Práticas integrativas e complementares de saúde em Sergipe / Integrative and complementary health practices in Sergipe

A atenção primária em saúde (APS) é o primeiro nível de atenção em saúde, sendo um elo entre a população e o setor de saúde. Tem-se buscado a humanização dos atendimentos, e essa mudança, refletida pelas mudanças da sociedade, trouxe a implementação da Política Nacional de Práticas Integrativas e Complementares (PNPIC) no SUS. O objetivo deste trabalho foi realizar uma análise da tendência da quantidade das práticas integrativas e complementares realizadas nas regionais de saúde de Sergipe de 2017 a 2023, associando com a cobertura da atenção primária. Foi realizada análise de dados secundários através do Departamento de Informática do Sistema Único de Saúde (DATASUS), como forma de organização no período de junho/2015 a junho/2023 por regional de saúde de Sergipe. As análises dos dados foram descritivas e de correlação e por meio de análise de série temporal. A regional de saúde de Lagarto foi a que mais executou as práticas integrativas e complementares no período analisado e algumas regionais não tiveram continuidade na realização destas práticas. A regional de saúde com maior cobertura de APS foi Itabaiana. Não foi possível observar associação entre o número de práticas e a cobertura de atenção primária. Com o intuito de que o atendimento aos indivíduos seja cada vez mais humanizado, e em virtude da realização das práticas integrativas ter baixo índice ou descontinuidade em algumas regiões de Saúde de Sergipe, é relevante que os profissionais de saúde busquem conhecimentos sobre essas práticas, como também, os gestores em saúde incentivem esta ação.

Primary health care (PHC) is the first level of health care, being a link between the population and the health sector. The aim has been to humanize care, and this change, reflected by changes in society, has led to the implementation of the National Policy on Integrative and Complementary Practices (PNPIC) in the SUS. The objective of this work was to carry out an analysis of the trend in the number of integrative and complementary practices carried out in the health regions of Sergipe from 2017 to 2023, associating it with primary care coverage. Secondary data analysis was carried out through the Department of Informatics of the Unified Health System (DATASUS), as a form of organization from June/2015 to June/2023 by health region in Sergipe. Data analyzes were descriptive and correlational and through time series analysis. The Lagarto health region was the one that carried out the most integrative and complementary practices in the period analyzed and some regions did not continue to carry out these practices. The health region with the highest PHC coverage was Itabaiana. Observing an association between the number of practices and primary care coverage was impossible. With the aim that care for individuals is increasingly humanized, and because the implementation of integrative practices has a low rate or discontinuity in some Health regions of Sergipe, health professionals must seek knowledge about these practices as well as health managers encourage this action.

Invisibilização e preconceitos velados: barreiras para o acesso aos serviços de atenção básica pela população trans / Invisibilization and veiled prejudices: barriers to access to primary care services for the transgender population / Invisibilización y prejuicios velados: barreras para el acceso de la población trans a los servicios de atención primaria

Introdução: No processo de edificação da Política Nacional de Saúde Integral LGBT+, a Atenção Básica ganha importante destaque, pois deveria funcionar como o contato preferencial dos usuários transgênero (trans). Objetivo: Investigar quais as percepções dos profissionais da Atenção Básica quanto às situações de vulnerabilidade enfrentadas pelas pessoas trans, bem como pesquisar os impedimentos que eles consideram existir na busca dessa população por acesso a esses serviços. Métodos: Utilizou-se uma abordagem qualitativa por meio de entrevistas semiestruturadas com 38 profissionais de saúde atuantes das Estratégias Saúde da Família de dois municípios do interior do estado de São Paulo. O material obtido foi submetido à análise de conteúdo de Bardin. Resultados: Os resultados apontaram para o desconhecimento quanto aos reais empecilhos que dificultam o acesso e seguimento de pessoas trans nos serviços de saúde. Observou-se ainda a manutenção de preconceitos e ideias que reforçam estereótipos ligados ao tema e que se estendem ao exercício da profissão. Isso se relaciona diretamente com a falta da abordagem de assuntos relacionados à sexualidade humana na graduação desses profissionais, além da falta de atualização quanto ao tema, o que impacta a qualidade do serviço que é ofertado à população em estudo. Conclusões: As normativas e portarias já existentes precisam ser efetivamente postas em prática, fazendo-se imperativas a ampliação e difusão do conhecimento a respeito da temática trans no contexto dos serviços públicos de saúde, o que pode servir como base para subsidiar a formação dos profissionais que atuam nesse setor, bem como políticas públicas efetivas.

Introduction: In the process of creating the National LGBT+ Comprehensive Health Policy, primary care has important prominence as it must work as the preferential contact of transgender (trans) users. Objective: To investigate the perceptions of primary care professionals about the vulnerability situations faced by trans persons and also hindrances they consider existing in this population's search for access to these services. Methods: A qualitative approach was used through semi-structured interviews with 38 health care professionals working in the Family Health Strategy of two cities in the countryside of the state of São Paulo. The material obtained was submitted to analysis of Bardin content. Results: The results pointed to a lack of knowledge about real hindrances that obstruct the access to and follow-up by health services for trans persons. It was also observed the maintenance of prejudices and ideas that reinforce stereotypes connected to the matter and extend to the practice of professionals. It is directly related to the lack of approach of issues related to human sexuality in the education of those professionals, in addition to lack of update about it, which impacts the quality of service offered to the population under study. Conclusions: The standards and ordinances already existing need to be effectively practiced, being crucial the extension and spread of knowledge about trans matters in the context of public health services. It can be the basis for subsidizing the education of professionals who work in this field, as well as effective public policies.

Introducción: En el proceso de edificación de la Política Nacional de Salud Integral LGBT+, la Atención Básica tiene importante destaque, pues debería funcionar como contacto preferente de los usuarios transgénero (trans). Objetivo: Investigar las percepciones de los profesionales de Atención Básica sobre las situaciones de vulnerabilidad que enfrentan las personas trans, así como investigar los impedimentos que consideran que existe en la búsqueda de esta población por el acceso a estos servicios. Métodos: Se utilizó un abordaje cualitativo por medio de entrevistas semiestructuradas con 38 profesionales de salud actuantes de las Estrategias de Salud de la Familia de dos municipios del interior del estado de São Paulo. El material obtenido fue sometido a análisis de contenido de Bardin. Resultados: Los resultados apuntaron al desconocimiento sobre los reales obstáculos que dificultan el acceso de personas trans a los servicios, además del segmento de los cuidados en las unidades. Se observó además que se mantienen los prejuicios e ideas que refuerzan estereotipos vinculados al tema y que se extienden al ejercicio de la profesión. Esto se relaciona directamente a la falta da abordaje de asuntos relacionados a la sexualidad humana en la graduación de estos profesionales, además de la falta de actualización sobre el tema, lo que impacta en la calidad del servicio que se ofrece a la población en estudio. Conclusiones: Las normas y ordenanzas ya existentes deben ser efectivamente puestas en práctica, por lo que es imperativo ampliar y difundir el conocimiento sobre la temática trans en el contexto de los servicios públicos de salud, que pueda servir de base para apoyar la formación de profesionales que actúan en este sector, así como políticas públicas efectivas.

Point-of-care biochemistry for primary healthcare in low-middle income countries: a qualitative inquiry.

BACKGROUND: Access to essential diagnostics is crucial for primary healthcare (PHC) in low-and-middle income countries (LMICs). Many LMICs have invested in equipping PHC with point-of-care (PoC) diagnostics for infectious diseases, however there has been no similar investment to improve PHC capacities for clinical chemistry. The biochemistry gap is among the deterrents to universal health coverage. METHODS: A social sciences project was conducted with the aim to understand the key PHC stakeholders' insights on the pertinence of PoC biochemistry for PHC in LMICs. Data generation was conducted between July-November 2023 in Mongolia, Nigeria and Peru. Decision-makers in healthcare delivery, healthcare professionals, and patient and community advocates were engaged using a combination of sampling techniques. Unstructured individual and group conversations, and non-participant observation were conducted. Analysis involved an inductive line-by-line coding on printed transcripts, followed by a deductive coding and theme-by-theme analysis on digitized transcripts. RESULTS: Fifteen, 51 and 20 informants from Mongolia, Nigeria and Peru, respectively, participated. Fifty-five of the 94 informants were female. Most informants considered that PoC biochemistry in PHC would be pertinent, from a clinical and a resources-saving perspective. Those households that currently bear the burden of referrals (i.e., the poor, the bedridden, the older adults) would benefit the most from the deployment of PoC biochemistry for essential biochemistry parameters. Improved access to PoC glycated hemoglobin (HbA1c), lipid, liver and kidney profile was perceived as helpful to inform clinicians' decision-taking. The value of PoC biochemistry for the management of noncommunicable diseases (diabetes, hypertension) and infectious conditions (dengue, malaria, tuberculosis), to improve child health outcomes (severe dehydration in children with diarrhea and/or malnutrition) and to reduce preventable causes of death (dengue-related renal failure) was highlighted. CONCLUSIONS: PoC biochemistry holds potential to revert the impact that the biochemistry gap has for patient care in some LMICs' PHC settings. PoC equipment for parameters such as HbA1c, urea, creatinine or electrolytes could enhance community-level management of preventable causes of mortality, improve service delivery for patients affected by locally-prevalent infectious conditions, and improve the psychosocial and economic wellbeing of patients facing the burden of referrals to remote biochemistry-equipped centers. TRIAL REGISTRATION: Not applicable.

Bypassing sources of care by level and coverage: Access to essential services in Peru and Uruguay in the post-pandemic era.

BACKGROUND AND AIMS: Healthcare provision to distinct social groups in Latin America contributes to inequities. Individuals make active choices by bypassing their coverage and intended healthcare source. After the pandemic, we sought to characterize bypassing behaviors and quantify their effects on access to essential services. METHODS: Cross-sectional data from a population-based telephone survey in Peru and Uruguay were analyzed. Participants were selected by random digit dialing. Outcomes were defined as access to preventive screenings and satisfaction of emerging health needs. Bypassing by level was defined as when participants went around primary care for the usual source of care or last preventive visit; bypassing by coverage when care was sought outside of public coverage or social security. Sociodemographic characteristics were included, and the adjusted average treatment effect was calculated. RESULTS: Data from 1,255 participants in Peru and 1,237 participants in Uruguay were analyzed. Bypassing behaviors by level (32% Peru; 60% Uruguay) and coverage (29% Peru; 21% Uruguay) were more prevalent in more privileged groups, especially in Peru. System competence was low overall and varied by bypassing mode, especially in Peru. In the adjusted analysis, statistically significant differences were found in bypassing by coverage in Peru (-8% difference in unmet health needs) and by level in Uruguay (5% more unmet needs). CONCLUSION: Provision of essential preventive services was insufficient in both countries. In Peru, bypassing could serve as a proxy measure of inequities. Reminders of preventive services could be offered to bypassers of primary care. Profound health system reforms are needed to ensure equitable access to essential services.

SPINE20 Recommendations 2024 -Spinal Disability: Social Inclusion as a Key to Prevention and Management.

Spine disorders are the leading cause of disability worldwide. To promote social inclusion, it is essential to ensure that people can participate in their societies by improving their ability, opportunities, and dignity, through access to high-quality, evidence-based, and affordable spine services for all.To achieve this goal, SPINE20 recommends six actions.- SPINE20 recommends that G20 countries deliver evidence-based education to the community health workers and primary care clinicians to promote best practice for spine health, especially in underserved communities.- SPINE20 recommends that G20 countries deliver evidence-based, high-quality, cost-effective spine care interventions that are accessible, affordable and beneficial to patients.- SPINE20 recommends that G20 countries invest in Health Policy and System Research (HPSR) to generate evidence to develop and implement policies aimed at integrating rehabilitation in primary care to improve spine health.- SPINE20 recommends that G20 countries support ongoing research initiatives on digital technologies including artificial intelligence, regulate digital technologies, and promote evidence-based, ethical digital solutions in all aspects of spine care, to enrich patient care with high value and quality.- SPINE20 recommends that G20 countries prioritize social inclusion by promoting equitable access to comprehensive spine care through collaborations with healthcare providers, policymakers, and community organizations.- SPINE20 recommends that G20 countries prioritize spine health to improve the well-being and productivity of their populations. Government health systems are expected to create a healthier, more productive, and equitable society for all through collaborative efforts and sustained investment in evidence-based care and promotion of spine health.

FLI and FIB-4 in diagnosing metabolic dysfunction-associated steatotic liver disease in primary care: High prevalence and risk of significant disease.

INTRODUCTION AND OBJECTIVES: Public health policies in metabolic dysfunction-associated steatotic liver disease (MASLD) are still lacking. This study aims to estimate the prevalence and severity of MASLD in primary health care (PHC) through non-invasive markers. PATIENTS AND METHODS: Two-phase study, including a retrospective (RETR) and a prospective (PROS) one, was carried out in PHC in Brazil. In RETR, metabolic and hepatic profiles of 12,054 patients, including FIB-4, were evaluated. In PROS, 350 patients were randomly selected and submitted to a clinical and nutritional assessment. RESULTS: RETR (65.4 % women, mean age 55.3 years old): dyslipidemia, hypertension, and type 2 diabetes mellitus (T2DM) present in 40.8 %, 34.3 %, and 12.2 % of the electronic health records, respectively. Fasting glucose >100 mg/dL in 34.5 %, and glycated hemoglobin higher than 5.7 % in 51.5 %, total cholesterol >200 mg/dL and triglycerides >150 mg/dL in 40.8 % and 32.1 %, respectively. Median FIB-4 was of 1.33, 5 % >2.67. No one had MASLD as a diagnostic hypothesis; PROS(71.8 % women, mean age 58 years old): body mass index (BMI) ≥30 kg/m² in 31.8 %. MASLD prevalence (FLI≥ 30 + cardiometabolic features) of 62.1 %; 39.4 % of patients had FLI ≥60, with higher BMI, waist circumference, fasting glucose, triglycerides, AST, ALT and GGT, as well as lower HDL-cholesterol (p < 0.001). FIB-4>1.3 in 40 % and NAFLD Fibrosis Score (NFS)>-1.45 in 59.2 % of steatotic patients. CONCLUSIONS: There is a high prevalence of MASLD in PHC, with a significant risk of liver fibrosis. These findings reinforce we need to develop public policies to defeat MASLD epidemics.

Knowledge about metabolic dysfunction-associated steatotic liver disease among the medical professionals from countries in the MENA region.

INTRODUCTION AND OBJECTIVES: Given the substantial burden of metabolic dysfunction-associated steatotic liver disease (MASLD), there is an urgent need to assess knowledge and awareness levels among physicians. We assessed MASLD knowledge among healthcare providers from Saudi Arabia, Egypt, and Türkiye. MATERIALS AND METHODS: Two global surveys containing 54-59 items assessed awareness and knowledge of MASLD/NAFLD- one was for hepatologists and gastroenterologists, and the second was for non-specialists (e.g. endocrinologists, primary care providers [PCPs], and other healthcare professionals). Data were collected using an electronic data collection form. Knowledge scores and variables associated with higher knowledge scores were compared across all specialties. RESULTS: A total of 584 physicians completed the survey (126 hepatologists, 178 gastroenterologists (GEs), 38 endocrinologists, 242 PCPs/others). Practice guidelines were the primary source for knowledge across all specialties (43-51%), then conferences (24-31%) except PCPs/others who selected the internet as the second common source (25%). Adherence to societal guidelines varied by specialty (81-84% of specialists vs 38-51% of non-specialists). Hepatologists and GEs showed similar mean knowledge scores (51-72% correct answers across three knowledge domains, p > 0.05); endocrinologists outperformed PCPs/others in knowledge scores in all knowledge domains, including Epidemiology/Pathogenesis (72% vs. 60%), Diagnostics (73% vs. 67%), and Treatment (78% vs. 67%) (all p < 0.01). Hospital-based practice and seeing a greater number of patients with MASLD/NAFLD were identified as independent predictors of higher knowledge scores among specialists (both p < 0.05). CONCLUSIONS: A knowledge gap in the identification, diagnosis, and management of MASLD/NAFLD was found despite the growing burden of MASLD/NAFLD in Saudi Arabia, Egypt, and Türkiye. Education to increase awareness is needed.

Assessment of parenteral estradiol and dihydroxyprogesterone use among other feminizing regimens for transgender women: insights on satisfaction with breast development from community-based healthcare services.

The practice of hormone therapy is crucial in aligning secondary sex characteristics with the gender identity of transgender adults. This study examines the effects of a commonly used injectable hormone combination, specifically estradiol enanthate with dihydroxyprogesterone acetophenide (EEn/DHPA), on serum hormonal levels and self-reported satisfaction with breast development in transwomen. Our research focused on a retrospective longitudinal study involving a large cohort of transwomen evaluated between 2020 and 2022, comprising 101 participants. We assessed serum levels of estradiol (E2), testosterone (T), luteinizing hormone (LH), and follicle-stimulating hormone (FSH), comparing the EEn/DHPA hormonal regimen with other combined estrogen-progestogen (CEP) therapies. Additionally, a subset of 43 transwomen completed a 5-question survey to evaluate self-reported satisfaction with breast development using Tanner scales. Our findings indicated that participants using the EEn/DHPA regimen exhibited significantly higher serum E2 levels (mean: 186 pg/mL ± 32 pg/mL) than those using other therapies (62 ± 7 pg/mL), along with lower FSH levels, but no significant differences in T and LH levels. Concerning satisfaction with breast development, 76% reported increased fulfillment with breast augmentation while using EEn/DHPA. These results suggest that an injectable, low-cost EEn/DHPA administered every three weeks could serve as an alternative feminizing regimen, particularly considering the extensive long-term experience of the local transgender community. Further longitudinal studies on the efficacy of feminizing-body effects and endovascular risks of various parenteral CEP types are warranted to improve primary healthcare provision for transgender persons.

Implementation of cancer prevention practices in primary care: results of a cohort study in Chile 2018-2022.

OBJECTIVES: The burden of cancer is increasing rapidly in Latin America. Primary care has an essential role in cancer prevention, but implementation levels of prevention practices are not well known. This study evaluated implementation levels and associated factors of cancer preventive practices in primary care over time. STUDY DESIGN: The study incorporated a retrospective multicentre cohort study. METHODS: A population of 59,949 patients registered at three primary care clinics was followed from January 2018 to December 2022 in Santiago, Chile. We studied human papillomavirus (HPV) and hepatitis B virus (HBV) immunisation, brief counselling for smoking cessation and alcohol consumption, and cervical and breast cancer screening practices. Standardised electronic medical records were utilised as the source of information. Social, clinical, and organisational factors associated with prevention practices were studied. RESULTS: The cohort attrition level was 17.1%. Most of the population was of a low socioeconomic status, and 70% visited a primary health centre yearly. Implementation rates of immunisation practices were 90.84% for HPV and 80.94% for HBV in 2022. In contrast, brief counselling for smoking and alcohol consumption was below 20% during the study period. Cervical cancer screening decreased by 25.58% between 2018 and 2022, whereas breast cancer screening reached only 41.71% of the target population. Opportunistic medical visits were strongly associated with brief counselling and breast cancer screening. CONCLUSION: Implementation practices for cancer prevention in a Chilean primary care cohort are high for immunisation and very low for brief counselling and screening practices. A comprehensive non-medical-based model is needed to improve cancer prevention in primary care.

Impact of a social media-delivered distance learning program on mhGAP training among primary care providers in Jalisco, Mexico.

BACKGROUND: The World Health Organization's (WHO) Mental Health Gap Action Programme (mhGAP) aims to provide evidence-based guidelines for the management of mental, neurological, and substance use disorders in non-specialized healthcare settings. However, implementing these guidelines remains a challenge due to various factors, including limited training opportunities for primary care providers. This study con the effectiveness of a social media-delivered distance education program on the mhGAP intervention guide, to overcome barriers of technology access and digital literacy, providing a familiar and accessible platform for primary care providers in Jalisco. METHODS: A quasi-experimental study with a pre-test/post-test design was conducted. Primary care providers from Jalisco were invited to participate in a distance education program on the mhGAP intervention guide. The program consisted of online modules, webinars, and discussion forums facilitated by mental health experts. Knowledge assessments were conducted before and after the intervention using a standardized questionnaire. Participant satisfaction and perceived utility were also evaluated through surveys and focus group discussions. RESULTS: A total of 1,096 primary care providers completed the program. The mean knowledge score significantly improved from 58.2% (SD = 12.8%) in the pre-test to 81.4% (SD = 9.6%) in the post-test (p < 0.001), with a large effect size (Cohen's d = 2.04). Subgroup analyses revealed consistent knowledge gains across different demographic and professional characteristics. Participant satisfaction was high, with 92% rating the program's overall quality as "good" or "excellent." Qualitative findings highlighted the benefits of accessibility, flexibility, interactivity, and practical applicability of the distance education approach. CONCLUSIONS: The social media-delivered distance education program on the mhGAP intervention guide effectively improved the knowledge of primary care providers in Jalisco, Mexico. Participants reported high levels of satisfaction and perceived utility. This study demonstrates the potential of distance education strategies to disseminate evidence-based guidelines and enhance mental health service delivery in primary care settings, particularly in resource-limited areas.

Colonisation by multidrug-resistant organisms in health workers in primary care: narrow spectrum oral antimicrobials are a risk factor.

BACKGROUND: Limited information exists on carriage of multidrug-resistant organisms (MDRO) by health workers (HWs) in primary care settings. This study aims to determine the prevalence of MDRO carriage among HWs in primary care and to identify associated risk factors. METHODS: A cross-sectional study was conducted across all 12 primary care units in São Caetano do Sul-SP, Brazil, from October to December 2023. Self-collected samples (nasal, oropharyngeal, and inguinal) were obtained. Environment cultures (potable water, sewage and stream water) were evaluated. Stenotrophomonas maltophilia isolates (human and environmental) were typed. RESULTS: The study included 265/288 (92%) of HWs in primary care teams, mostly women with a median age of 47 years (IQR 38-57); 78% had no comorbidities. MDRO colonisation was found in 8.7% (23 HWs). The following bacteria were found: S. maltophilia (n = 9; 3.4%) in inguinal swabs; methicillin-resistant Staphylococcus aureus (n = 8; 3%) from all sites; extended-spectrum ß-lactamase-producing bacteria (n = 5; 2%) in inguinal swabs; and vancomycin-resistant enterococci in an inguinal swab (n = 1; 0.4%). Previous antibiotic use was significantly associated with MDRO colonisation (OR 2.91, 95% CI 1.19-7.09, p = 0.018), mainly narrow spectrum oral beta-lactams and macrolides. S. malthophilia was polyclonal and human and environmental isolates differed. CONCLUSION: Colonisation by MRSA, VRE, and ESBL-producing bacteria was low; however, 4% were surprisingly colonized by polyclonal S. maltophilia. This pathogen may also suggest using narrow-spectrum rather than the expected broad-spectrum antimicrobials. Antibiotic use was the only risk factor found, mainly with oral narrow-spectrum drugs.

The Adoption and Impact of Telemedicine on Health Equity: A Narrative Review From the Jamaican Context.

Telemedicine rose to popularity during the coronavirus disease 2019 (COVID-19) pandemic but is yet to be fully developed. Hence, this study explores the current status of telehealth in Jamaica, looking at its benefits, challenges with its implementation, the regulatory landscape, and solutions to using this technology. Due to the limited research on this topic, a majority of the sources utilized were gray literature with qualitative and quantitative studies. This review seeks to transform policy and practice, promoting telemedicine as a feasible solution for improving Jamaica's healthcare quality and access. By comparing telemedicine in Jamaica to a more developed nation like the United States, the review highlights not only benefits but also major challenges, including healthcare disparities due to the digital divide, less advanced technology, privacy breaches, and significant financing required for telemedicine infrastructure, among other barriers to its integration. The analysis advocates for improvement in various areas, such as cybersecurity measures, advanced training for healthcare professionals, further investments in technological infrastructure, refinement of regulatory frameworks and policies, and incorporation of community-based initiatives. This investigation further highlights the need for additional research to gain insights and a broader perspective.

More doctors, better health? A generalised synthetic control approach to estimating impacts of increasing doctors under Brazil's Mais Medicos programme.

Worldwide, there are an insufficient number of primary care physicians to provide accessible, high-quality primary care services. Better knowledge on the health impacts of policies aimed at improving access to primary care physicians is important for informing future policies. Using a generalised synthetic control estimator (GSC), we estimate the effect of the increase in primary care physicians from the Programa Mais Médicos in Brazil. The GSC allows us to estimates a continuous treatment effects which are heterogenous by region. We exploit the variation in physicians allocated to each Brazilian microregion to identify the impact of an increasing Mais Médicos primary care physicians. We explore hospitalisations and mortality rates (both total and from ambulatory care sensitive conditions) as outcomes. Our analysis differs from previous work by estimating the impact of the increase in physician numbers, as opposed to the overall impact of programme participation. We examine the impact on hospitalisations and mortality rates and employ a panel dataset with monthly observations of all Brazilian microregion over the period 2008-2017. We find limited effects of an increase in primary care physicians impacting health outcomes - with no significant impact of the Programa Mais Médicos on hospitalisations or mortality rates. Potential explanations include substitution of other health professionals, impacts materialising over the longer-term, and poor within-region allocation of Mais Médicos physicians.

Evaluating the implementation of a hypertension program based on mHealth and community pharmacies integration to primary care centers at a municipality level in Argentina during the COVID-19 pandemic.

Introduction: While pharmacists-led interventions in hypertension have proven effective in high-income countries, their implementation and impact in low- and middle-income countries (LMIC) remain limited. This study assessed the implementation and outcomes of the hypertension program FarmaTeCuida (FTC), which integrated community pharmacies into the public primary care level using information and communication technologies. The study took place during the pandemic in General Pueyrredón, Buenos Aires, Argentina, so modifications to the implementation strategy and expected outcomes were also analyzed. Methods: A mixed-methods study was conducted using the non-adoption, abandonment, scaling-up, dissemination, and sustainability (NASSS) conceptual model. Qualitative in-depth interviews were conducted with key stakeholders using snowball sampling until thematic saturation was achieved. The quantitative approach employed a quasi-experimental, prospective, longitudinal design in a cohort of hypertensive patients enrolled in the FTC program since October 2020 to March 2022. Adoption, access, adherence to follow-up, and blood pressure levels were assessed. Clinical outcomes were compared to a cohort of hypertensive patients attending primary health care centers (PHCCs) in 2021 but not enrolled in the FTC program. Routine data from this cohort was obtained from the municipal health information system (HIS). Results: Out of 33 PHCCs, 23 adopted the FTC program, but only four collaborated with community pharmacies. A total of 440 patients were recruited, with 399 (91%) enrolled at PHCCs. Hypertension was detected in 63% (279/440) of cases at the first visit (113 were possible hypertensive patients; 26 new hypertensive patients and 140 already diagnosed). During follow-up, FTC identified 52 new hypertensive patients (12% out of 440). Reduction of systolic blood pressure (SBP) was observed in patients enrolled in both the FTC program and the comparison group over 60 days. In the multivariate analysis that included all hypertensive patient (FTC and HIS) we found strong evidence that for each month of follow up, SBP was reduced by 1.12 mmHg; however, we did not find any significant effect of the FTC program on SBP trend (interaction FTC*months has a p-value = 0.23). The pandemic was identified as the main reason for the program's underperformance; in addition we identified barriers related to technology, patient suitability, implementation team characteristics, and organizational factors. Discussion: Our study, grounded in the NASSS model, highlights the profound complexity of introducing innovative strategies in low- and middle-income settings. Despite substantial challenges posed by the pandemic, these obstacles provided valuable insights, identified areas for improvement, and informed strategies essential for reshaping the care paradigm for conditions like hypertension in resource-constrained environments.

Primary care performance measurement in Brazil (Previne Brasil Program), 2022-2023.

BACKGROUND: Previne Brasil is a new way of financing Primary Health Care (PHC) in Brazil that places users of public health services at the center of the system's analysis and attention through the use of seven performance indicators. This study aims to analyze the performance of Primary Health Care in Brazil under the new financing model (Previne Brasil) in the period from the first four months of 2022 to the first four months of 2023. METHODS: This is a territorial ecological study using secondary data from the Primary Care Health Information System (SISAB). Seven performance indicators were included and analyzed according to Brazil, its regions, states and capitals. A comparative descriptive analysis was carried out between the spatial units. RESULTS: Of the seven indicators analyzed, only one (Proportion of pregnant women tested for syphilis and HIV) reached the proposed target considering the average of the four-month periods evaluated (target: 60%; Observed: 62.5%). The Northeast was the region with the best performance, surpassing the target in three of the seven indicators (prenatal consultations, tests for syphilis and HIV in pregnant women and dental care for pregnant women). The states and capitals showed progressive improvement in the performance indicators over the four quarters analyzed, although unevenly between the indicators. The indicators related to hypertension and diabetes were the worst. The Final Synthetic Indicator (FSI) showed an increase in the median over the four quarters (4.78; 5.65; 6.02 6.29), which represents an increase of 1.51 in the indicator between the first four months of 2022 and the first four months of 2023. CONCLUSION: Although there have been improvements in the performance of Primary Health Care in Brazil, the achievement of the agreed targets for the indicators seems a long way off. The socio-spatial inequalities in the indicators reflect the country's health complexity and reinforce the need for policies that take into account the local-regional context.

Leprosy knowledge among primary care physicians in Southern Brazil: are we underdiagnosing?

BACKGROUND: Leprosy is a chronic infection with high morbidity in Brazil. Primary care physicians' lack of knowledge about the disease may play a significant role in underdiagnosis. This study aimed to assess primary care physicians' ability to identify typical leprosy skin lesions and their knowledge of the subject. METHODS: This cross-sectional study relied on a questionnaire in which participating doctors chose one main diagnostic hypothesis and two differential diagnoses for each skin lesion presented. Five leprosy lesions were included. Questions regarding management, follow-up, and diagnostic workup for the disease were also included. The questionnaire was sent to primary care physicians working in Curitiba, in the Southern Brazilian state of Paraná, and dermatologists, who constituted the control group. RESULTS: Thirty-two primary care physicians and 26 dermatologists agreed to participate in the study. Primary care physicians accurately identified a mean of 1.8 ± 1.2 of the five leprosy skin lesions, while dermatologists accurately identified 2.5 ± 0.9 (P = 0.009). The main misdiagnosed leprosy forms were the lepromatous and histoid variants. Among primary care physicians, 56.2% claimed to have little knowledge of the subject and a large share of participants was unaware of recent updates in treating paucibacillary forms, even within the dermatologist subgroup. CONCLUSIONS: Primary care physicians in Curitiba have little information regarding the diagnosis, treatment, and follow-up of leprosy. Even dermatologists had difficulties with treatment and patient management, emphasizing the constant need for education on this subject.

Regulation and participation of the private sector in the pursuit of universal health coverage: Challenges and strategies for health systems.

The 1978 Alma Ata Declaration established recommendations for health systems, which significantly impacted low-income countries. These guidelines marked improvements in access to health, coverage and financial equity, especially in Latin American countries. Objectives: This paper focuses on the role of the private sector (including for-profit and non-profit organizations) in achieving Universal Health Coverage (UHC). It examines their involvement in the management, service delivery, resource investment and financing of primary health care (PHC) within the sustainable development goals (SDGs). Methods: The study covers a review of health systems, emphasizing the influence of private institutions on public health, and evaluates how private sector experiences contribute to system functions and progress towards UHC. Results: The findings indicate the crucial role of the private sector in global health systems, notably expanded in several countries. Private actors are essential to improve access and coverage, particularly in countries with low health indicators. The article highlights the importance of primary care physicians understanding these dynamics since their management is vital in implementing public policies for UHC.

Standardization of Dental Vulnerability Scale scores (EVO-BR).

BACKGROUND: Dental Vulnerability Scale (EVO-BR) is an instrument developed to help identifying oral health-vulnerable individuals. This scale comprises 15 items distributed into 4 dimensions. It is the first instrument with the potential to guide clinical and managerial decisions in the oral health field. The aim is to validate a score to enable using EVO-BR in Primary Health Care (PHC). METHOD: The investigated sample included PHC users in five Brazilian regions. Data were collected at two different stages: in 2019 (São Paulo) and in 2022 (Minas Gerais, Mato Grosso, Roraima, Pernambuco e Paraná). Exploratory descriptive study of this scale scores was carried out to create classification ranges. Subsequently, discriminant analysis was performed to assess the accuracy of the established classification. Boosting regression was carried out to check items' weight for the instrument score. RESULTS: EVO-BR score ranged from 0 (highest vulnerability) to 15 (lowest vulnerability). Four (4) classification configurations were tested. Score equal to 12 points was the one presenting the best classification of the assessed individuals (100% were correctly classified). Boosting regression has evidenced that items 1 and 2 (Overall health domain) and 14 and 15 (Health Services domain) had the strongest influence on this instrument's score. CONCLUSION: The process to standardize the EVO-BR score and, consequently, to develop assessment ranges, is an important step in the fight against health inequalities, since it provides a tool to help planning actions and interventions aimed at meeting specific needs of the population in the Primary Health Care context.

Improving patient-centered mental health promotion in primary care in vulnerable communities through mindfulness training in Rio de Janeiro, Brazil.

Introduction: Brazilian Primary Health Care (PHC) is responsible for all-sanitary actions for a community-based population, including health promotion and mental health care. Mindfulness Based Health Promotion (MBHP) is an intervention that can promote self-care and psychosocial support in PHC. Objective: To discuss the effects of mindfulness based psychosocial group interventions for health promotion in primary care units in Rio de Janeiro, Brazil. Methods: The intervention was based on the MBHP model adapted for SUS. Nine groups were held in Rio de Janeiro. A quali-quanti research was held with two parts: (a) quantitative study, pre and after the 8 weeks intervention, evaluating the effect on mindfulness and self-compassion and their association with levels of anxiety, depression, and quality of life. (b) Qualitative research using Focus Groups with the participants to investigate their experience at the end of the mindfulness groups. Results and discussion: Sixty-two participants finished the 9 groups where 86% were women, mostly between 30 and 59 years of age and low income, and around 80% under regular medical care in PHC in SUS. In the studied sample 80% had at least one chronic health condition under treatment, including 42% with anxiety and 35% with depression. The effects included significant improvement in Anxiety and Depression and in Quality of Life, mainly in the psychological but also in the physical and interrelation domains. The qualitative study showed that most patients joined the group on the recommendation of health professionals for managing physical and mental health symptoms. Patients reported being able to use the practices taught in the sessions to manage symptoms such as insomnia and emotionally distressing situations in their daily lives. Including family members in mindfulness practices was a strategy to negotiate not only a space at home to meditate, but also to obtain a different approach to health problems. Participants pointed to mindfulness as a complementary therapeutic option to medication and psychotherapy. Conclusion: Mindfulness-Based Intervention have shown to be a feasible, well-accepted and efficacious method of offering psychosocial support and promoting well-being for low-income patients in primary care in LAMIC.

Food Consumption Inequalities in Primary Care in a Large Metropolis.

The aim of this study was to examine the association between health vulnerability and food consumption according to the NOVA classification within primary care in a major Brazilian city. A cross-sectional study was conducted among adults over 20 years old. These participants were part of a representative sample from the Health Academy Program (PAS) in Belo Horizonte, Brazil. We evaluated socio-demographic variables, self-reported illnesses, perceived health and quality of life, and the length of participation in PAS. Health vulnerability was gauged through the Health Vulnerability Index (HVI), which is calculated for each census sector and classified as low, medium, and high/very high. On the other hand, food consumption was determined by evaluating the average consumption described in a 24 h diet recall (24HR) and categorizing it under the NOVA classification: culinary preparations, processed foods, and ultra-processed foods (UPFs). The average calorie intake was 1429.7 kcal, primarily from culinary preparations (61.6%) and UPFs (27.4%). After adjustments, individuals residing in high/very high-HVI areas consumed more culinary preparations (ß = 2.7; 95%CI: 4.7; 0.7) and fewer UPFs (ß = -2.7; 95%CI: -4.7; -0.7) compared to those from low-vulnerability areas. PAS participants residing in more vulnerable areas reported healthier dietary habits, consuming more homecooked meals and fewer UPFs. These findings underscore the importance of concentrating efforts on promoting and preserving healthy eating habits and emphasizing the value of home cooking in the most vulnerable regions.