Célia Szwarcwald

This study proposes a methodology for estimating maternal mortality rates (MMR) in Brazil between 2008 and 2011 using data obtained from Ministry of Health information systems. The method assesses underreporting of maternal deaths, the investigation rates of deaths among women of reproductive age, as well as the proportion of maternal deaths that were misclassified as other causes before investigation. MMR was estimated for each state in Brazil in the 2009 to 2011 triennium. Overall MMR in Brazil was lower in 2011 (60.8 per 100,000 live births) and higher in 2009 (73.1 per 100.000 live births) probably due to the H1N1 influenza epidemic that occurred in the same year. MMR was highest in the States of Maranhão and Piauí (over 100 per 100,000 live births) and lowest in the State of Santa Catarina, the only state with a MMR of less than 40 per 100,000 live births. The results show that rates are higher than the target rate of the fifth Millennium Development Goal, but indicated a signi...

Epidemiology has investigated the relationship between health status and different social and economic factors ever since the field emerged. Studies have consistently shown that the population's health status bears a strong social gradient, invariably unfavorable to the less privileged groups. Increasing interest in understanding and characterizing health inequalities has broadened the discussion in the recent literature on appropriate concepts and methodological procedures for measuring differences in health status according to socioeconomic level. This study presents a critical assessment of health inequality indicators, focusing on the following: the redistribution principle and its application to health status; the influence of income inequality; epidemiological and statistical approaches to the problem; and evaluation of health system performance in reducing health inequalities. As an example, inequalities in the neonatal mortality rate are analyzed in the city of Rio de Janeiro, Brazil, 2000, according to the mother's level of schooling, reviewing the minimum requisites for defining an adequate health inequality indicator.

The aim of the present study was to characterize the utilization of medicines by the Brazilian population, using data from the Brazilian World Health Survey. Medicines were grouped according to the active pharmaceutical ingredient based on an adaptation of the World Health Organization standard list of essential medicines. The analysis included the characteristics of individuals who keep medicines at home and who had used them within the reference period (within two weeks prior to the interview), according to presence of medical prescription. Nearly half of the participants (49.0%) reported use of medicines during the reference period. Older and wealthier individuals and those with chronic diseases or disabilities and with poor self-rated health keep and use medicines more frequently. For 25.0% of the individuals that had used medicines during the reference period, none of the drugs had been prescribed by a health professional. Among the individuals who had medicines prescribed in the last appointment, 13.0% were unable to obtain the prescribed medication (of these, 55.0% could not afford it). The most widely utilized group was that of the analgesics (22.0%), and only 51.0% of the individuals using this type of medicine had received a medical prescription for it.

Background: antibody binding assays carried out by our group have consistently indicated a higher reactivity of sera from male HIV-1 infected individuals. This study was carried out in order to analyze the importance of gender, route of transmission, disease progression and HIV-1 genotype in seroreactivity assays.Study design: specificity of antibody binding was studied in plasma of 247 HIV-1 seropositive individuals

To present selected results of military conscript surveys related to HIV/AIDS, conducted in Brazil, 1997-2002. Questionnaires including information on socio-demographic data, sexual behavior practices, sexually transmitted infections-related problems, and use of injecting drugs were completed by 30970 individuals, obtained through a 2-stage sampling. An index of sexual risk behavior was developed to take into account multiplicity of partners and irregularity of condom use. The HIV infection prevalence rate was estimated for 2002. Logistic regression was used to identify the most important determinants of HIV infection. The percentage of regular condom use increased from 38% (1997) to 49% (2002), and the index of sexual risk behavior decreased from 0.98 in 1997 to 0.87, in 2002. The HIV infection prevalence rate was 0.09%, in 2002, which remained unchanged since 1998 Riskier sexual practices among young men with incomplete education and among "men who have sex with men" were found as well as among the participants who reported at least one sexually transmitted infections - related problem. The most important predictor of HIV infection was to be positive for syphilis. The estimated value of the HIV infection prevalence supports the diagnosis of a concentrated HIV epidemic, in Brazil. Results indicate that particular attention needs to be paid for regional differentials, and for special subgroups, in Brazil.

The domestic survey carried out in the population of four of the 22 municipalities with more than 100 thousand inhabitants of the State of Rio de Janeiro that implemented the PROESF aims at institutionalizing assessment and moni- toring of primary health care. This study was de- veloped in the context of the baseline studies of the PROESF. The tool used

Page 1. 7 Cad. Saúde Pública, Rio de Janeiro, 16(Sup. 1):7-19, 2000 ARTIGO ARTICLE A disseminação da epidemia da AIDS no Brasil, no período de 1987-1996: uma análise espacial The spread of the AIDS epidemic in Brazil from 1987 to 1996: a spatial analysis ...

OBJECTIVE To investigate differences in HIV infection- related risk practices by Female Sex Workers according to workplace and the effects of homophily on estimating HIV prevalence. METHODS Data from 2,523 women, recruited using Respondent-Driven Sampling, were used for the study carried out in 10 Brazilian cities in 2008-2009. The study included female sex workers aged 18 and over. The questionnaire was completed by the subjects and included questions on characteristics of professional activity, sexual practices, use of drugs, HIV testing, and access to health services. HIV quick tests were conducted. The participants were classified in two groups according to place of work: on the street or indoor venues, like nightclubs and saunas. To compare variable distributions by place of work, we used Chi-square homogeneity tests, taking into consideration unequal selection probabilities as well as the structure of dependence between observations. We tested the effect of homophily by workplace on estimated HIV prevalence. RESULTS The highest HIV risk practices were associated with: working on the streets, lower socioeconomic status, low regular smear test coverage, higher levels of crack use and higher levels of syphilis serological scars as well as higher prevalence of HIV infection. The effect of homophily was higher among sex workers in indoor venues. However, it did not affect the estimated prevalence of HIV, even after using a post-stratification by workplace procedure. CONCLUSIONS The findings suggest that strategies should focus on extending access to, and utilization of, health services. Prevention policies should be specifically aimed at street workers. Regarding the application of Respondent-Driven Sampling, the sample should be sufficient to estimate transition probabilities, as the network develops more quickly among sex workers in indoor venues.

The Brazilian World Health Survey, carried out in 2003, included questions about diagnosis of six chronic diseases: arthritis, angina, asthma, depression, schizophrenia and diabetes mellitus. The probabilistic sample of 5,000 adults was selected in 250 census tracts. We analyzed the socio-demographic profile, the coverage of treatment, and self-rated health of the individuals that reported diagnosis of one of these diseases. To control for age and sex, logistic regression models were used. Among the 5,000 participants, 39.1% reported medical diagnosis of at least one of the six diseases. Depression was the most prevalent (19.2%), followed by asthma (12.0%), arthritis (10.5%), angina (6.7%), diabetes (6.2%) and schizophrenia (1.7%). Significant differences by age were found for all diseases, except for asthma. All diseases were more prevalent among women, except angina. Analysis by educational level showed that the diabetes prevalence rate was significantly larger among those with incomplete schooling. Although the six diseases presented different treatment coverage rates, for individuals with diagnosis of any one of the six diseases, the self-rated health was always worst, even after controlling for age and sex.

This paper describes the sample design for the National Survey into Labor and Birth in Brazil. The hospitals with 500 or more live births in 2007 were stratified into: the five Brazilian regions; state capital or not; and type of governance. They were then selected with probability proportional to the number of live births in 2007. An inverse sampling method was used to select as many days (minimum of 7) as necessary to reach 90 interviews in the hospital. Postnatal women were sampled with equal probability from the set of eligible women, who had entered the hospital in the sampled days. Initial sample weights were computed as the reciprocals of the sample inclusion probabilities and were calibrated to ensure that total estimates of the number of live births from the survey matched the known figures obtained from the Brazilian System of Information on Live Births. For the two telephone follow-up waves (6 and 12 months later), the postnatal woman's response probability was modell...

OBJECTIVE To propose a method of redistributing ill-defined causes of death (IDCD) based on the investigation of such causes. METHODS In 2010, an evaluation of the results of investigating the causes of death classified as IDCD in accordance with chapter 18 of the International Classification of Diseases (ICD-10) by the Mortality Information System was performed. The redistribution coefficients were calculated according to the proportional distribution of ill-defined causes reclassified after investigation in any chapter of the ICD-10, except for chapter 18, and used to redistribute the ill-defined causes not investigated and remaining by sex and age. The IDCD redistribution coefficient was compared with two usual methods of redistribution: a) Total redistribution coefficient, based on the proportional distribution of all the defined causes originally notified and b) Non-external redistribution coefficient, similar to the previous, but excluding external causes. RESULTS Of the 97,31...

The article analyzes the World Health Organization Report for 2000, with emphasis placed on the methodology used to analyze the indicators utilized to compare and classify the performance of the health systems of the 191 member countries. The Report's contribution was the compromise of monitoring the performance of the health systems of member countries, but because of the inconsistent way it was elaborated, and the utilization of questionable scientific evaluation methodologies, the Report fails to give a clear picture. A criterion-based methodology revision is imposed. The main problems in evidence are the choice of individual indicators of disparity in health that discount the population profile, the inadequate control of the impact of social disparities over the performance of the systems, the evaluation of the responsibility of systems that are only partially articulated to the right of the citizens, the lack of data for a great number of countries, consequently having inconsistent estimations, and the lack of transparency in the methodological procedures in the calculation of some indicators. The article suggests a wide methodological revision of the Report.

Self-rated health has been used extensively in epidemiologic studies, not only due to its importance per se but also due to the validity established by its association with clinical conditions and with greater risk of subsequent morbidity and mortality. In this study, the socio-demographic determinants of good self-rated health are analyzed using data from the World Health Survey, adapted and carried out in Brazil in 2003. Logistic regression models were used, with age and sex as covariables, and educational level, a household assets index, and work-related indicators as measures of socioeconomic status. Besides the effects of sex and age, with consistently worst health perception among females and among the eldest, the results showed pronounced socioeconomic inequalities. After adjusting for age, among females the factors that contributed most to deterioration of health perception were incomplete education and material hardship; among males, besides material hardship, work related indicators (manual work, unemployment, work retirement or incapable to work) were also important determining factors. Among individuals with long-term illness or disability, the socioeconomic gradient persisted, although of smaller magnitude.

To evaluate the actual coverage of HIV infection detection during pregnancy at national level. The actual coverage of HIV testing during pregnancy was defined as the proportion of women who attended prenatal care visits (at least one visit), ordering HIV testing and knowledge of test result before delivery. The coverage was estimated by sampling procedures based on the 2002 Sentinel Surveillance Study data. Actual coverage Inequalities were assessed by: country regions; population size of the municipality where delivery took place; and mother's schooling. The actual coverage of HIV testing during pregnancy was 52%. Huge sociogeographic inequalities are seen between the Northeastern (24%) and Southern regions (72%); illiterate mothers (19%) and those with complete basic education (64%); mothers who delivered in small municipalities (36%) and those who delivered in municipalities with more than 500,000 inhabitants (66%). Ministry of Health recommendations were fully followed by only 27% pregnant women. The study results show a need for actions aiming at increasing HIV detection coverage during pregnancy, and indicate that HIV/STD programs should be intensified with joint strategies between the National AIDS Program and infant-maternal programs.

This paper is the result of a Brazilian multidisciplinary public health working group and consists of a methodology developed to: a) identify the factors that influence the efficiency, effectiveness, and equity of the Brazilian public health system and understand how these factors function; b) improve the formulation of health policies; and c) monitor inequalities in access to and quality of

... Rodrick Wallace e colaboradores, em di-versos trabalhos (Wallace & Wallace, 1995; Wal-lace et al., 1996; Wallace et al., 1997 ... há evidências de que a população negra brasileira está mais su-jeita às conseqüências adversas da violência estrutural (Pinho, 1998) presente nas ...

Adolescents are vulnerable to sexually transmitted infections (STIs) and unplanned pregnancy. Prevention measures and assistance are of significant public health importance in this population. The objective of this study was to identify demographic, behavioral, and clinical factors for STIs and to determine the prevalence of Chlamydia trachomatis infection (CT) among female adolescents in Vitória, Brazil. We performed a cross-sectional study among female adolescents (15-19 years) served by the Health Family Program. Participants were screened for CT and Neisseria gonorrhoeae (GC) using ligase chain reaction applied to urine and answered a face-to-face questionnaire to assess demographic, behavioral, and clinical factors. All participants and their parents signed the informed consent. Four hundred sixty-four young women were sampled. The prevalence of CT was 8.9% (95% confidence interval [CI], 6.5-11.9%) overall. Among sexually active women, CT and gonorrhea prevalence were 12.2 (95% CI, 9.4-17.0%) and 1.9% (95% CI, 1.1-2.7%), respectively. Previously diagnosed STI was reported by 12.8%. Women who reported regular condom use and having condoms at home were significantly less likely to have CT, and having never purchased condoms was significantly associated with a positive CT result. A high prevalence of CT was found in this population, and behavioral risk was high despite readily available STI prevention information. Women who reported positive condom use behaviors were less likely to have CT. These results demonstrate the need for ongoing STI prevention activities, including STI screening and continued successful risk reduction activities such as condom use to further decrease CT and other STI among adolescents.

The dynamics of the Brazilian AIDS epidemic was analyzed by occupation, taken as a proxy for individual socioeconomic status. The analysis comprised AIDS cases aged 20-49 and diagnosed in 1987-1998. The temporal trend in AIDS incidence rates was analyzed by sex, occupational category, and quintiles defined by a Brazilian scale for socioeconomic status (SES). The proportions of AIDS cases stratified by SES quintiles were analyzed by exposure category. Among men, incidence rates increased in the 1st time period in almost all occupational categories, decreasing among those classified as "non-manual" occupations during the 2nd period. Among females, an annual increment was observed from 1987 to 1998 in nearly all occupational strata. The highest relative increases were observed among the lowest SES scales for both sexes. The intravenous drug user (IDU) exposure category had the lowest socioeconomic status for both sexes, whereas the homo/bisexual category had the highest. The analysis highlighted a progressive change in the epidemic's social gradient during the period, with a faster spread among the lower socioeconomic strata.