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Background: Violence is a worldwide public health challenge and has been linked to depression in many settings. Depression is higher in women and differential exposure to violence is a potential risk factor – especially in countries with high-levels of violence. This paper provides a comprehensive characterization of the association between violence victimization and depression in Brazil, focusing on sex/gender inequalities. Methods: We used data from the 2019 wave of the National Health Survey (PNS) in Brazil to assess whether respondents had depression (using PHQ-9) and if they were victims of violence, differentiating by the type of violence, the frequency of victimization, and the primary aggressor. We used logit models to assess the association between victimization and the likelihood of having depression. We predicted probabilities of being depressed, considering the interaction between violence victimization and sex/gender, to analyze the differences between men and women. Results: Rates of violence victimization and depression were higher among women than among men. The odds of being depressed were 3.8 (95%CI: 3.5–4.2) times higher among victims of violence than among non-victims, and 2.3 (95%CI: 2.1–2.6) times higher among women than among men, adjusting for socioeconomic factors. For any given income level, racial/ethnic or age group, victims of violence who were women had the highest predicted probabilities of being depressed – e.g., 29.4% (95%CI: 26.1–32.8) for lower-income women, 28.9% (95%CI: 24.4–33.2) for black women, and 30.4% (95%CI: 25.4–35.4) for younger women that suffered violence. Over one in three women that suffered multiple types of violence, experienced violence more frequently, or where the aggressor was an intimate partner or another family member were predicted to have depression. Conclusions: Being a victim of violence was strongly associated with higher risk of depression in Brazil, with women more likely to be both victims of violence and develop depression. Frequent, sexual, physical or psychological violence, and intimate partners or family member perpetrators were major risk factors for depression and should be a public health priority. [ABSTRACT FROM AUTHOR]

Background: Considerable success in reducing malaria incidence and mortality has been achieved in Brazil, leading to discussions over the possibility of moving towards elimination. However, more than reporting and counting clinical cases, elimination will require the use of efficient tools and strategies for measuring transmission dynamics and detecting the infectious reservoir as the primary indicators of interest for surveillance and evaluation. Because acquisition and maintenance of anti-malarial antibodies depend on parasite exposure, seroprevalence rates could be used as a reliable tool for assessing malaria endemicity and an adjunct measure for monitoring transmission in a rapid and cost-effective manner. Methods: This systematic review synthesizes the existing literature on seroprevalence of malaria in the Brazilian Amazon Basin. Different study designs (cross-sectional surveys and longitudinal studies) with reported serological results in well-defined Brazilian populations were considered. Medline (via PubMed), EMBASE and LILACS databases were screened and the articles were included per established selection criteria. Data extraction was performed by two authors and a modified critical appraisal tool was applied to assess the quality and completeness of cross-sectional studies regarding defined variables of interest. Results: From 220 single records identified, 23 studies were included in this systematic review for the qualitative synthesis. Five studies reported serology results on Plasmodium falciparum, 14 papers assessed Plasmodium vivax and four articles reported results on both Plasmodium species. Considerable heterogeneity among the evaluated malarial antigens, including sporozoite and blood stage antigens, was observed. The majority of recent studies analysed IgG responses against P. vivax antigens reflecting the species distribution pattern in Brazil over the last decades. Most of the published papers were cross-sectional surveys (73.9%) and only six cohort studies were included in this review. Three studies pointed to an association between antibodies against circumsporozoite protein of both P. falciparum and P. vivax and malaria exposure. Furthermore, five out 13 cross-sectional studies evidenced a positive association between IgG antibodies to the conserved 19-kDa C-terminal region of the merozoite surface protein 1 of P. vivax (PvMSP119) and malaria exposure. Conclusions: This systematic review identifies potential biomarkers of P. falciparum and P. vivax exposure in areas with variable and unstable malaria transmission in Brazil. However, this study highlights the need for standardization of further studies to provide an ideal monitoring tool to evaluate trends in malaria transmission and the effectiveness of malaria intervention programmes in Brazil. Moreover, the score-based weighted tool developed and used in this study still requires further validation. [ABSTRACT FROM AUTHOR]

Background: In the past decade, Brazil has significantly reduced the prevalence of schistosomiasis through a combined effort of early treatment of infected people, expansion of basic sanitation infrastructure and educational measures. Despite these efforts, in some areas, prevalence of schistosomiasis exceeds 20% of the school population, who lack knowledge of the risks of the disease. Action can be taken in schools to empower this population about their health condition. This paper describes the role of the teacher as a multiplier of knowledge about schistosomiasis and proposes two different approaches to training these teachers.Methods: This study used mixed methods to evaluate training of teachers and educational intervention with those teachers' pupils. Two training courses, each with 40 h of face-to-face activity, were offered to 19 teachers, using two different but complementary approaches, based on theoretical references and specific educational strategies: Critical Pedagogical Approach (Training Course I, held in 2013) and Creative Play Approach (Training Course II, held in 2014).The courses included classroom activities, laboratory and field work. After the training, the teachers conducted activities on schistosomiasis with their pupils. These activities involved constructing educational materials and cultural productions. The pupils' knowledge about the disease was evaluated before the activities and 12 months later. The teachers' acceptance and perceptions were assessed through structured interviews and subsequent thematic analysis. The Shistosoma mansoni infection status of teachers and their students was also assessed using the Kato Katz stool test.Results: The parasitological study showed 31.6% of the teachers and 21.4% of the pupils to be positive for S. mansoni. The teachers' knowledge of important aspects of schistosomiasis transmission and prevention was fragmented and incorrect prior to the training. The teachers' knowledge changed significantly after the training and they were strongly accepting of the pedagogical methods used during the training. The level of their pupils' knowledge about the disease had increased significantly (p < 0.05). However, pupils responded that, even after the educational activities, they still had contact with the city's contaminated waters (p > 0.05).Conclusions: The results of this study underline the importance of schools and teachers as partners in controlling and eliminating schistosomiasis. Teacher training on the disease significantly increases their pupils' knowledge, reflecting empowerment with regard to local health conditions. [ABSTRACT FROM AUTHOR]

Background: Mobile health (m-health) tools are a promising strategy to facilitate the work of community health workers (CHWs) in low- and middle-income countries (LMICs). Despite their potential value, little is known about CHWs' experiences working with m-health tools in their outreach activities with community members.Methods: To understand the benefits of and barriers to using m-health tools for CHWs, we conducted semi-structured interviews with 57 CHWs employed in six primary care centers in São Paulo, Brazil. All CHWs had experience using a cell phone application called Geohealth for collecting health and demographic data of community members. We assessed their experiences using Geohealth and recommendations for improvements.Results: CHWs described key benefits of using Geohealth as helping them save time with bureaucratic paperwork, organizing the data that they needed to collect, and by replacing sheaves of paper, reducing the weight that they carried in the field. However, there were many technical and social barriers to the successful adoption of the m-health tool. Key among these were poor quality hardware, faulty software programs, and negative community member perceptions of the m-health program. The CHWs provided valuable input as to how Geohealth could be improved to fit their needs.Conclusion: m-health tools have the potential to facilitate the work of CHWs in LMICs. However, such tools must be designed and implemented thoughtfully. Technical barriers related to both hardware and software must be anticipated and addressed to maximize their efficiency and successful adoption. CHW input on the design of the tool should be sought to maximize its utility and minimize barriers to use. [ABSTRACT FROM AUTHOR]

Background: Given the persistence of Indigenous health inequities across national contexts, many countries have adopted strategies to improve the health of Indigenous peoples. Governmental recognition of the unique health needs of Indigenous populations is necessary for the development of targeted programs and policies to achieve universal health coverage. At the same time, the participation of Indigenous peoples in decision-making and program and policy design helps to ensure that barriers to health services are appropriately addressed and promotes the rights of Indigenous peoples to self-determination. Due to similar patterns of Indigenous health and health determinants across borders, there have been calls for greater global collaboration in this field. However, most international studies on Indigenous health policy link Anglo-settler democracies (Canada, Australia, Aotearoa/New Zealand and the United States), despite these countries representing a small fraction of the world's Indigenous people. Aim: This paper examines national-level policy in Australia, Brazil, Chile and New Zealand in relation to governmental recognition of differential Indigenous health needs and engagement with Indigenous peoples in health. The paper aims to examine how Indigenous health needs and engagement are addressed in national policy frameworks within each of the countries in order to contribute to the understanding of how to develop pro-equity policies within national health care systems. Methods: For each country, a review was undertaken of national policies and legislation to support engagement with, and participation of, Indigenous peoples in the identification of their health needs, development of programs and policies to address these needs and which demonstrate governmental recognition of differential Indigenous health needs. Government websites were searched as well as the following databases: Google, OpenGrey, CAB Direct, PubMed, Web of Science and WorldCat. Findings: Each of the four countries have adopted international agreements regarding the engagement of Indigenous peoples in health. However, there is significant variation in the extent to which the principles laid out in these agreements are reflected in national policy, legislation and practice. Brazil and New Zealand both have established national policies to facilitate engagement. In contrast, national policy to enable engagement is relatively lacking in Australia and Chile. Australia, Brazil and New Zealand each have significant initiatives and policy structures in place to address Indigenous health. However, in Brazil this is not necessarily reflected in practice and although New Zealand has national policies these have been recently reported as insufficient and, in fact, may be contributing to health inequity for Māori. In comparison to the other three countries, Chile has relatively few national initiatives or policies in place to support Indigenous engagement or recognise the distinct health needs of Indigenous communities. Conclusions: The adoption of international policy frameworks forms an important step in ensuring that Indigenous peoples are able to participate in the formation and implementation of health policy and programs. However, without the relevant principles being reflected in national legislature, international agreements hold little weight. At the same time, while a national legislative framework facilitates the engagement of Indigenous peoples, such policy may not necessarily translate into practice. Developing multi-level approaches that improve cohesion between international policy, national policy and practice in Indigenous engagement in health is therefore vital. Given that each of the four countries demonstrate strengths and weaknesses across this causal chain, cross-country policy examination provides guidance on strengthening these links. [ABSTRACT FROM AUTHOR]

In Brazil, governmental and non-governmental organisations develop practice guidelines (PGs) in order to optimise patient care. Although important improvements have been made over the past years, many of these documents still lack transparency and methodological rigour. In order to conduct a critical analysis and define future steps in PG development in Brazil, we carried out a structured assessment of strengths, weaknesses, opportunities and threats (SWOT analysis) for the development of a national guideline programme. Participants consisted of academia, methodologists, medical societies and healthcare system representatives. In summary, the PG development process has improved in Brazil and current investments in methodological research and capacity-building are ongoing. Despite the centralised processes for public PGs, standardised procedures for their development are not well established and human resources are insufficient in number and capacity to develop the amount of trustworthy documents needed. Brazil's capacity could be strengthened and initial efforts have been made such as the adoption of standards proposed by world-renowned institutions in PG development and enhancement of the involvement of key stakeholders. Further steps involve the alignment between health technology assessment and PG processes for synergy and the development of a national network to promote the interaction between groups involved in the development of PGs. The lessons learned from this paper could be used to foster debate on guideline development, especially for countries facing similar threats on this topic. [ABSTRACT FROM AUTHOR]

Background: Studies have examined the impact of contextual factors on the use of contraceptives among adolescents and found that many measures of income and social inequality are associated with contraceptive use. However, few have focused on maternal and primary health indicators and its influence on adolescent contraceptive use. This paper assesses whether maternal mortality rates, antenatal care visits, and primary healthcare coverage are associated with pill and condom use among female adolescents in Brazil.Methods: We used data from the Study of Cardiovascular Risks in Adolescents (ERICA), a national, school-based cross-sectional study conducted in Brazil. A subsample of all female adolescents who had ever had sexual intercourse and were living in one of the 26 State capitals and the Federal District was selected (n = 7415). Multilevel mixed effects logistic regression models were estimated to examine the effect of contextual variables on pill and condom use.Results: Sixty-five percent of female adolescents reported using pill while 21.9% reported using condom during the last sexual intercourse. Adolescents living in municipalities with low maternal mortality and high antenatal care coverage were significantly more likely to use pill during the last sexual intercourse compared to those from municipalities with high maternal mortality and low antenatal care coverage. Primary healthcare coverage (proportion of the population covered by primary healthcare teams) was not significantly associated with either condom or pill use during the last sexual intercourse.Conclusion: Our findings suggest that promoting the use of pill among female adolescents may require approaches to strengthen healthcare systems rather than those focused solely on individual attributes. [ABSTRACT FROM AUTHOR]

Background: The shortage of doctors and their unequal distribution serve as challenges to advancing primary healthcare (PHC) and achieving effective universal healthcare coverage in Brazil. In an effort to use nurses' potential more efficiently, the country is investigating the introduction of the advanced practice nurse (APN) into PHC. This paper presents a situational analysis of the practices of Brazilian nurses based on the following components: regulation, practice, and education.Methods: This is a national multi-method study with triangulated data from a documentary study, a scoping review, and an exploratory study. The regulation component involved the analysis of official normative documents on the regulation of nursing education and nurses' scope of practice. The practice component aimed to identify the practices performed by nurses in Brazilian PHC based on primary studies. The education component intended to identify the practices taught in nursing training based on a survey and interviews with directors of undergraduate nursing programs.Results: Federal legislation in Brazil authorizes nursing graduates to perform a set of advanced practices as part of the PHC nurse's daily routine. They can request and interpret complementary tests and prescribe medication. However, in the local context, municipalities define the scope of this assistance based on technical norms or nursing protocols. Furthermore, this study indicates that undergraduate nursing programs do not fully prepare students to adequately execute these tasks.Conclusions: In the context of Brazilian PHC, advanced practices have already been implemented and respond to main healthcare demands. Therefore, it is unnecessary to introduce the APN as a new professional category. Upon detecting deficiencies in the training process, the current education model should undergo reforms that seek to incorporate the skills compatible with the regulated advanced practices and in-service training for practicing nurses. Regarding the introduction of APN along international lines, this article presents recommendations that may support the operationalization of a Brazilian APN model. [ABSTRACT FROM AUTHOR]

Background: This paper explores patterns of women's medicinal plant knowledge and use in an urban area of the Brazilian Amazon. Specifically, this paper examines the relationship between a woman's age and her use and knowledge of medicinal plants. It also examines whether length of residence in three different areas of the Amazon is correlated with a woman's use and knowledge of medicinal plants. Two of the areas where respondents may have resided, the jungle/seringal and farms/colonias, are classified as rural. The third area (which all of the respondents resided in) was urban. Methods: This paper utilizes survey data collected in Rio Branco, Brazil. Researchers administered the survey to 153 households in the community of Bairro da Luz (a pseudonym). The survey collected data on phytotherapeutic knowledge, general phytotherapeutic practice, recent phytotherapeutic practice and demographic information on age and length of residence in the seringal, on a colonia, and in a city. Bivariate correlation coefficients were calculated to assess the inter-relationships among the key variables. Three dependent variables, two measuring general phytotherapeutic practice and one measuring phytotherapeutic knowledge were regressed on the demographic factors. Results: The results demonstrate a relationship between a woman's age and medicinal plant use, but not between age and plant knowledge. Additionally, length of residence in an urban area and on a colonia/farm are not related to medicinal plant knowledge or use. However, length of residence in the seringal/jungle is positively correlated with both medicinal plant knowledge and use. Conclusions: The results reveal a vibrant tradition of medicinal plant use in Bairro da Luz. They also indicate that when it comes to place of residence and phytotherapy the meaningful distinction is not rural versus urban, it is seringal versus other locations. Finally, the results suggest that phytotherapeutic knowledge and use should be measured separately since one may not be an accurate proxy for the other. [ABSTRACT FROM AUTHOR]

Background: Prenatal care coverage is still not universal or adequately provided in many low and middle income countries. One of the main barriers regards the presence of socioeconomic inequalities in prenatal care utilization. In Brazil, prenatal care is supplied for the entire population at the community level as part of the Family Health Strategy (FHS), which is the main source of primary care provided by the public health system. Brazil has some of the greatest income inequalities in the world, and little research has been conducted to investigate prenatal care utilization of FHS across socioeconomic groups. This paper addresses this gap investigating the socioeconomic and regional differences in the utilization of prenatal care supplied by the FHS in the state of Minas Gerais, Brazil. Methods: Data comes from a probabilistic household survey carried out in 2012 representative of the population living in urban areas in the state of Minas Gerais. The sample size comprises 1,420 women aged between 13 and 45 years old who had completed a pregnancy with a live born in the last five years prior to the survey. The outcome variables are received prenatal care, number of antenatal visits, late prenatal care, antenatal tests, tetanus immunization and low birthweight. A descriptive analysis and logistic models were estimated for the outcome variables. Results: The coverage of prenatal care is almost universal in catchment urban areas of FHT of Minas Gerais state including both antenatal visits and diagnostic procedures. Due to this high level of coverage, socioeconomic inequalities were not observed. FHS supplied care for around 80% of the women without private insurance and 90% for women belonging to lower socioeconomic classes. Women belonging to lower socioeconomic classes were at least five times more likely to receive antenatal visits and any of the antenatal tests by the FHS compared to those belonging to the highest classes. Moreover, FHS was effective in reducing low birthweight. Women who had prenatal care through FHS were 40% less likely to have a child with low birthweight. Conclusion: This paper presents strong evidence that FHS promotes equity in antenatal care in Minas Gerais, Brazil. [ABSTRACT FROM AUTHOR]

Background: Latin America (LATAM) encompasses a vast region with diverse populations. Despite publicly funded health care systems providing universal coverage, significant socioeconomic and ethno-racial disparities persist in health care access across the region. Breast cancer (BC) incidence and mortality rates in Brazil are comparable to those in other LATAM countries, supporting the relevance of Brazilian data, with Brazil's health care policies and expenditures often serving as models for neighboring countries. We evaluated the impact of mobility on oncological outcomes in LATAM by analyzing studies of patients with BC reporting commuting routes or travel distances to receive treatment or diagnosis. Methods: We searched MEDLINE (PubMed), Embase, Cochrane CENTRAL, LILACS, and Google Scholar databases. Studies eligible for inclusion were randomized controlled trials and observational studies of patients with BC published in English, Portuguese, or Spanish and conducted in LATAM. The primary outcome was the impact of mobility or travel distance on oncological outcomes. Secondary outcomes included factors related to mobility barriers and access to health services. For studies meeting eligibility, relevant data were extracted using standardized forms. Risk of bias was assessed using the Newcastle-Ottawa Scale. Quantitative and qualitative evidence synthesis focused on estimating travel distances based on available data. Heterogeneity across distance traveled or travel time was addressed by converting reported travel time to kilometers traveled and estimating distances for unspecified locations. Results: Of 1142 records identified, 14 were included (12 from Brazil, 1 from Mexico, and 1 from Argentina). Meta-analysis revealed an average travel distance of 77.8 km (95% CI, 49.1-106.48) to access BC-related diagnostic or therapeutic resources. Nonetheless, this average fails to precisely encapsulate the distinct characteristics of each region, where notable variations persist in travel distance, ranging from 88 km in the South to 448 km in the North. Conclusion: The influence of mobility and travel distance on access to BC care is multifaceted and should consider the complex interplay of geographic barriers, sociodemographic factors, health system issues, and policy-related challenges. Further research is needed to comprehensively understand the variables impacting access to health services, particularly in LATAM countries, where the challenges women face during treatment remain understudied. Trial registration: CRD42023446936. [ABSTRACT FROM AUTHOR]

Introduction: Participatory governance is about state and society jointly responsible for political decisions and services. The origins and trajectory of participatory governance initiatives are determined by the socio-political context and specifically the nature of state-society relations. Participation by communities in health interventions has been promoted globally as a strategy to involve citizens in health decision-making but with little success. Such participatory governance in health should be seen not as a strategy alone but as a political project in which organized communities challenge the status-quo in health. Methods: This paper deals with the wider socio-political context of participatory governance initiatives. It uses comparative politics literature to analyze socio-political context in Brazil and Venezuela, historically spanning half century prior to 2015, to assess whether it was conducive to participatory governance. The focus of this paper's analysis particularly is on the socio-political changes that were taking place in Brazil and Venezuela in the decades of the 1980s and 1990s. Those decades formed the bedrock on which the two countries experienced democratization and a socialist transformation that has lasted well into the first decade of the twenty-first century. The situation in the health sector is also described for the two countries showing a parallel trajectory to the wider political context and that reflected the political ideology. For this assessment, we use a contemporary framework called the 'socialist compass' which links dynamics of power relations in various ways among three domains of power, namely, state power, economic power, and social power. Socialist compass can be used to assess whether such reforms are moving towards or against social empowerment. Conclusion: Our analysis reveals that both Brazil and Venezuela were moving in the direction of social empowerment until at least the year 2015, just before the political turmoil started engulfing the left-leaning regimes in both the countries. [ABSTRACT FROM AUTHOR]

Background: Government-led, population-wide initiatives are crucial for advancing the management of hypertension − a leading cause of cardiovascular disease (CVD) morbidity and mortality. An urban population health initiative was conducted against this backdrop, focussing on hypertension in the primary health system in São Paulo, Brazil. Within the frame of the initiative and under the supervision and leadership of the municipal health authorities, a situational analysis was conducted on the needs in hypertension management, marking the first phase of a Design Thinking process. This article describes the situational analysis process and presents the identified elements to be strengthened considering hypertension diagnosis, treatment and control. Methods: First, a mixed-methods approach was used, starting with a literature review of municipal hypertension data followed by meetings (N = 20) with the local public health administration to assess health system level components. To investigate activities on hypertension diagnosis, treatment and control, nine primary healthcare units were selected from two districts of São Paulo city– Itaquera and Penha– which received an online form addressed to managers, participated in conversation circles of staff and patients, and underwent shadowing of community health agents. Results: Data gave rise to two main outputs: (i) a patient care journey map; and (ii) a matrix summarizing the identified needs at patient, healthcare professional and health system level for diagnosis, treatment and control of hypertension. Patient awareness and knowledge of hypertension was found to be insufficient and its management needs to be improved. For health professionals, disease awareness, technical training, more time dedicated to patients, and simplified guidelines and clinical decision-making tools for hypertension management were identified as principal needs. The situational analysis found that the healthcare systems efficiency might be improved by establishing defined treatment and care delivery goals with a focus on outcomes and implemented through action plans. Conclusions: This situational analysis identified several needs related to hypertension control in São Paulo that are in line with global challenges to improve the control of CVD risk factors. Findings were also confirmed locally in an expansion phase of this situational analysis to additional primary care facilities. As a consequence, solutions were designed, promptly taken up and implemented by the municipal health secretariat. [ABSTRACT FROM AUTHOR]

Background: Rhipicephalus (Boophilus) microplus is the most important tick species affecting cattle in the world. Under field conditions, the non-parasitic phase of R. (B.) microplus is unknown in the Amazon biome, including Brazil. The present study aimed to evaluate the non-parasitic phase of R. (B.) microplus in field (grass plots) and laboratory conditions. Methods: The study was conducted from September 2020 to April 2022 in an Amazonian region (Maranhão State, Brazil). We evaluated the biological parameters of R. (B.) microplus under laboratory and field conditions. Engorged females were exposed to experimental conditions every 14 days, totaling 20 months of study. The following biological parameters were observed: pre-oviposition period, egg mass incubation period, and maximum larval survival period. Results: Abiotic data (e.g., temperature and humidity) varied little throughout the year. Precipitation was the factor that varied the most throughout the year (dry ~ 30 mm3 and rain 400 mm3), and the parameters of pre-oviposition and pre-hatching are longer during the rainy season. A possible negative effect of the dry season on the percentage of hatched eggs was observed. Larval longevity in the plots of both control and free females was short (mean ~ 50–60 days), below that recorded for larvae under controlled conditions (mean ~ 95 days). Conclusions: Rhipicephalus (Boophilus) microplus was able to complete its non-parasitic phase by producing host-seeking larvae in the pasture during all months of the study. The results indicate that R. (B.) microplus can complete up to six generations per year in biome Amazon. To our knowledge, this is the highest number of annual generations for R. (B.) microplus in Latin America. [ABSTRACT FROM AUTHOR]

Background: Transgender women are disproportionately affected by both HIV and gender-based violence (GBV), defined as physical, sexual, or emotional violence perpetrated against an individual based on their gender identity/expression. While a growing body of evidence demonstrates that GBV leads to poor HIV care and treatment outcomes among cisgender women, less research has examined this association among transgender women. We assessed the impact of lifetime experiences of GBV on subsequent retention in HIV care and laboratory confirmed viral suppression among a sample of transgender women living with HIV (TWH) in Brazil. Methods: A pilot trial of a peer navigation intervention to improve HIV care and treatment among TWH was conducted in São Paulo, Brazil between 2018 and 2019. TWH were recruited and randomized into the intervention or control arm and participated in a baseline and 9-month follow-up survey and ongoing extraction of clinical visit, prescribing, and laboratory data. Generalized linear model regressions with a Poisson distribution estimated the relative risk (RR) for the association of lifetime physical and sexual violence reported at baseline with treatment outcomes (retention in HIV care and viral suppression) at follow-up, adjusting for baseline sociodemographic characteristics. Results: A total of 113 TWH participated in the study. At baseline, median age was 30 years, and the prevalence of lifetime physical and sexual violence was 62% and 45%, respectively. At follow-up, 58% (n = 66/113) were retained in care and 35% (n = 40/113) had evidence of viral suppression. In adjusted models, lifetime physical violence was non-significantly associated with a 10% reduction in retention in care (aRR: 0.90, 95% CI: 0.67, 1.22) and a 31% reduction in viral suppression (aRR: 0.69; 95% CI: 0.43, 1.11). Lifetime sexual violence was non-significantly associated with a 28% reduction in retention in HIV care (aRR: 0.72, 95% CI: 0.52, 1.00) and significantly associated with a 56% reduction in viral suppression (aRR: 0.44; 95% CI: 0.24, 0.79). Conclusion: Our findings are among the first to demonstrate that lifetime experiences with physical and sexual violence are associated with poor HIV outcomes over time among transgender women. Interventions seeking to improve HIV treatment outcomes should assess and address experiences of GBV among this population. Trial registration: ClinicalTrials.gov Identifier: NCT03525340. [ABSTRACT FROM AUTHOR]

Background: The demographic shift and epidemiologic transition in Brazil have drawn attention to ways of measuring population health that complement studies of mortality. In this paper, we investigate regional differences in healthy life expectancy based on information from the National Health Survey (PNS), 2013. Methods: In the survey, a three-stage cluster sampling (census tracts, households and individuals) with stratification of the primary sampling units and random selection in all stages was used to select 60,202 Brazilian adults (18 years and over). Healthy life expectancies (HLE) were estimated by Sullivan's method according to sex, age and geographic region, using poor self-rated health for defining unhealthy status. Logistic regression models were used to investigate socioeconomic and regional inequalities in poor self-rated health, after controlling by sex and age. Results: Wide disparities by geographic region were found with the worst indicators in the North and Northeast regions, whether considering educational attainment, material deprivation, or health care utilization. Life expectancy at birth for women and men living in the richest regions was 5 years longer than for those living in the less wealthy regions. Modeling the variation across regions for poor self-rated health, statistically significant effects (p < 0.001) were found for the North and Northeast when compared to the Southeast, even after controlling for age, sex, diagnosis of at least one non-communicable chronic disease, and schooling or socioeconomic class. Marked regional inequalities in HLE were found, with the loss of healthy life much higher among residents of the poorest regions, especially among the elderly. Conclusions: By combining data on self-rated health status and mortality in a single indicator, Healthy Life Expectancy, this study demonstrated the excess burden of poor health experienced by populations in the less wealthy regions of Brazil. To mitigate the effects of social exclusion, the development of strategies at the regional level is essential to provide health care to all persons in need, reduce risk exposures, support prevention policies for adoption of healthy behaviors. Such strategies should prioritize population groups that will experience the greatest impact from such interventions. [ABSTRACT FROM AUTHOR]

Background: Socioeconomic differences in health in Brazil are largely driven by differences in educational attainment. In this paper, we assess whether educational gradients in chronic disease prevalence have narrowed in Brazil from 1998 to 2013, a period of a booming economy accompanied by major investments in public health in the country. Methods: Individual-level data came from the 1998, 2003 and 2008 Brazilian National Household Survey and the 2013 National Health Survey. We first evaluate age-standardized prevalence rates of chronic disease by education and second, we predict the estimated prevalence rate between those in low vs. high education to assess if relative changes in chronic disease have narrowed over time. Third, we estimate the slope index of inequality (SII) that evaluates the absolute change in the predicted prevalence of a disease between those in low vs. high education. Finally, we tested for statistically significant time trends in adult chronic disease inequalities by education. Results: Prevalence of diabetes and hypertension have increased over the period, whereas the prevalence of heart disease decreased. Brazilian adults with no education had higher levels of diabetes, hypertension and heart disease than those with some college or more. Adjusted prevalence for hypertension and heart disease indicate some progress in reducing educational disparities over time. However, for diabetes, adjusted results show a continuously increasing educational disparity from 1998 to 2013. By 2013, individuals with no education had about two times higher diabetes prevalence than those with higher education with larger disparity among women. Conclusions: Results confirm findings from previous work that educational inequalities in health are large in Brazil but also provide evidence suggesting some improvement in narrowing these differentials in recent times. Recent policies aiming at reducing the prevalence of obesity, smoking and alcohol consumption, and increasing physical activity and consumption of fruits and vegetables may increase the overall health and wellbeing of the Brazilian population. These programs are likely to be more effective if they target those with low socioeconomic status, as they appeared to be at a higher risk of developing chronic conditions, and promote educational opportunities. [ABSTRACT FROM AUTHOR]

Background: Health is recognized as a fundamental right in Brazil's constitution. In the absence of a clearly defined benefit packages of healthcare services that are financed under the Unified Health System (Sistema Único de Saúde, SUS), courts have become important in adjudicating coverage decisions. Empirical assessments of equity and the right to health tend to focus on simple measures of access. However, these empirical perspectives belie the significant inequalities and rights violations that arise in the case of more complex health needs such as cancer. To shed light on these issues, this paper focuses on the care pathways for breast and cervical cancer and explores access and quality issues that arise at different points along the care pathway with implications for the realization of the right to health in Brazil. Method: A mixed method approach is used. The analysis is primarily based on a quantitative analysis of national representative administrative data principally from the cervical and breast cancer information systems and the hospital cancer registry. To gain more insights into the organization of cancer care, qualitative data was collected from the state of Bahia, through document analysis, direct observation, roundtable discussions with health workers (HWs), and structured interviews with health care administrators. Results: The paper reveals that the volume of completed screening exams is well below the estimated need, and a tendency toward lower breast cancer screening rates in poorer states and for women in the lowest income brackets. Only 26% of breast cancer cases and 29% of cervical cancer cases are diagnosed at an early stage (stage 0 or I), thereby reducing the survival prospects of patients. Waiting times between confirmed diagnosis and treatment are long, despite new legislation that guarantees a maximum of 60 days. The waiting times are significantly longer for patients that follow the recommended patient pathways, and who are diagnosed outside the hospital. Conclusion: The study reveals that there are large variations between states and patients, where the poorest states and patients fare worse on key indicators. More broadly, the paper shows the importance of collecting data both on patient characteristics and health system performance and carry out detailed health system analysis for exposing, empirically, rights violations and for identifying how they can be addressed. [ABSTRACT FROM AUTHOR]

Background: Migration is common among transgender women (TGW), often driven by the desire to escape stigma, find acceptance, establish new connections, access body modifications, or enter new avenues of sex work. Given the heightened mobility of TGW, they are mostly vulnerable to human immunodeficiency virus (HIV) due to migration. This study aimed to evaluate the association between in-country migration and HIV infection among TGW in Northeast Brazil. Methods: The DIVAS was a cross-sectional, multicity study investigating risk behaviors and sexually transmitted infections (STI) among TGW in 2016–2017. A total of 864 TGW were recruited through respondent-driven sampling from three capital cities in Northeast Brazil. Logistic regression estimating odds ratios (OR) and 95% confidence intervals (CI) was used to assess the relationship between in-country migration and HIV infection. Results: The prevalence of HIV among TGW was 24.5%, 21.4% among those aged 18–34 and 36.1% among those ≥ 35 years old. In-country migration increased the odds of HIV infection among TGW aged 18–34 years (OR = 1.84; 95%CI:1.04–3.27) and even higher among those aged ≥ 35y old (OR = 3.08; 95%CI:1.18–8.04). Conclusions: These data reinforce the pressing need for public health policies that provide comprehensive access and strategies for demand creation for HIV/AIDS prevention and care for TGW who are already highly vulnerable to infection. [ABSTRACT FROM AUTHOR]

Background: Interventions on adolescents' lifestyle are important, but the main mechanisms that explain the changes (mediating variables) on lifestyle are unclear. This paper presents the rationale and methods of an intervention program focused on promoting active and healthy lifestyles (especially physical activity [PA] practice and reducing screen time) among Brazilian students-the Fortaleça sua Saúde program (Portuguese for "strengthen your health").Methods/design: This is a school-based cluster-randomized controlled trial. Three intervention and three control (no intervention) full-time public schools were randomly selected in Fortaleza, northeastern Brazil. Students (n = 1,272) from classes in Grades 7-9 were eligible, and 1,085 (548 in the intervention and 537 in control schools) completed the baseline and follow-up measures. The program duration was approximately four months and took place in 2014. Intervention strategies focused on teacher training, activities on health in the curriculum, active opportunities in the school environment (the availability of equipment for PA), and health education (health materials for students and parents). Data collection was undertaken before and immediately after the intervention. The primary variables included the practice of PA (weekly PA volume, PA behavior change stage and preference for PA during leisure-time) and screen time (TV and computer/video games). Potential intrapersonal, interpersonal and environmental mediators of PA and screen time were evaluated by a standardized questionnaire. Other lifestyle components (e.g., eating habits, substance use), psychological (e.g., self-rated health, body satisfaction) and biological (general and abdominal obesity) aspects, as well as academic performance were also evaluated in the total sample. Depressive symptoms, eating disorders, sleep quality, objectively-measured PA, and sedentary time were evaluated in obese students.Discussion: If effective, this program will contribute to the development of public policies for the promotion of active and healthy lifestyles in youth, especially those from low- and middle-income countries. The main intrapersonal, interpersonal and/or environmental mediators of PA and screen time may also be indicated. Finally, we anticipate that the proposed strategies may be adaptable to public schools and may even be extended to the entire school system.Trial Registration: ClinicalTrials.Gov: NCT02439827 . Registration date: May 3, 2015. [ABSTRACT FROM AUTHOR]

Background: Multimorbidity is a public health problem with high prevalence and important consequences. The aim of this paper was to verify the prevalence and distribution of multimorbidity in Brazilian older adults.Methods: A population-based survey was carried out in 2008 through face-to-face interviews with 1593 older adults (aged 60 or over) living in Bagé, a medium-sized city in Southern Brazil. Multimorbidity was evaluated by 17 morbidities and operationalized according to two cutoff points: 2 or more and 3 or more morbidities. Descriptive analysis examined the occurrence of multimorbidity by demographic, socioeconomic and health services variables. Observed and expected dyads and triads of diseases were calculated.Results: From total sample, 6 % did not have morbidities. Mean morbidity was 3.6. Morbidities showing higher prevalence were high blood pressure - HBP - (55.3 %) and spinal column disease (37.4 %). The percent of participants with multimorbidity was 81.3 % (95 % CI: 79.3; 83.3) for 2 or more morbidities and 64.0 % (95 % CI: 61.5; 66.4) for 3 or more morbidities. In both measures occurrence was higher among women, the more elderly, less socioeconomic status, the bedridden, those who did not have a health private plan, those who used health services and those living in Family Health Strategy catchment areas. We found 22 dyads of morbidities with prevalence 10 % or more and 35 triads with prevalence 5 % or more. The most prevalent observed pair and triplet of morbidities were HBP and spinal column disease (23.6 %) and HBP, rheumatism/arthritis/arthrosis and spinal column disease (10.6 %), respectively.Conclusions: Multimorbidity frequency was high in the sample studied, in keeping with percentage found in other countries. The social inequities identified increase the health system challenges for the management of multimorbidity, requiring a comprehensive and multidimensional care. The combinations of diseases can provide initial input to include multimorbidity in Brazilian clinical protocols. [ABSTRACT FROM AUTHOR]

Background: Unhealthy lifestyle choices, such as smoking and sedentary behavior, are among the main modifiable risk factors for chronic non-communicable diseases. The workplace is regarded as an important site of potential health risks where preventive strategies can be effective. We investigated independent associations among psychosocial job strain, leisure-time physical inactivity, and smoking in public servants in the largest Brazilian adult cohort. Methods: We conducted a cross-sectional analysis of baseline data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)-a multicenter prospective cohort study of civil servants. Our analytical samples comprised 11,779 and 11,963 current workers for, respectively, analyses of job strain and leisure-time physical activity and analyses of job strain and smoking. Job strain was assessed using the Brazilian version of the Swedish Demand-Control-Support Questionnaire; physical activity was evaluated using a short form of the International Physical Activity Questionnaire. We also examined smoking status and number of cigarettes smoked per day. The association reported in this paper was assessed by means of multinomial and logistic regression, stratified by sex. Results: Among men, compared with low-strain activities (low demand and high control), job strain showed an association with physical inactivity (odds ratio [OR] = 1.34; 95% confidence interval [CI] = 1.09-1.64) or with the practice of physical activities of less than recommended duration (OR = 1.44; 95% CI = 1.15-1.82). Among women, greater likelihood of physical inactivity was identified among job-strain and passive-job groups (OR = 1.47; 95% CI = 1.22-1.77 and OR = 1.42; 95% CI = 1.20-1.67, respectively). Greater control at work was a protective factor for physical inactivity among both men and women. Social support at work was a protective factor for physical inactivity among women, as was smoking for both genders. We observed no association between demand or control dimensions and smoking. Conclusions: Job strain, job control, and social support were associated with physical activity. Social support at work was protective of smoking. Our results are comparable to those found in more developed countries; they provide additional evidence of an association between an adverse psychosocial work environment and health-related behaviors. [ABSTRACT FROM AUTHOR]

Background: The regulation of working hours is governed by legal standards in formal employment. While the association between long working hours and various health outcomes has been extensively studied, there is limited evidence regarding Brazil. The objective of this study was to investigate the association among working hours, employment status, and self-rated health (SRH), taking into account differences between men and women in a national representative sample of the working population in Brazil. Methods: A cross-sectional study was conducted among a representative sample of 33,713 workers in Brazil to assess self-rated health (SRH). We examined the associations between working hours and employment status, categorizing working hours as standard (40–44 h per week) or long (> 44 h per week), and employment status as formal or informal. Logistic regression models were employed, adjusting for sociodemographic, occupational characteristics, and health behaviors. Probabilities of negative SRH were calculated for men and women in different exposure profiles. Results were stratified by gender, and 95% confidence intervals (CIs) were applied to the findings. Results: The prevalence of long working hours was higher among informal workers for both men and women. Adjusted odds ratio (AOR) results revealed that informal employment (AORwomen = 1.53; 95% CI: 1.13–2.07 and AORmen = 1.55; 95% CI: 1.22–1.96) and long working hours (AORwomen = 1.23; 95% CI: 1.06–1.43 and AORmen = 1.14; 95% CI: 1.00-1.30) were independently associated with negative SRH. Significant interactions between long working hours and informal employment were observed. Among individuals with the same exposure profile, women who engaged in long working hours had a higher probability of reporting negative SRH compared to men. Conclusions: The results of this study are in line with the literature, as differences between men and women in the likelihood of negative self-rated health were observed. The adverse health effects underscore the importance of implementing intersectoral actions to inform the revision of regulations concerning weekly working hours and the expansion of informal employment in low- and middle-income countries. [ABSTRACT FROM AUTHOR]

Background: Despite the preventive policies adopted, reduction in sexually transmitted infections (STIs) among men who have sex with men (MSM) has been limited. The risk of hepatitis C virus (HCV) infection has increased among the most vulnerable population groups, including MSM. The aim of this study was to estimate the prevalence of HCV infection and to assess risky practices among MSM from 12 Brazilian cities. Methods: This study was carried out from June to December 2016 using respondent driven sampling (RDS). Participants completed a self-administered questionnaire to collect behavioral, socioeconomic, and demographic variables. In addition, the rapid diagnostic test (RDT) for HCV was offered. Positive results were sent to Instituto Adolfo Lutz for confirmation. Results: A total of 4,176 participants were recruited and 23 samples were sent for confirmation. Of these, 16 were confirmed, resulting in a prevalence of 0.7% (95% CI: 0.3%—1.7%). The Southeast region showed a prevalence of 0.9% (95% CI: 0.3—2.6), followed by the South region, with 0.6% (95% CI: 0.2—2.1). The Northeast region had a prevalence of 0.3% (95% CI: 0.1—1.0) and the Midwest 0.1% (95% CI: 0.0—0.7). No positive cases were found in the North. Single men aged 40 years or older were the majority of participants exposed to HCV. High levels of alcohol consumption, illicit drug use, irregular condom use, in addition to infection with other STIs, were associated with exposure to HCV. Conclusions: STIs continue to be important health problems in Brazil and globally. Many STIs are inapparent for many years until they bring more serious consequences. Extra investment in HCV is also warranted, given that it can be eliminated. Relying solely on clinical data to provide information about inapparent infection, especially in stigmatized populations, will make that goal more difficult to achieve. Surveillance studies, such as the one reported here need to be repeated over time to demonstrate trends and to provide information for evaluation, program and policies. Investments in the most vulnerable populations are critical to achieve the World Health Organization global health goals including the elimination of viral hepatitis by 2030. [ABSTRACT FROM AUTHOR]

Background: In 2021, Brazil was responsible for more than 25% of malaria cases in the Americas. Although the country has shown a reduction of cases in the last decades, in 2021 it reported over 139,000 malaria cases. One major malaria control strategy implemented in Brazil is the "Malaria Supporters Project", which has been active since 2012 and is directed to municipalities responsible for most Brazil's cases. The objective of this study is to analyse the intervention effect on the selected municipalities. Methods: An ecological time-series analysis was conducted to assess the "Malaria Supporters Project" effect. The study used data on Annual Parasitic Incidence (API) spanning the period from 2003 to 2020 across 48 intervention municipalities and 88 control municipalities. To evaluate the intervention effect a Prais–Winsten segmented regression model was fitted to the difference in malaria Annual Parasitic Incidence (API) between control and intervention areas. Results: The intervention group registered 1,104,430 cases between 2012 and 2020, a 50.6% reduction compared to total cases between 2003 and 2011. In 2020 there were 95,621 cases, 50.4% fewer than in 2011. The number of high-risk municipalities (API > 50 cases/1000) reduced from 31 to 2011 to 17 in 2020. The segmented regression showed a significant 42.0 cases/1000 residents annual decrease in API compared to control group. Conclusions: The intervention is not a silver bullet to control malaria, but it has reduced API in locations with high malaria endemicity. Furthermore, the model has the potential to be replicated in other countries with similar epidemiological scenarios. [ABSTRACT FROM AUTHOR]

Background In the last 20 years, Brazil has undergone dramatic changes in terms of socioeconomic development and health care. In the first decade of the 2000s, the Ministry of Health (MoH) developed a series of programs focused on reducing infant mortality, including the Family Health Program as a national policy for primary care. In this paper, we propose a method to correct underreporting of deaths and live births. After vital statistics are corrected, infant mortality trends are analyzed for the period 2000-2010 by macro-geographical region. Methods A proactive search of live births and deaths was carried out in the Amazon and Northeast regions in 2010 to find vital events that occurred in 2008 and were not reported to the Ministry of Health. The probabilistic sample of 133 municipalities was stratified by adequacy of vital information reporting. For each municipality, the adequacy analysis was based on the reported age-standardized mortality rate per 1,000 population and the ratio between reported and estimated live births. Correction factors were estimated by strata based on additional vital events found in the proactive search. The procedure was generalized to correct municipal vital statistics for the period 2000-2010. Results In the proactive search, 35% of non-reported deaths were found within the health system (hospitals and other health establishments), but 28% were found in non-official sources, like illegal cemeteries. In areas of extreme poverty and unreliable vital information, the estimated completeness of infant death reporting was only 33%. After correction of vital information, the estimated infant mortality rate decreased from 26.1 in 2000 to 16.0 in 2010, with an annual rate of decrease of 4.7%, greater than the required rate to achieve the Millennium Development Goal. Among Brazilian regions, the Northeast showed the largest decrease, from 38.4 to 20.1 per 1,000 live births. Conclusions The proactive search for vital events was shown to be a good strategy both in terms of understanding local irregularities and for correcting vital statistics. The methodology could be applied in other countries to routinely assess the pattern and extent of birth and death under-registration in order to improve the utility of these data to inform health policies. [ABSTRACT FROM AUTHOR]

Background: Although case studies indicate that indigenous peoples in Brazil often suffer from higher morbidity and mortality rates than the national population, they were not included systematically in any previous national health survey. Reported here for the first time, the First National Survey of Indigenous People's Health and Nutrition in Brazil was conducted in 2008-2009 to obtain baseline information based on a nationwide representative sample. This paper presents the study's rationale, design and methods, and selected results. Methods: The survey sought to characterize nutritional status and other health measures in indigenous children less than 5 years of age and indigenous women from 14 to 49 years of age on the basis of a survey employing a representative probabilistic sample of the indigenous population residing in villages in Brazil, according to four major regions (North, Northeast, Central-West, and South/Southeast). Interviews, clinical measurements, and secondary data collection in the field addressed the major topics: nutritional status, prevalence of hypertension and diabetes mellitus in women, child hospitalization, prevalence of tuberculosis and malaria in women, access to health services and programs, and characteristics of the domestic economy and diet. Results: The study obtained data for 113 villages (91.9% of the planned sample), 5,305 households (93.5%), 6,692 women (101.3%), and 6,128 children (93.1%). Multiple household variables followed a pattern of greater economic autonomy and lower socioeconomic status in the North as compared to other regions. For non-pregnant women, elevated prevalence rates were encountered for overweight (30.3%), obesity (15.8%), anemia (32.7%), and hypertension (13.2%). Among children, elevated prevalence rates were observed for height-for-age deficit (25.7%), anemia (51.2%), hospitalizations during the prior 12 months (19.3%), and diarrhea during the prior week (23.6%). Conclusions: The clinical-epidemiological parameters evaluated for indigenous women point to the accentuated occurrence of nutrition transition in all regions of Brazil. Many outcomes also reflected a pattern whereby indigenous women's and children's health indicators were worse than those documented for the national Brazilian population, with important regional variations. Observed disparities in health indicators underscore that basic healthcare and sanitation services are not yet as widely available in Brazil's indigenous communities as they are in the rest of the country. [ABSTRACT FROM AUTHOR]

Introduction: The prevalence of undernutrition, which is closely associated with socioeconomic and sanitation conditions, is often higher among indigenous than non-indigenous children in many countries. In Brazil, in spite of overall reductions in the prevalence of undernutrition in recent decades, the nutritional situation of indigenous children remains worrying. The First National Survey of Indigenous People's Health and Nutrition in Brazil, conducted in 2008-2009, was the first study to evaluate a nationwide representative sample of indigenous peoples. This paper presents findings from this study on the nutritional status of indigenous children < 5 years of age in Brazil. Methods: A multi-stage sampling was employed to obtain a representative sample of the indigenous population residing in villages in four Brazilian regions (North, Northeast, Central-West, and Southeast/South). Initially, a stratified probabilistic sampling was carried out for indigenous villages located in these regions. Households in sampled villages were selected by census or systematic sampling depending on the village population. The survey evaluated the health and nutritional status of children < 5 years, in addition to interviewing mothers or caretakers. Results: Height and weight measurements were taken of 6,050 and 6,075 children, respectively. Prevalence rates of stunting, underweight, and wasting were 25.7%, 5.9%, and 1.3%, respectively. Even after controlling for confounding, the prevalence rates of underweight and stunting were higher among children in the North region, in low socioeconomic status households, in households with poorer sanitary conditions, with anemic mothers, with low birthweight, and who were hospitalized during the prior 6 months. A protective effect of breastfeeding for underweight was observed for children under 12 months. Conclusions: The elevated rate of stunting observed in indigenous children approximates that of non-indigenous Brazilians four decades ago, before major health reforms greatly reduced its occurrence nationwide. Prevalence rates of undernutrition were associated with socioeconomic variables including income, household goods, schooling, and access to sanitation services, among other variables. Providing important baseline data for future comparison, these findings further suggest the relevance of social, economic, and environmental factors at different scales (local, regional, and national) for the nutritional status of indigenous peoples. [ABSTRACT FROM AUTHOR]

Reef fish usually display a remarkable variety of colours and coloration patterns. The colour patterns are largely used for species identification, and some morphologically conservative genera are highly dependent on coloration for this purpose. In this context, this paper aims to briefly describe unusual colour patterns recorded for territorial damselfish of the genus Stegastes in the south-western Atlantic Ocean. Four unreported coloration pattern types were observed in three species (S. fuscus, S. rocasensis and S. pictus). The pale morph which is characterized by individuals presenting whitish marks over the regular coloration pattern was recorded in S. fuscus in north-eastern reefs and S. rocasensis in Fernando de Noronha archipelago. On the other hand, S. fuscus and S. pictus presented other types of unusual coloration patterns, which are characterized by an irregular cover (blue or dusky) over the regular colour pattern. Another type of unusual coloration pattern was recorded for S. fuscus, which presented a yellowish/reddish dorso-anterior band. Additionally, two distinct colour patterns of adult S. variabilis, from the south-eastern and north-eastern Brazilian reefs are reported. [ABSTRACT FROM AUTHOR]

Background: Knowledge of pharmacology is crucial for physicians to perform rational and safe medicine. Medical professionals are responsible for prescribing drugs and a weak performace of those can result in medication errors leading to disability, hospitalization, and death, among other situations. It occurs worldwide, including in Brazil, so that learning pharmacology impacts on public health service. We aim to investigate the current pharmacology educational practices in medical schools in the state of Rio de Janeiro, Brazil. Methods: We surveyed 14 of 22 medical schools in Rio de Janeiro. Pharmacology teachers (n=16) and medical students (n=89) answered a semi-structured questionnaire that included questions about the staff characteristics, pharmacology content, teacher's concepts, and common practices and resources that were used in pharmacology classes. Results: Our results revealed that the medical schools had similar overall curriculums. Pharmacology teachers work more than 30hs a week (75%) and conducted both research and teaching (62.5%). We also found that the multimedia projector was the most common resource (71.9%), and passive pedagogical methodologies (e.g., expository classes) remain a current strategy in pharmacology classes (89.9%). In general, medical students are poorly motivated (55%), which may be related to their performance in assessments. In addition, students believe that pharmacology is a complex (52%) or very complex subject (46%) since for its full understanding the student needs concepts from other disciplines, which can have an impact on the performance and motivation of students. As a result, these medical students do not fully understand the integration between pharmacology's basic concepts and their clinical applications. Conclusion: These data seem to demonstrate that the adopted teaching and learning pharmacology strategies and methodologies can be improved in Rio de Janeiro. [ABSTRACT FROM AUTHOR]

Objective: Estimate the effects of age, period, and birth cohort on suicide mortality in Brazil by major geographic region in the overall population and by sex. Methods: This was a time trend ecological study. National and regional suicide mortality data from 1981 to 2020 were analyzed for the overall population and by sex. Age, period, and cohort effects were calculated with a Poisson regression model using estimable functions with the Epi package of the R statistical program, version 4.2.1. Results: There were 272,716 suicides in individuals ranging from 20 to 79 years old. In the overall population, the age model-adjusted suicide mortality rates showed an upward pattern for Brazil. The most recent cohort showed the highest associated risk, 1.67 (95%CI 1.63; 1.71), while for the reference period, it was the highest risk among all the periods. Conclusions: Suicide mortality rates have shown an upward trend with advancing age in both men and women in the Brazilian population. However, the behavior of the period effect and cohort depends on the population analyzed and regional distribution. [ABSTRACT FROM AUTHOR]

Objectives: Primary health care builds the backbone of an effective healthcare system and can improve population health, reduce cost growth, and lessen inequality. We offer a machine-readable and open-access dataset on primary health care coverage in Brazil from 1998 to 2020. This dataset is interoperable with epidemiological data from two major studies and reusable by the research community worldwide for other purposes, such as monitoring progress toward universal health coverage and studying the association between primary health care and health outcomes. Data description: The dataset gathers official and public information from the "e-Gestor AB" platform of the Ministry of Health of Brazil and restricted data obtained by the Brazilian Access to Information Law. It includes 1,509,870 observations and 35 attributes aggregated by months/years and policy-relevant geographic units (country, macroregions, states, municipalities, and capitals) on primary health care team count and their absolute and relative population coverage estimates, information on the More Doctors Program implementation and physician counts, and spatial, demographic, and socioeconomic characteristics. We automated all data processing and curation in the free and open software R. The codes can be audited, replicated, and reused to produce alternative analyses. [ABSTRACT FROM AUTHOR]

Background: Litigation for health care, also known as health judicialization, is frequent in Brazil. It involves recourse to the court system to access health services. The study aimed to evaluate whether cancer patients in Belo Horizonte, Minas Gerais, Brazil, increased their overall survival by increasing access to certain drugs or treatments through litigation, controlling for the effect of demographic and disease-related variables. Methods: A retrospective cohort study was conducted. Patients with breast, prostate, brain, lung, or colon cancers from 2014 to 2019 were included. Survival analysis was performed using the Cox proportional hazards model. Results: In the multivariate analysis, litigation was significantly associated with increased survival in cancers of breast (HR = 0.51, 95%CI 0.33–0.80), prostate (HR = 0.50, 95%CI 0.30–0.85), colon (HR = 0.59, 95%CI 0.38–0.93), and lung (HR = 0.36, 95%CI 0.22–0.60). Five-year survival rates of patients who sued for treatment were 97.8%, 88.7%, 59.3%, and 26.0%, compared to median survival of 95.7%, 78.7%, 41.2%, and 2.4%, respectively, among patient that did not resort to court action. The study suggests that litigation for access to cancer treatment may represent a step forward in obtaining more effective treatment. This study´s main limitations are the lack of patients´ clinical information for use as control variables and the lack of variables to assess patients´ quality of life. The study also found that many cases involved claims that could have been solved by administrative rather than legal action. Some claims thus reflect the lack of adequate administrative procedures. Conclusion: When based on scientific evidence, access to new therapies, combined with other technologies already available, can favor patient survival. Access to new therapies through litigation may increase health inequalities since low-income patients have limited access to legal recourse against the State to meet their needs. The timely approval of new effective therapies can mitigate the judicialization of cancer treatment. [ABSTRACT FROM AUTHOR]

Background: Health providers are under unprecedented pressures to perform in the COVID-19 health crisis and under unprecedented risks. We initiated a large mixed-method survey of health professionals in five large metropolitan areas in Brazil to document the risks and needs of health professionals. To initiate the study, we conducted formative research. Methods: We conducted 77 open-ended semi-structured interviews online in a convenience sample of physicians, nurses, nurse technicians, and physiotherapists in Belem, Fortaleza, Porto Alegre, Recife, and São Paulo, Brazil. Design, data collection, and analysis were informed by Rapid Ethnographic Analysis (REA). Results: Responses are organized into three themes that emerged in the interviews: the lack of preparation – both locally and nationally—for the pandemic and its effects on staffing and training; the overlap of personal, family, and professional risk and consequences; and inadequately addressed anxiety and suffering among health staff. Conclusions: Our respondents were unprepared for the epidemic, especially the institutional sequelae and psychological cost. These consequences were exacerbated by both lack of leadership and sweeping changes undercutting the Brazilian health system noted by almost all participants. [ABSTRACT FROM AUTHOR]

Background: Estimates of completeness of death registration are crucial to produce estimates of life tables and population projections and to estimate the burden of disease. They are an important step in assessing the quality of data. In the case of subnational data analysis in Brazil, it is important to consider spatial and temporal variation in the quality of mortality data. There are two main sources of data quality evaluation in Brazil, but there are few comparative studies and how they evolve over time. The aim of the paper is to compare and discuss alternative estimates of completeness of death registration, adult mortality (45q15) and life expectancy estimates produced by the National Statistics Office (IBGE), Institute for Health Metrics and Evaluation (IHME), and estimates presented in Queiroz et al. (2017) and Schmertmann and Gonzaga (2018), for 1980 and 2010. Methods: We provide a descriptive and comparative analysis of aforementioned estimates from four (4) sources of estimates at subnational level (26 states and one Federal District) in Brazil from two different points in time. Results: We found significant differences in estimates that affect both levels and trends of completeness of adult mortality in Brazil and states. IHME and Queiroz et al. (2017) estimates converge by 2010, but there are large differences when compared to estimates from the National Statistics Office (IBGE). Larger differences are observed for less developed states. We have showed that the quality of mortality data in Brazil has improved steadily overtime, but with large regional variations. However, we have observed that IBGE estimates show the lowest levels of completeness for the Northern of the country compared to other estimates. Choice of methods and approaches might lead to very unexpected results. Conclusion: We produced a detailed comparative analysis of estimates of completeness of death registration from different sources and discuss the main results and possible explanations for these differences. We have also showed that new improved methods are still needed to study adult mortality in less developed countries and at a subnational level. More comparative studies are important in order to improve quality of estimates in Brazil. [ABSTRACT FROM AUTHOR]

Background: The predictive value of the serology to detection of IgM against the Mycobacterium leprae-derived phenolic glycolipid-I/PGL-I to identify leprosy patients who are at higher risk of developing reactions remains controversial. Whether baseline results of the ML Flow test can predict leprosy reactions was investigated among a cohort of patients enrolled in The Clinical Trial for Uniform Multidrug Therapy for Leprosy Patients in Brazil (U-MDT/CT-BR). Methods: This was a descriptive study focusing on the main clinical manifestations of leprosy patients enrolled in the U-MDT/CT-BR from March 2007 to February 2012 at two Brazilian leprosy reference centers. For research purposes, 753 leprosy patients were categorized according to a modified Ridley-Jopling (R&J) classification and according to the development of leprosy reactions (reversal reaction/RR and erythema nodosum leprosum/ENL), and whether they had a positive or negative bacillary index/BI. Results: More than half of the patients (55.5%) reported leprosy reaction: 18.3% (138/753) had a RR and 5.4% (41/753) had ENL. Leprosy reactions were more frequent in the first year following diagnosis, as seen in 27% (205/753) of patients, while 19% (142/753) developed reactions during subsequent follow-up. Similar frequencies of leprosy reactions and other clinical manifestations were observed in paucibacillary (PB) and multibacillary (MB) leprosy patients treated with U-MDT and regular MDT (R-MDT) (P = 0.43 and P = 0.61, respectively). Compared with PB patients, leprosy reactions were significantly more frequent in MB patients with a high BI, and more patients developed RR than ENL. However, RR and neuritis were also reported in patients with a negative BI. At baseline, the highest rate of ML Flow positivity was observed in patients with a positive BI, especially those who developed ENL, followed by patients who had neuritis and RR. Among reaction-free patients, 81.9% were ML Flow positive, however, the differences were not statistically significant compared to reactional patients (P = 0.45). Conclusions: MB and PB patients treated with R-MDT and U-MDT showed similar frequencies of RR and other clinical manifestations. Positive ML Flow tests were associated with MB leprosy and BI positivity. However, ML Flow test results at baseline showed limited sensitivity and specificity for predicting the development of leprosy reactions. [ABSTRACT FROM AUTHOR]

Background: Depression is a significant contributor to disability in Brazil, with most Brazilians affected by depression receiving no treatment. As the community, including family and friends, plays a crucial role in providing support for someone with depression, it is important that evidence-based resources are available to support people who wish to help. The aim of this study was to culturally adapt the English-language mental health first aid guidelines for assisting a person with depression for the Brazilian culture. Methods: A Delphi expert consensus study was conducted, with two expert panels; health professionals (n = 29) and people with lived experience of depression (n = 28). One hundred and seventy-four statements from the English-language guidelines were translated into Brazilian Portuguese and administered as a survey. Participants were asked to rate statements based on how appropriate those statements were for the Brazilian culture and to suggest new statements if appropriate. Results: Data were collected over two survey rounds. Consensus was achieved on 143 statements. A total of 133 statements were adopted from the English-language guidelines, whereas 10 new endorsed statements were generated from suggestions of the two expert panels. Conclusions: There were similarities between the English-language and Brazilian guidelines, mainly related to family involvement and the value of empathy. More research on dissemination and incorporation of the guidelines into the Mental Health First Aid (MHFA) training course for Brazil is required. [ABSTRACT FROM AUTHOR]

Background: One of the primary objectives of the Brazilian health care system is to improve the health and well-being of all citizens. Since the establishment of the Unified Health System/Sistema Único de Saúde (SUS) in 1988, Brazil has made strides towards reducing inequalities in health care services utilisation. However, there are currently no comprehensive and up-to-date studies focused on inequalities in both curative and preventive health care services utilisation. Methods: We evaluated data from the National Household Sample Survey and the Brazilian National Health Survey, which are two nationally representative studies that include findings from 1998, 2003, and 2008 and 2013 and 2019, respectively. We calculated Erreygers-corrected Concentration Indices (CInds) to evaluate the magnitude of socioeconomic-related inequalities associated with five indicators of health care services utilisation, including physician visits, hospital admissions, surgical procedures, Pap smears, and mammograms. The main factors associated with these inequalities were identified via a decomposition analysis of the calculated CInds. Results: While the results of our analysis revealed persistent inequalities in health care services utilisation that favour the wealthy, we found that the overall magnitude of these inequalities decreased over time. The largest inequalities were observed in the utilisation of preventive care services (Pap smears and mammograms) and services available in the poorest regions of the country. Except for admissions for labour and delivery, our findings revealed that wealthier individuals were more likely to utilise hospital services; this represents a change from findings reported in previous years. Private health insurance coverage and individual socioeconomic status are significantly associated with inequalities in health care services utilisation throughout Brazil. Conclusions: Collectively, our findings suggest that we must continue to monitor potential inequalities in health care service utilisation to determine whether Brazilian policy objectives focused on improved health outcomes for all will ultimately be achieved. [ABSTRACT FROM AUTHOR]

Early diagnosis of genetic rare diseases is an unmet need in Brazil, where an estimated 10–13 million people live with these conditions. Increased use of chromosome microarray assays, exome sequencing, and whole genome sequencing as first-tier testing techniques in suitable indications can shorten the diagnostic odyssey, eliminate unnecessary tests, procedures, and treatments, and lower healthcare expenditures. A selected panel of Brazilian experts in fields related to rare diseases was provided with a series of relevant questions to address before a multi-day conference. Within this conference, each narrative was discussed and edited through numerous rounds of discussion until agreement was achieved. The widespread adoption of exome sequencing and whole genome sequencing in Brazil is limited by various factors: cost and lack of funding, reimbursement, awareness and education, specialist shortages, and policy issues. To reduce the burden of rare diseases and increase early diagnosis, the Brazilian healthcare authorities/government must address the barriers to equitable access to early diagnostic methods for these conditions. Recommendations are provided, including broadening approved testing indications, increasing awareness and education efforts, increasing specialist training opportunities, and ensuring sufficient funding for genetic testing. [ABSTRACT FROM AUTHOR]

Microbial diversity positively influences community resilience of the host microbiome. However, extinction risk factors such as habitat specialization, narrow environmental tolerances, and exposure to anthropogenic disturbance may homogenize host-associated microbial communities critical for stress responses including disease defense. In a dataset containing 43 threatened and 90 non-threatened amphibian species across two biodiversity hotspots (Brazil's Atlantic Forest and Madagascar), we found that threatened host species carried lower skin bacterial diversity, after accounting for key environmental and host factors. The consistency of our findings across continents suggests the broad scale at which low bacteriome diversity may compromise pathogen defenses in species already burdened with the threat of extinction. [ABSTRACT FROM AUTHOR]

This case study analyses the challenges to providing specialized care in Brazilian remote rural municipalities (RRM). Interviews were conducted with managers from two Brazilian states (Piauí and Bahia). We identified that the distance between municipalities is a limiting factor for access and that significant care gaps contribute to different organizational arrangements for providing and accessing specialized care. Physicians in all the RRMs offer specialized care by direct disbursement to users or sale of procedures to managers periodically, compromising municipal and household budgets. Health regions do not meet the demand for specialized care and exacerbate the need for extensive travel. RRM managers face additional challenges for the provision of specialized care regarding the financing, implementation of cooperative arrangements, and the provision of care articulated in networks to achieve comprehensive care, seeking solutions to the locoregional specificities. [ABSTRACT FROM AUTHOR]

Background: Suicide is a major public health concern in Brazil, with nearly 115,000 Brazilians dying by suicide in 2010–2019. As support for individuals at risk of suicide may come from the community, particularly family and friends, it is fundamental that evidence-based programs or resources to improve such support are in place when needed. This study aimed to culturally adapt the mental health first aid guidelines for assisting a person at risk of suicide used in English-speaking countries for Brazil. Methods: A Delphi expert consensus study was conducted among a diverse range of Brazilian health professionals and individuals with lived experience of suicide (n = 60). A total of 161 items from the mental health first aid questionnaire used in English-speaking countries were translated and used in the Brazilian questionnaire. Participants were asked to rate the appropriateness of those items to the Brazilian culture and to recommend any new items when appropriate. Results: Data were collected over two survey rounds. Consensus was achieved on 145 items. While 123 out of 161 items were adopted from the English guidelines, 22 new endorsed items were created from the expert panel comments. Conclusions: Even though there were similarities among the Brazilian and English-language guidelines, the adapted guidelines incorporated actions that were specific to the Brazilian culture, such as new items emphasising the role of family and friends. Further research is warranted on dissemination and uptake of the guidelines in Brazil as well as research into incorporation of the guidelines into Mental Health First Aid (MHFA) training for Brazil. [ABSTRACT FROM AUTHOR]

Background: The HIV epidemic still high among key-populations in Brazil, especially among transgender women (TGW). The aim of this study was to investigate the prevalence of HIV infection among TGW and to analyze factors associated with HIV seropositivity across two cross-sectional surveys conducted in Salvador, Bahia, one of the largest urban centers of Brazil.Methods: The studies were conducted between 2014 and 2016 and 2016-2017 and employed Respondent-Driven Sampling (RDS) sampling, comprising 127 and 161 TGW residents of Salvador, Bahia. The outcome was the positive rapid antigen testing for HIV infection. Odds ratios (OR) and 95% confidence intervals (95%CI) were obtained using binomial logistic regression.Results: The HIV prevalence was 9.0% (95%CI: 4.2-18.2) and 24.3% (95%CI: 16.2-34.9). In the first study, factors associated with HIV prevalence were experiencing discrimination by the family (OR 8.22; 95%CI: 1.49-45.48) and by neighbors (OR 6.55; 95%CI: 1.12-38.14) as well as having syphilis (OR 6.56; 95%CI:1.11-38.65); in the subsequent study gender-based discrimination (OR 8.65; 95%CI:1.45-51.59) and having syphilis (OR 3.13; 95%CI: 1.45-51.59) were associated with testing positive for HIV.Conclusion: We found disproportionately high HIV prevalence among TGW, which underscores the context of vulnerability for this population. The data point to the urgency for intensification and expansion of access to HIV prevention and strategies to stop discrimination in health care and services for this population. [ABSTRACT FROM AUTHOR]

Background: While maternal health is a priority in international goals, maternal health outcomes remain poor in many regions of the world. In Brazil, maternal mortality has decreased over the past decades, but the country's maternal mortality ratio is higher than over half of all countries at 59 deaths per 100,000 live births. The Brazilian maternal health care model facilitates high rates of medical interventions during labor and childbirth; 56% of births are by cesarean birth. Doula support is considered a potential strategy to reduce medically unnecessary interventions during childbirth that contribute to maternal mortality.Methods: The cross-sectional study analyses associations with use of doula support and normal birth among Brazilian women who participated in a health education intervention named the Senses of Birth (SoB). The SoB intervention, implemented in five cities from 2015 to 2017, was developed to educate about normal birth and to evidence-based practices (EBP) reduce medically in childbirth. Chi-Square tests were performed to identify the relationship between doula support during childbirth and sociodemographic characteristics, childbirth information, perceived knowledge, and use of EBPs during labor. Logistic regression was performed to identify associations in adjusted analysis.Results: Controlling for covariates, doula support was associated with vaginal delivery (OR 2.47, 95% CI: 1.37-4.45.) Findings also suggest that women who had doula support were more likely to use non-pharmacological pain relief methods during labor (OR 9.68, 95% CI: 2.67-34.61), deliver in a public hospital (OR 2.02, 95% CI: 1.09-3.72), and be low and mid-level income compared to women with high income.Conclusion: This study's findings suggest that doula support is significantly associated with vaginal birth. The results may be useful for advocating for changes to the childbirth care model in Brazil. Incorporating EBPs, such as doula support, for all women who desire may improve maternal and child outcomes. [ABSTRACT FROM AUTHOR]

Brazil is a country of continental dimensions, with many social inequalities. The latter are reflected on its health system, which comprises a large public component called SUS, a small paid health insurance component and a third very small private component, in which patients pay personally for medical services. Seventy five percent of the population depends on SUS, which thus far does not provide adequate coverage for genetic medical procedures. In 2014, SUS introduced the "Policy for the Integral Attention to Subjects with Rare Diseases", establishing guidelines for offering diagnosis and treatment. The policy defines the two main axes, genetic and non-genetic rare diseases. In this fashion, public genetic services in SUS will be installed and funded not by themselves, but as part of the more general policy of rare diseases. Unfortunately, up to now this policy is still depending on financial allowances to be effectively launched. In this article, our intention was to describe activities developed in the area of inborn errors of metabolism by a Brazilian reference center. In spite of the lack of support of SUS, thousands of Brazilian families affected by rare genetic metabolic disorders, and many health professionals from all regions of Brazil, already have benefited from the services, training programs and research projects provided by this comprehensive center. [ABSTRACT FROM AUTHOR]

On the detection and identification of enteroviruses circulating in children with acute gastroenteritis in Brazil: reply to Luchs, A. Comments on Detection and identification of enteroviruses circulating in children with acute gastroenteritis in Pará State, Northern Brazil (2010–2011). [ABSTRACT FROM AUTHOR]

Background: The association between diabetes and obesity is very well established. Faced with this, several anthropometric indices of adiposity are often involved in studies on diabetes. Our main goal in this paper is to evaluate the association between body adiposity index (BAI) and type 2 diabetes mellitus (T2DM) in a sample of the Brazilian population after 5-year follow-up. Methods: The data used come from the Baependi Heart Study cohort, which consists of two periods: cycle 1 (2005–2006) and cycle 2 (2010–2013). Individuals of both sexes (n = 1121) were selected by excluding participants with type 2 diabetes mellitus at baseline or those that were lost to follow-up. Results: The diabetic subjects showed higher systolic blood pressure, BAI, body mass index, waist circumference and fasting glucose levels. In addition, using mixed-effects logistic regression, we found that the elevation of a single unit of BAI represented an increase of 8.4% in the risk of a patient developing T2DM (OR = 1.084 [95% CI 1.045–1.124]). Conclusions: Obesity is recognised as one of the most important risk factors for T2DM and BAI has proven to be a useful tool in estimating the risk of a patient developing T2DM in a Brazilian population. [ABSTRACT FROM AUTHOR]

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Objective: To perform a molecular screening to detect infections by the mayaro virus and possible coinfections with Chikungunya during an outbreak in the state of Tocantins/Brazil in 2017. Results: Of a total 102 samples analyzed in this study, 6 cases were identified with simultaneous infection between mayaro and chikungunya viruses (5.88%). In these 6 samples, the mean Cycle threshold (Ct) for CHIKV was 26.87 (SD ± 10.54) and for MAYV was 29.58 (SD ± 6.34). The mayaro sequences generated showed 95–100% identity to other Brazilian sequences of this virus and with other MAYV isolates obtained from human and arthropods in different regions of the world. The remaining samples were detected with CHIKV monoinfection (41 cases), DENV monoinfection (50 cases) and coinfection between CHIKV/DENV (5 cases). We did not detect MAYV monoinfections. [ABSTRACT FROM AUTHOR]

Objectives: We present a database on Brazilian spatial, demographic, and socioeconomic characteristics from 1996 to 2020. This database aims for integration and harmonization with epidemiological data from two major studies. It can also be a valuable database for designing and conducting various types of epidemiologic research, such as health inequality studies, ecological studies (mapping and time-trends), and multi-level analysis. Data description: The database gathers official information obtained via open sources from the Brazilian Institute of Geography and Statistics, the Institute for Applied Economic Research, and the Ministry of Health. It includes 139,153 observations and 26 attributes aggregated by years and policy-relevant geographic units on geocoding of municipality centroids, total population size, child population by age-group, birth and mortality measures, Brazilian Municipal Human Development Index, Gini coefficient, Gross Domestic Product, and sanitation. We automated all data processing and curation in the free and open software R. [ABSTRACT FROM AUTHOR]