Intersectorality in a conditional cash transfer programme: Actors, convergences and conflicts.

This study aimed to analyse intersectoral arrangements among the health, education and social assistance sectors in the operationalization of the Bolsa Família Program (BFP). A qualitative approach was carried out, in a peripheral region of a large urban centre of Southeast Brazil. Data content analysis was performed on the basis of reference in the Actor-Network Theory (ANT) using statements by the actors and considering ideas in dispute and work processes in the geopolitical territorial context. Seventeen managers of Municipal Secretariats of Health, Education and Social Assistance were interviewed, as were basic education, primary health care and social assistance professionals. One-off, episodic and discontinuous intersectoral actions were identified, with limited integration among sectors. Convergences and conflicts were found with respect to the institutional processes of BFP. The convergences referred to the conceptions shared among the actors about the role of intersectoral collaboration, as they recognize themselves as providing care to the same vulnerable population. Considering the multiple vulnerabilities of these families, the convergence of actions from different sectors can impact factors that condition inequalities. The conflicts were related to institutional conditions, to sectorized work processes and to a lack of understanding by professionals about the duties of their respective sectors.

Atenção nutricional na Atenção Primária à Saúde: um estudo comparativo de duas macrorregiões do estado de São Paulo, Brasil / Nutritional care in Primary Health Care: a comparative study of two macro-regions in the State of São Paulo, Brazil

Resumo Introdução Ainda que a importância das ações relacionadas à alimentação e à nutrição sejam reconhecidas, especialmente para a Estratégia Saúde da Família, são escassos os estudos voltados à organização da atenção nutricional no Sistema Único de Saúde. Objetivo Descrever e comparar a organização da Atenção Nutricional (AN) na Atenção Primária à Saúde em duas macrorregiões do estado de São Paulo, Brasil. Método O presente estudo transversal contemplou 115 serviços da Estratégia Saúde da Família, utilizando um instrumento estruturado, realizando uma análise descritiva dos dados e aplicando o teste exato de Fisher para verificar as associações entre a variável "região" e as demais variáveis de interesse. Resultados Foram realizadas 115 entrevistas com os gestores de 31 municípios. Verificou-se uma frequência maior de ações na RMBS, com diferenças estatisticamente significantes para as seguintes variáveis: papel do agente comunitário de saúde; avaliação individual do consumo alimentar, campanhas de vacinação e atividades grupais; mensuração do Índice de Massa Corporal na curva gestacional; apoio ao aleitamento materno; orientações sobre alimentação complementar e atendimento de equipe multidisciplinar para sobrepeso. Conclusão Foi observada uma predominância da AN na RMBS. Entretanto, existem limites a serem superados em ambas as regiões, demandando uma análise da qualidade dessas ações para alcançar a integralidade.

Abstract Background Although the importance of food and nutrition actions is recognized, especially in the Family Health Strategy, there are few studies on the organization of nutritional care in the Unified Health System. Objective To describe and compare the organization of Nutritional Care-AN in Primary Health Care in two macroregions of the State of São Paulo, Brazil. Method This is a cross-sectional study conducted in 115 Family Health Strategy services. A structured instrument was used. Descriptive data analysis and Fisher's exact test were performed to verify associations between the variable 'region' and those of interest. Results 115 interviews were conducted with managers from 31 municipalities. There was a higher frequency of actions at RMBS, with statistically significant differences for the following variables: role of community health agent; individual assessment of food intake, vaccination campaigns, and group activities; measurement of body mass index in the gestational curve; breastfeeding support; guidelines on complementary feeding and multidisciplinary team care for overweight. Conclusion AN predominated in RMBS. However, in both regions, there are limits to be overcome, requiring the analysis of the quality of these actions to achieve completeness.

Direito humano à alimentação adequada: percepções de participantes do Programa Bolsa Família / Human Right to Adequate Food: perceptions from Bolsa Família Program participants

Introdução: A Política Nacional de Segurança Alimentar e Nutricional teve no Programa Bolsa Família (PBF) uma de suas principais expressões para combater a miséria e a fome. Objetivo: Identificar percepções e conhecimentos de titulares do PBF acerca das dimensões de Direito Humano à Alimentação Adequada (DHAA) e de alimentação saudável. Métodos: Estudo qualitativo com amostra representativa de mulheres titulares do PBF da região dos Morros de Santos-SP (n=190). Entrevistas semiestruturadas foram registradas em áudio e transcritas literalmente, para análise temática de conteúdo. Núcleos temáticos e categorias foram produzidos em cada uma das dimensões de interesse. Resultados: As participantes, com média de idade de 33 anos e consideradas de baixa renda, demonstraram desconhecimento sobre DHAA. Poucos discursos destacaram o combate à fome e a busca por cidadania, mas desvelaram ceticismo em relação às garantias consolidadas. A rotina nos serviços de saúde para o acompanhamento das condicionalidades do PBF emergiu na dimensão de direitos. A definição de alimentação saudável pelas participantes enfatizou a importância dos alimentos in natura e minimamente processados, mas revelou os produtos ultraprocessados como alternativa diante das dificuldades financeiras para acessar alimentos saudáveis. Conclusões: Os achados explicitam a necessidade de viabilizar políticas públicas e ações para emancipação e fortalecimento das famílias titulares do PBF, na perspectiva cidadã de defesa da exigibilidade do DHAA.

Introduction: The National Policy for Food and Nutrition Security instituted the BolsaFamília Program (BFP) as one of its main measures to combat extreme poverty and hunger. Objective: To identify the perceptions and knowledge of BFPparticipantsregarding the dimensions of the Human Right to Adequate Food (HRAF) and healthy eating. Methods: This was a qualitative study with a representative sample of women who participate in the BFP in the Morros de Santos region-SP (n=190). Semistructured interviews were audio recorded and transcribed for thematic content analysis. Thematic centres and categories were produced for each dimension of interest. Results: The participants, with a mean age of 33 years and considered low income, showed a lack of knowledge about HRAF. Few interviews highlighted the fight against hunger and the search for citizenship, but they revealed scepticism regarding the consolidated guarantees. The routine in the health services for monitoring the conditionalities of the BFP emerged in the rights dimension. The definition of healthy eating by the participants emphasized the importance of fresh and minimally processed foods but revealed the use of ultra-processed foods asalternatives given the financial difficulties in accessing healthy foods. Conclusions: The findings reveal the need to develop public policies and actions for the emancipation and strengthening of families entitled to the BFP from the citizen perspective of defending the enforceability of the HRAF.

Hunger and its associated factors in the western Brazilian Amazon: a population-based study.

BACKGROUND: Hunger affects millions of people worldwide. In the current pandemic scenario of coronavirus Brazil has experienced an epidemic peak of hunger, amplifying existing prepandemic vulnerabilities, mainly in the North Region of the country. The aim of the present study was to investigate the prevalence of food insecurity and its associated factors in homes with children under 5 years of age in an urban area of a municipality of the western Brazilian Amazon. METHODS: A household survey was conducted with a probabilistic sample of 557 children and their families. Food insecurity (FI) was determined using the Brazilian Food Insecurity Scale. Associations between variables were analyzed based on the prevalence ratio (PR) and respective 95% confidence intervals (CI) calculated through multiple Poisson regression analysis. Variables with a P value < 0.05 after adjustments were considered significantly associated with the outcome. RESULTS: A prevalence of 76.5% (CI 1.36-2.67) food insecurity was found among the families in the study; 42.9% had moderate (CI 1.31-2.83) and severe (CI 1.10-1.83) food insecurity. Moderate and severe FI was associated with low family income (P = 0.00), participation in governmental income transfer programs (P = 0.01), and heads of household with less than 7 years of schooling (P = 0.02). Moreover, substantial frequencies of height deficit and being overweight were found among the children. CONCLUSIONS: The high prevalence of hunger and food insecurity and its associated factors reflects the context of geographic isolation and social exclusion in which these families live, suggesting that a substantial portion of the population under 5 years of age had experienced episodes of hunger in the 90 days prior to the survey. The prevalence of height deficit and being overweight among the children reveals a scenario of epidemiological/nutritional polarization, requiring the formulation of specific public policies for this population.

Health services, intersectoriality and social control: a comparative study on a conditional income transfer program.

The Bolsa Família Program (BFP) is one of the largest conditional cash transfer programs in the world, providing cash transfers and intersectoral actions. The aim of this study was to compare whether there is a difference in access to health services, intersectoral actions and social control, between families entitled or not, to the BFP. A cross-sectional study was carried out. A representative sample of a peripheral, socioeconomically vulnerable population from a large urban center in southeastern Brazil was calculated, totaling 380 families. Chi-square or Fisher's exact tests and multiple correspondence analysis were used to compare groups. Families entitled to the BFP had worse living conditions in general and greater access to health services, such as: medical care (p-value 0.009), community healthcare agent (p-value 0.001) and home visits (p-value 0.041). Being entitled or not affected the variability in the pattern of access to services by 31%; low access to intersectoral actions was identified in both groups; social control was incipient. There was an adequate focus on the program; greater access to health services was related to compliance with conditionalities; low access to intersectoral actions can restrict the interruption of the cycle of intergenerational transmission of poverty.

The Brazilian cash transfer program (Bolsa Família): A tool for reducing inequalities and achieving social rights in Brazil.

Conditional cash transfer programs are strategies used by countries over the past two decades, and they play a key role in reducing income inequalities and expanding access to basic services such as health and education. The Brazilian Cash Transfer Program (Bolsa Família), the largest conditional cash transfer program in the world, aims to bring immediate poverty alleviation and eradicate hunger. The objective of this study was to analyse the contributions of the Brazilian Cash Transfer Program for reducing social inequalities and ensuring the right to health, food, education and social assistance in Brazil. A review of the scientific literature published between 2003 and 2020 was conducted, associated with documentary research on government websites. There was a relationship between the Brazilian Cash Transfer Program, reduction of child mortality and increase in access to Primary Health Care services; increased access to food, including in natura; higher school attendance and reduced dropout. However, no improvement in the nutritional status of the families entitled to the program was observed, nor the interruption of the intergenerational cycle of poverty was ensured. The Brazilian Cash Transfer Program continues as a potent intersectoral policy for reducing inequities, which reinforces the need to strengthen and combine complementary policies to expand its effects.

Unemployment, poverty, and hunger in Brazil in Covid-19 pandemic times / Desemprego, pobreza e fome no Brasil em tempos de pandemia por Covid-19

ABSTRACT This scientific note presents preliminary developments of the Covid-19 pandemic on unemployment, poverty, and hunger in Brazil. The data on unemployment rate, un employment insurance claims, contingent of families in extreme poverty, and food insecurity was collected in government information systems, research published by public agencies, scientific articles, and in news portals. In an upward trajectory since 2015, the increase in unemployment and the number of families in extreme poverty was exacerbated after the pandemic began, drastically reducing the purchase power and access to healthy and adequate food, affecting mainly women and the populations of the Northern and Northeastern regions. Between January and September 2020, there was a 3% increase in unemployment in Brazil and, in October 2020, there were almost 485 thousand more families in extreme poverty compared to January of the same year. There are inadequate and insufficient responses from the Brazilian government to the articulated set of problems. The Covid-19 pandemic is a new element that potentiates the recent increase in hunger in Brazil, which occurs in parallel with the dismantling of the Food and Nutrition Security programs and the expansion of fiscal austerity measures, started with the political-economic crisis in 2015. There is an urgent need to recover the centrality of the agenda to fight hunger in Brazil, associated with the development of more robust contributions on the impact of the pandemic on the phenomena of poverty and hunger.

RESUMO Nesta nota científica apresentam-se desdobramentos preliminares da pandemia de Covid-19 sobre o desemprego, a pobreza e a fome no Brasil. Utilizaram-se dados sobre a taxa de desocupação, solicitações de seguro-desemprego e contingente de famílias em extrema pobreza e em insegurança alimentar, coletados em sistemas de informação governamentais, em pesquisas publicadas por órgãos públicos, em artigos científicos e em portais de notícias. Em trajetória ascendente, desde 2015, identificou-se um aumento do desemprego e do número de famílias em extrema pobreza após a instauração da pandemia, o que pode reduzir drasticamente o poder de compra e o acesso à alimentação adequada e saudável, afetando, principalmente, as mulheres e a população das regiões Norte e Nordeste. Entre janeiro e setembro de 2020, houve o aumento de 3% desemprego no Brasil e, em outubro de 2020, havia quase 485 mil famílias a mais em situação de extrema pobreza, relativamente a janeiro do mesmo ano. Verificam-se respostas inadequadas e insuficientes do governo brasileiro frente ao conjunto articulado de problemas. A pandemia de Covid-19 consiste em um novo elemento potencializador do aumento recente da fome no Brasil, que ocorre paralelamente ao desmonte dos programas de Segurança Alimentar e Nutricional e à ampliação de medidas de austeridade fiscal iniciadas com a crise político-econômica em 2015. Urge resgatar a centralidade da agenda de combate à fome no Brasil, associadamente ao desenvolvimento de contribuições mais robustas sobre o impacto da pandemia nos fenômenos da pobreza e da fome.

Public policies of food and nutrition in Brazil: From Lula to Temer / Políticas públicas de alimentação e nutrição do Brasil: de Lula a Temer

ABSTRACT Objective To analyze public policies on food and nutrition in Brazil, with emphasis on the last fifteen years (2003-2018). Methods Historical-documentary analysis based on a bibliographical survey on indexed bases and exploratory visits to websites of government agencies. Results The scientific and governmental findings were organized according to the Lula, Dilma and Temer governments. They explore the development of several public policies and welfare programs in food and nutrition, focusing mainly on Brazilian Hunger Eradication Program, Assistance for Needy Families Program, National Policy on Food and Nutrition Security, Food Acquisition Program, National School Nutrition Program, National Food and Nutrition Security Policy, National Food and Nutrition Surveillance System and Brazilian Misery Eradication Program. The centrality of the idea of the fight against hunger and misery in public policies during Lula's first and second terms and Dilma's first term stand out. Dilma's second term is marked by the focus on healthy eating, as well as presenting the first signs of fragilization of public policies on food and nutrition. Currently, the Temer government is characterized by processes of institutional and programmatic rupture, budget cuts and setbacks in acquired rights. There is evidence of the need to activate national and international instruments to enforce the human right to adequate food and consequent strengthening of public policies on food and nutrition. Conclusion This period presents an expansion and qualification of public policies on food and nutrition, mainly in the Lula and Dilma administration, with setbacks in the Temer administration, in which continuous budget cuts weaken social, hunger reduction, poverty reduction and food and nutrition security policies.

RESUMO Objetivo Realizar análise da política pública de alimentação e nutrição no Brasil, com ênfase nos últimos quinze anos (2003-2018). Métodos Análise histórico-documental, realizada a partir de levantamento bibliográfico em bases indexadas e visitas exploratórias a sítios eletrônicos de órgãos governamentais. Resultados Os achados científicos e governamentais foram organizados de acordo com os governos Lula, Dilma e Temer. Exploram o desenvolvimento de diversas políticas públicas e programas em alimentação e nutrição, com enfoque principalmente no Fome Zero, Programa Bolsa Família, Política Nacional de Segurança Alimentar e Nutricional, Programa de Aquisição de Alimentos, Programa Nacional de Alimentação Escolar, Política Nacional de Alimentação e Nutrição, Sistema Nacional de Vigilância Alimentar e Nutricional e Programa Brasil sem Miséria. Destaca-se a centralidade do discurso do combate à fome e à miséria nas políticas públicas durante os governos Lula e primeiro governo Dilma. O segundo governo Dilma é marcado pelo enfoque na alimentação saudável, além de apresentar um início de fragilização das políticas públicas em alimentação e nutrição. O governo Temer se caracteriza por processos de ruptura institucionais e programáticas, cortes orçamentários e retrocessos em direitos conquistados. Evidencia-se a necessidade de instrumentos nacionais e internacionais de exigibilidade do direito humano à alimentação adequada. Conclusão O período analisado apresenta uma expansão e qualificação das políticas públicas em alimentação e nutrição, principalmente nos governos Lula e Dilma, com retrocessos no governo Temer, em que cortes orçamentários contínuos fragilizam as políticas sociais, de redução da fome, da miséria, da pobreza e da promoção da segurança alimentar e nutricional.

Evaluation of nutritional care of overweight adults from the perspective of comprehensive health care / Avaliação da atenção nutricional ao excesso de peso sob a ótica da integralidade em saúde

ABSTRACT Objective: Describe and evaluate the nutritional care provided for overweight adults by the Primary and Secondary Health Care services of Santos, São Paulo, Brazil. Methods: This study was carried out between 2013 and 2015 integrating quantitative and qualitative approaches; it was divided into two phases: (1) characterization and (2) evaluation. In phase 1, a census of Primary Health Care Units (n=28) and Secondary Health Care Units (n=4) was conducted using interviews with health service managers and/or health professionals. Data were analyzed using exploratory data analysis. In phase 2, in-depth interviews were conducted with health service managers and/or health professionals investigating a sample of the Primary Health Care services and the totality of Secondary Health Care services provided. Thematic analysis was carried out using the theoretical framework for comprehensive health care proposed by Pinheiro & Mattos. Results: A total of 40 professionals were interviewed: 36 in the primary health care services and 4 in the secondary health care services. Nutritional care in the Primary Care services is focused on individual care and referrals to other services; nutrition diagnosis and health promotion occur only when overweight is associated with another disease. It was observed that the referral and counter-referral system and intersectorial collaborations were ineffective. In Secondary Care services, nutritional care is focused on clinical care using traditional approaches to nutrition education. Limiting factors for promoting comprehensive care were identified at the two levels of care: unproductive actions, lack of actions for health promotion and protection, and little dialogue between the Primary and Secondary care services. Conclusion: Overweight is not an outcome based on Primary and Secondary Care, but rather on prescriptive practices, which are not very effective in promoting users' autonomy. It is necessary to guide the actions taken in these two levels of care to ensure the promotion of effective nutritional care.

RESUMO Objetivo: Descrever e avaliar a atenção nutricional aos adultos com excesso de peso, na Atenção Primária e Secundária à Saúde, em Santos, São Paulo. Métodos: Estudo de caráter quanti e qualitativo, realizado entre 2013 e 2015, em duas etapas: diagnóstico (1) e avaliação (2). Na etapa 1, fez-se um censo dos serviços de Atenção Primária e Secundária (n=28) e Atenção Secundária a Saúde (n=4), entrevistando gestores e/ou profissionais; realizou-se análise exploratória dos dados. Na etapa 2, entrevistaram-se, em profundidade, gestores e/ou profissionais com uma amostra dos serviços da Atenção Primária a Saúde e a totalidade dos de Atenção Secundária a Saúde; realizou-se análise temática, utilizando o referencial teórico de integralidade segundo Pinheiro & Mattos. Resultados: Entrevistaram-se 40 profissionais: 36 na Atenção Primária a Saúde e quatro na Atenção Secundária a Saúde. A atenção nutricional na Atenção Primária a Saúde, restringe-se ao atendimento individual, com encaminhamento a outro ponto; diagnóstico nutricional e ações de promoção da saúde só ocorrem quando o excesso de peso se associa a outra doença; verificaram-se fragilidades na referência e contrarreferência e na efetivação da intersetorialidade. Na Atenção Secundária a Saúde, a atenção nutricional direciona-se ao atendimento clínico, utilizando abordagens tradicionais de educação alimentar. Nos dois pontos de atenção identificaram-se fatores limitantes da integralidade: ações fragmentadas; ausência de ações de promoção e proteção da saúde e pouco diálogo entre a Atenção Primária a Saúde e Atenção Secundária a Saúde. Conclusão: O excesso de peso não é um desfecho pautado na Atenção Primária a Saúde e, na Atenção Secundária a Saúde, pauta-se por práticas prescritivas, pouco potentes para promover a autonomia dos sujeitos. Faz-se necessário reorientar as ações nesses dois pontos de atenção, para qualificar a atenção nutricional.