELSA-Brasil with non-hypertensive individuals at baseline. We applied the FFQ at the baseline and categorised energy intake by degree of processing, using the NOVA classification. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured at baseline (2008-2010) and again at first follow-up (2012-2014). Incidence of arterial hypertension was defined as SBP ≥ 140 mmHg or DBP ≥ 90 mmHg or antihypertensive medication during the previous 2 weeks. A mixed-effect linear regression model and mixed-effect logistic regression model were used to estimate associations between UPF consumption and, respectively, changes in blood pressure and incidence of hypertension. SETTING: Brazil. PARTICIPANTS: Civil servants of Brazilian public academic institutions in six cities (n 8754), aged 35-74 years at baseline (2008-2010). RESULTS: UPF consumption contributed 25·2 % (sd = 9·6) of total energies consumed. After adjustment, participants with high UPF consumption presented a 23 % greater risk of developing hypertension (OR = 1·23, 95 % CI 1·06, 1·44) than those with low UPF consumption. We did not find association between UPF consumption and changes in blood pressure over time. CONCLUSIONS: The higher the UPF consumption, the higher the risk of hypertension in adults. Reducing UPF consumption is thus important to promote health and prevent hypertension.

Predicting risk of early discontinuation of exclusive breastfeeding at a Brazilian referral hospital for high-risk neonates and infants: a decision-tree analysis.

BACKGROUND: Determinants at several levels may affect breastfeeding practices. Besides the known historical, socio-economic, cultural, and individual factors, other components also pose major challenges to breastfeeding. Predicting existing patterns and identifying modifiable components are important for achieving optimal results as early as possible, especially in the most vulnerable population. The goal of this study was building a tree-based analysis to determine the variables that can predict the pattern of breastfeeding at hospital discharge and at 3 and 6 months of age in a referral center for high-risk infants. METHODS: This prospective, longitudinal study included 1003 infants and was conducted at a high-risk public hospital in the following three phases: hospital admission, first visit after discharge, and monthly telephone interview until the sixth month of the infant's life. Independent variables were sorted into four groups: factors related to the newborn infant, mother, health service, and breastfeeding. The outcome was breastfeeding as per the categories established by the World Health Organization (WHO). For this study, we performed an exploratory analysis at hospital discharge and at 3 and at 6 months of age in two stages, as follows: (i) determining the frequencies of baseline characteristics stratified by breastfeeding indicators in the three mentioned periods and (ii) decision-tree analysis. RESULTS: The prevalence of exclusive breastfeeding (EBF) was 65.2% at hospital discharge, 51% at 3 months, and 20.6% at 6 months. At hospital discharge and the sixth month, the length of hospital stay was the most important predictor of feeding practices, also relevant at the third month. Besides the mother's and child's characteristics (multiple births, maternal age, and parity), the social context, work, feeding practice during hospitalization, and hospital practices and policies on breastfeeding influenced the breastfeeding rates. CONCLUSIONS: The combination algorithm of decision trees (a machine learning technique) provides a better understanding of the risk predictors of breastfeeding cessation in a setting with a large variability in expositions. Decision trees may provide a basis for recommendations aimed at this high-risk population, within the Brazilian context, in light of the hospital stay at a neonatal unit and period of continuous feeding practice.

Breastfeeding patterns in cohort infants at a high-risk fetal, neonatal and child referral center in Brazil: a correspondence analysis.

BACKGROUND: To investigate the prevalence and patterns of breastfeeding at discharge and in the first six months of life in a high-risk fetal, neonatal and child referral center. METHODS: Prospective, longitudinal study that included the following three steps: hospital admission, first visit after hospital discharge and monthly telephone interview until the sixth month of life. The total number of losses was 75 mothers (7.5%). Exposure variables were sorted into four groups: factors related to the newborn, the mother, the health service and breastfeeding. The dependent variable is breastfeeding as per categories established by the WHO. All 1200 children born or transferred to the high-risk fetal, neonatal and child referral center, within a seven-day postpartum period, from March 2017 to April 2018, were considered eligible for the study, and only 1003 were included. The follow-up period ended in October 2018. For this paper, we performed an exploratory analysis at hospital discharge in three stages, as follows: (i) frequencies of baseline characteristics, stratified by risk for newborn; (ii) a multiple correspondence analysis (MCA); and (iii) clusters for variables related to hospital practice and exclusive breastfeeding (EBF). RESULTS: The prevalence of EBF at hospital discharge was 65.2% (62.1-68.2) and 20.6% (16.5-25.0) in the six months of life. Out of all at-risk newborns, 45.7% were in EBF at discharge. The total inertia corresponding to the two dimensions in the MCA explained for 75.4% of the total data variability, with the identification of four groups, confirmed by the cluster analysis. DISCUSSION: Our results suggest that robust breastfeeding hospital policies and practices influence the establishment and maintenance of breastfeeding in both healthy and at-risk infants. It is advisable to plan and implement additional strategies to ensure that vulnerable and healthy newborns receive optimal feeding. It is necessary to devote extra effort particularly to at-risk infants who are more vulnerable to negative outcomes. CONCLUSION: At-risk newborns did not exclusively breastfeed to the same extent as healthy newborns at hospital discharge. A different approach is required for at-risk neonates, who are more physically challenged and more vulnerable to problems associated with initiation and maintenance of breastfeeding.

Combined Use of Job Stress Models and the Incidence of Glycemic Alterations (Prediabetes and Diabetes): Results from ELSA-Brasil Study.

Evidence of psychosocial stress at work as a risk factor for diabetes and prediabetes is restricted. OBJECTIVES: Analyze the independent and combined association of the models, demand-control and social support (DC-SS) and the effort-reward imbalance and overcommitment (ERI-OC), and the incidence of glycemic alterations (prediabetes and diabetes). METHODS: A prospective study was carried out with data from 7503 active workers from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) study in the period 2008-2014. Work stress was measured by two stress models. Glycemic levels were evaluated by glycated hemoglobin (HbA1c) in two moments and classified in four groups: normal, maintenance of prediabetes, incident prediabetes, and incident diabetes. Multinomial logistic regression was analyzed with 5% significance levels stratified by sex, and multiplicative interactions were investigated. RESULTS: Work stress and glycemic alterations were more frequent in women. Psychosocial stress at work was shown to be associated to the risk of prediabetes and diabetes only among women. For women, the combination of models enlarged the magnitude of the association: prediabetes (DC-ERI = OR 1.51, 95% CI 1.15-1.99) and diabetes (DC-ERI = OR 2.10, 95% CI 1.20-3.65). Highly-educated women exposed to ERI-OC were four times more likely to have diabetes. CONCLUSION: Both models may contribute to explaining the psychosocial stress load according to each pattern of glycemic alteration among women.

Structural equation modeling of associations between night work and glycemic levels

ABSTRACT Objective Different pathways may lead from night work to metabolic diseases, including type 2 diabetes. This study aimed to explore the direct and indirect pathways from night work to glycemic levels, considering the role of physical activity, waist circumference and snacking using data from ELSA-Brasil. Materials and methods A structural equation model was used to confirm the pathways from night work to glycemic levels. The latent variable, "glycemic levels", included fasting glucose, glycated hemoglobin and 2-hour plasma glucose. Results A total of 10.396 participants were included in the analyses. The final model showed that among women, night work was associated with increased glycemic levels. A statistical significant association between night work and glycemic levels mediated by waist circumference was observed among women and men. Conclusions The association between night shift and glycemic levels can be interpreted as an important step toward understanding the pathways that could explain night work as a risk factor for diabetes using epidemiological data.

Structural equation modeling of associations between night work and glycemic levels.

OBJECTIVE: Different pathways may lead from night work to metabolic diseases, including type 2 diabetes. This study aimed to explore the direct and indirect pathways from night work to glycemic levels, considering the role of physical activity, waist circumference and snacking using data from ELSA-Brasil. MATERIALS AND METHODS: A structural equation model was used to confirm the pathways from night work to glycemic levels. The latent variable, "glycemic levels", included fasting glucose, glycated hemoglobin and 2-hour plasma glucose. RESULTS: A total of 10.396 participants were included in the analyses. The final model showed that among women, night work was associated with increased glycemic levels. A statistical significant association between night work and glycemic levels mediated by waist circumference was observed among women and men. CONCLUSIONS: The association between night shift and glycemic levels can be interpreted as an important step toward understanding the pathways that could explain night work as a risk factor for diabetes using epidemiological data.

Regional governance arrangements of the Brazilian Unified National Health System: provider diversity and spacial inequality in service provision. / Arranjos regionais de governança do Sistema Único de Saúde: diversidade de prestadores e desigualdade espacial na provisão de serviços.

The study analyzes regional Brazilian Unified National Health System (SUS, in Portuguese) governance arrangements according to providers' legal sphere and the spacial provision of middle and high-complexity services. These arrangements express the way in which State and health system reforms promoted the redistribution of functions between governmental and private entities in the territory. We carried out an exploratory study based on national-scope secondary data from 2015-2016. Using cluster analysis based on the composition of the provision percentages of the main providers, we classified 438 health regions. In middle-complexity health care, municipal public providers (outpatient) and private philanthropic providers (hospital) predominate. In high complexity provision, philanthropic and for-profit providers (outpatient and hospital) predominate. Middle-complexity provision was recorded in all health regions. However, in 12 states, more than half of the provision is concentrated in only one health region. High-complexity provision is concentrated in state capital regions. Governance arrangements may be more or less diverse and unequal, if different segments and regional concentration levels of middle and high-complexity provision are considered. The study suggests that the convergence between decentralization and mercantilization favored re-scaling of service provision, with increase in the scale of participation of private providers and strengthening of reference municipalities. Governance arrangement characteristics challenge SUS regionalization guided by the collective needs of the population.

O estudo analisa os arranjos regionais de governança do Sistema Único de Saúde (SUS), segundo esfera jurídica dos prestadores e distribuição espacial da produção de serviços de média e alta complexidade no Brasil. Tais arranjos expressam o modo como a reforma do Estado e do sistema de saúde promoveram a redistribuição de funções entre entes governamentais e privados no território. Realizou-se estudo exploratório com base em dados secundários de abrangência nacional, do biênio 2015-2016. Por meio da análise de agrupamentos baseada na composição dos percentuais da produção dos principais prestadores, foram classificadas 438 regiões de saúde. Na assistência de média complexidade, predominou o prestador público municipal (ambulatorial) e o prestador privado filantrópico (hospitalar). Na alta complexidade, predominou o prestador filantrópico e lucrativo (ambulatorial e hospitalar). A produção de média complexidade foi registrada em todas as regiões de saúde, porém, em 12 estados, mais da metade dela está concentrada em apenas uma região de saúde. A produção de alta complexidade é concentrada nas regiões das capitais estaduais. Os arranjos de governança podem ser mais ou menos diversos e desiguais, se considerados os diferentes segmentos e níveis de concentração regional da produção de média e alta complexidade. O estudo sugere que a convergência entre descentralização e mercantilização favoreceu o reescalonamento da função de prestação de serviços, com ampliação da escala de atuação de prestadores privados e fortalecimento dos municípios polos. As características dos arranjos de governança desafiam a regionalização do SUS orientada pelas necessidades coletivas das populações.

El estudio analiza las modalidades regionales de gestión en el Sistema Único de Salud (SUS), según la categoría jurídica de los prestadores y la distribución espacial para la provisión de servicios de media y alta complejidad en Brasil. Tales modalidades expresan el modo mediante el cual la reforma del Estado y del sistema de salud promovieron la redistribución de funciones entre entes gubernamentales y privados en el territorio nacional. Se realizó un estudio exploratorio, basado en datos secundarios de alcance nacional, durante el bienio 2015-2016. Mediante un análisis de agrupamientos, basado en la composición de porcentajes relacionados con la provisión de servicios de los principales prestadores, se clasificaron 438 regiones de salud. En la asistencia de media complejidad, predominó el prestador público municipal (ambulatorio) y el prestador privado filantrópico (hospitalario). En la alta complejidad, predominó el prestador filantrópico y lucrativo (ambulatorio y hospitalario). La provisión de media complejidad se registró en todas las regiones de salud, sin embargo, en 12 estados, más de la mitad de la misma está concentrada en sólo una región de salud. La producción de alta complejidad está concentrada en las regiones de las capitales de los estados. Las modalidades de gestión pueden ser más o menos diversas y desiguales, si se consideran los diferentes segmentos y niveles de concentración regional en la provisión de servicios de media y alta complejidad. El estudio sugiere que la convergencia entre descentralización y mercantilización favoreció el reescalonamiento de la función de prestación de servicios, con una ampliación de la escala de actuación de prestadores privados y el fortalecimiento de los municipios más importantes. Las características de las modalidades de gestión desafían la regionalización del SUS, orientada por las necesidades colectivas de las poblaciones.

Origin-destination flows in chemotherapy for breast cancer in Brazil: implications for pharmaceutical services.

This study maps and analyzes patient flows for breast cancer chemotherapy in order to identify the potential implications for organization of pharmaceutical services in the cancer care network. An ecological study design sought to correlate the place of residence with place of care for breast cancer patients. All chemotherapy procedures financed by Brazil's Unified Health System (SUS) and performed from January to December 2013 were included. Flows were mapped using TerraView® software. A total of 1 347 803 outpatient chemotherapy procedures were delivered by 243 cancer care units located in 156 municipalities. Seventeen cities concentrated approximately 50.0 % of the procedures. A total of 8 538 origin-destination flows were generated and 49.2% of procedures were performed in services located outside the municipality in which the patient resided. Context challenges, related to inequality of access to chemotherapy and hindrances in planning and management of pharmaceutical services, were discussed.

Origin-destination flows in chemotherapy for breast cancer in Brazil: implications for pharmaceutical services / Fluxos origem-destino para quimioterapia para o câncer de mama no Brasil: implicações para a assistência farmacêutica

Abstract This study maps and analyzes patient flows for breast cancer chemotherapy in order to identify the potential implications for organization of pharmaceutical services in the cancer care network. An ecological study design sought to correlate the place of residence with place of care for breast cancer patients. All chemotherapy procedures financed by Brazil's Unified Health System (SUS) and performed from January to December 2013 were included. Flows were mapped using TerraView® software. A total of 1 347 803 outpatient chemotherapy procedures were delivered by 243 cancer care units located in 156 municipalities. Seventeen cities concentrated approximately 50.0 % of the procedures. A total of 8 538 origin-destination flows were generated and 49.2% of procedures were performed in services located outside the municipality in which the patient resided. Context challenges, related to inequality of access to chemotherapy and hindrances in planning and management of pharmaceutical services, were discussed.

Resumo Este estudo mapeia e analisa os fluxos percorridos por pacientes em uso de quimioterapia para o tratamento do câncer de mama no Brasil, usando metodologia de redes, de forma a identificar potenciais implicações para a organização da assistência farmacêutica na rede de atenção oncológica. Realizou-se um estudo ecológico correlacionando o local de residência com o de atendimento de pacientes com câncer de mama. Incluiu-se todos os procedimentos de quimioterapia financiados pelo Sistema Único de Saúde (SUS), realizados no ano de 2013. O mapeamento dos fluxos foi efetuado no programa TerraView®. Foram realizados 1.347.803 procedimentos ambulatoriais de quimioterapia em 243 unidades habilitadas pelo SUS, sediadas em 156 municípios brasileiros. Dezessete cidades concentraram aproximadamente 50,0% dos atendimentos. Foram gerados 8.538 fluxos de origem-destino e 49,2% dos procedimentos foram realizados em serviços sediados fora do município de residência da mulher. Alguns aspectos da organização da assistência farmacêutica, relacionados a desigualdades no acesso à quimioterapia e dificuldades no planejamento de ações e serviços farmacêuticos foram problematizados frente ao contexto apresentado.

Arranjos regionais de governança do Sistema Único de Saúde: diversidade de prestadores e desigualdade espacial na provisão de serviços / Modalidades regionales de gestión en el Sistema Único de Salud: diversidad de prestadores y desigualdad espacial en la provisión de servicios / Regional governance arrangements of the Brazilian Unified National Health System: provider diversity and spacial inequality in service provision

O estudo analisa os arranjos regionais de governança do Sistema Único de Saúde (SUS), segundo esfera jurídica dos prestadores e distribuição espacial da produção de serviços de média e alta complexidade no Brasil. Tais arranjos expressam o modo como a reforma do Estado e do sistema de saúde promoveram a redistribuição de funções entre entes governamentais e privados no território. Realizou-se estudo exploratório com base em dados secundários de abrangência nacional, do biênio 2015-2016. Por meio da análise de agrupamentos baseada na composição dos percentuais da produção dos principais prestadores, foram classificadas 438 regiões de saúde. Na assistência de média complexidade, predominou o prestador público municipal (ambulatorial) e o prestador privado filantrópico (hospitalar). Na alta complexidade, predominou o prestador filantrópico e lucrativo (ambulatorial e hospitalar). A produção de média complexidade foi registrada em todas as regiões de saúde, porém, em 12 estados, mais da metade dela está concentrada em apenas uma região de saúde. A produção de alta complexidade é concentrada nas regiões das capitais estaduais. Os arranjos de governança podem ser mais ou menos diversos e desiguais, se considerados os diferentes segmentos e níveis de concentração regional da produção de média e alta complexidade. O estudo sugere que a convergência entre descentralização e mercantilização favoreceu o reescalonamento da função de prestação de serviços, com ampliação da escala de atuação de prestadores privados e fortalecimento dos municípios polos. As características dos arranjos de governança desafiam a regionalização do SUS orientada pelas necessidades coletivas das populações.

El estudio analiza las modalidades regionales de gestión en el Sistema Único de Salud (SUS), según la categoría jurídica de los prestadores y la distribución espacial para la provisión de servicios de media y alta complejidad en Brasil. Tales modalidades expresan el modo mediante el cual la reforma del Estado y del sistema de salud promovieron la redistribución de funciones entre entes gubernamentales y privados en el territorio nacional. Se realizó un estudio exploratorio, basado en datos secundarios de alcance nacional, durante el bienio 2015-2016. Mediante un análisis de agrupamientos, basado en la composición de porcentajes relacionados con la provisión de servicios de los principales prestadores, se clasificaron 438 regiones de salud. En la asistencia de media complejidad, predominó el prestador público municipal (ambulatorio) y el prestador privado filantrópico (hospitalario). En la alta complejidad, predominó el prestador filantrópico y lucrativo (ambulatorio y hospitalario). La provisión de media complejidad se registró en todas las regiones de salud, sin embargo, en 12 estados, más de la mitad de la misma está concentrada en sólo una región de salud. La producción de alta complejidad está concentrada en las regiones de las capitales de los estados. Las modalidades de gestión pueden ser más o menos diversas y desiguales, si se consideran los diferentes segmentos y niveles de concentración regional en la provisión de servicios de media y alta complejidad. El estudio sugiere que la convergencia entre descentralización y mercantilización favoreció el reescalonamiento de la función de prestación de servicios, con una ampliación de la escala de actuación de prestadores privados y el fortalecimiento de los municipios más importantes. Las características de las modalidades de gestión desafían la regionalización del SUS, orientada por las necesidades colectivas de las poblaciones.

The study analyzes regional Brazilian Unified National Health System (SUS, in Portuguese) governance arrangements according to providers' legal sphere and the spacial provision of middle and high-complexity services. These arrangements express the way in which State and health system reforms promoted the redistribution of functions between governmental and private entities in the territory. We carried out an exploratory study based on national-scope secondary data from 2015-2016. Using cluster analysis based on the composition of the provision percentages of the main providers, we classified 438 health regions. In middle-complexity health care, municipal public providers (outpatient) and private philanthropic providers (hospital) predominate. In high complexity provision, philanthropic and for-profit providers (outpatient and hospital) predominate. Middle-complexity provision was recorded in all health regions. However, in 12 states, more than half of the provision is concentrated in only one health region. High-complexity provision is concentrated in state capital regions. Governance arrangements may be more or less diverse and unequal, if different segments and regional concentration levels of middle and high-complexity provision are considered. The study suggests that the convergence between decentralization and mercantilization favored re-scaling of service provision, with increase in the scale of participation of private providers and strengthening of reference municipalities. Governance arrangement characteristics challenge SUS regionalization guided by the collective needs of the population.

Micropolítica do cuidado de uma usuária com câncer de mama / Micropolitics of the care of a user with breast cancer

Objetivo: investigar a trajetória de uma usuária com câncer de mama cuidada por uma equipe de Saúde da Família e por profissionais de um Hospital de Assistência Especializada. Método: trata-se de estudo qualitativo, exploratório e retrospectivo, do tipo estudo de caso. Realizaram-se entrevistas com a usuária, quatro enfermeiros e um médico que atuam na Estratégia Saúde da Família e um enfermeiro da Assistência Especializada. Apresentou-se o estudo de caso de forma descritiva. Resultados: evidenciou-se que, na comunicação entre os profissionais na rede de cuidado, os sentidos produzidos nas falas geram confrontos e, ao regularem a trajetória da usuária no interior do Sistema Único de Saúde (SUS), produzem assujeitamento. Conclusão: observou-se que as atividades que caracterizam a prática de cuidado em redes, no que se refere ao câncer de mama, não se articulam com os fluxos instituídos no Sistema de Atenção à Saúde e a usuária demonstrou resistência no seu caminhar-peregrinação pelas redes de serviços.(AU)

Association between demand-control model components and blood pressure in the ELSA-Brasil study: exploring heterogeneity using quantile regression analyses.

Objectives This study aimed to investigate which components of the demand-control model (DCM) are associated with blood pressure (BP) and ascertain whether these associations vary over the BP distribution. Methods We evaluated the baseline date of 11 647 current workers enrolled in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) (2008-2010), a multicenter cohort study of 35-74-year-old civil servants. Job demands, skill discretion and decision authority were measured using the Brazilian version of the Demand-Control-Support Questionnaire. The associations between DCM components and systolic and diastolic BP (SBP and DBP, respectively) were examined by gamma regression, indicated for modelling skewed continuous variables, and quantile regression. Tests were conducted for interaction with gender and use of antihypertensives. Results In the adjusted gamma models, no association was observed between DCM components and BP in the total study population. Among non-users of antihypertensives, high decision authority was marginally associated with an increase of 0.59 mmHg (95% CI 0.00-1.18) in SBP. In the quantile models, this association was found to be significant from quantiles 35-60. Further significant but inconsistent positive associations were observed between decision authority and DBP among users of antihypertensives (quantiles 5 and 10) and between skill discretion and SBP in the total study population (quantile 5). The results did not differ by gender. Conclusions Decision authority associates positively with SBP, but only in the central portion of the SBP distribution and among non-users of antihypertensives. No consistent associations were observed for skill discretion or job demands.