Highways and outposts: economic development and health threats in the central Brazilian Amazon region

<p>Abstract</p> <p>Background</p> <p>Economic development is often evoked as a driving force that has the capacity to improve the social and health conditions of remote areas. However, development projects produce uneven impacts on local communities, according to their different positions within society. This study examines the spatial distribution of three major health threats in the Brazilian Amazon region that may undergo changes through highway construction. Homicide mortality, AIDS incidence and malaria prevalence rates were calculated for 70 municipalities located within the areas of influence of the Cuiabá-Santarém highway (BR-163), i.e. in the western part of the state of Pará state and the northern part of Mato Grosso.</p> <p>Results</p> <p>The municipalities were characterized using social and economic indicators such as gross domestic product (GDP), urban and indigenous populations, and recent migration. The municipalities' connections to the region's main transportation routes (BR-163 and Trans-Amazonian highways, along with the Amazon and Tapajós rivers) were identified by tagging the municipalities that have boundaries crossing these routes, using GIS overlay operations. Multiple regression was used to identify the major driving forces and constraints relating to the distribution of health threats. The main explanatory variables for higher malaria prevalence were: proximity to the Trans-Amazonian highway, high proportion of indigenous population and low proportion of migrants. High homicide rates were associated with high proportions of migrants, while connection to the Amazon River played a protective role. AIDS incidence was higher in municipalities with recent increases in GDP and high proportions of urban population.</p> <p>Conclusions</p> <p>Highways induce social and environmental changes and play different roles in spreading and maintaining diseases and health threats. The most remote areas are still protected against violence but are vulnerable to malaria. Rapid economic and demographic growth increases the risk of AIDS transmission and violence. Highways connect secluded localities and may threaten local populations. This region has been undergoing rapid localized development booms, thus creating outposts of rapid and temporary migration, which may introduce health risks to remote areas.</p

Socioeconomic inequalities in the use of outpatient services in Brazil according to health care need: evidence from the World Health Survey

<p>Abstract</p> <p>Background</p> <p>The Brazilian health system is founded on the principle of equity, meaning provision of equal care for equal needs. However, little is known about the impact of health policies in narrowing socioeconomic health inequalities. Using data from the Brazilian World Health Survey, this paper addresses socioeconomic inequalities in the use of outpatient services according to intensity of need.</p> <p>Methods</p> <p>A three-stage cluster sampling was used to select 5000 adults (18 years and over). The non-response rate was 24.7% and calibration of the natural expansion factors was necessary to obtain the demographic structure of the Brazilian population. Utilization was established by use of outpatient services in the 12 months prior to the interview. Socioeconomic inequalities were analyzed by logistic regression models using years of schooling and private health insurance as independent variables, and controlling by age and sex. Effects of the socioeconomic variables on health services utilization were further analyzed according to self-rated health (good, fair and poor), considered as an indicator of intensity of health care need.</p> <p>Results</p> <p>Among the 5000 respondents, 63.4% used an outpatient service in the year preceding the survey. The association of health services utilization and self-rated health was significant (p < 0.001). Regarding socioeconomic inequalities, the less educated used health services less frequently, despite presenting worse health conditions. Highly significant effects were found for both socioeconomic variables, years of schooling (p < 0.001) and private health insurance (p < 0.00), after controlling for age and sex. Stratifying by self-rated health, the effects of both socioeconomic variables were significant among those with good health status, but not statistically significant among those with poor self-rated health.</p> <p>Conclusions</p> <p>The analysis showed that the social gradient in outpatient services utilization decreases as the need is more intense. Among individuals with good self-rated health, possible explanations for the inequality are the lower use of preventive services and unequal supply of health services among the socially disadvantaged groups, or excessive use of health services by the wealthy. On the other hand, our results indicate an adequate performance of the Brazilian health system in narrowing socioeconomic inequalities in health in the most serious situations of need.</p

Inequalities in healthy life expectancy by Federated States

OBJETIVO Estimar a esperança de vida saudável aos 60 anos por sexo e Unidade da Federação e investigar as desigualdades geográficas e por nível socioeconômico. MÉTODOS A esperança de vida saudável foi estimada pelo método de Sullivan, com base nas informações da Pesquisa Nacional de Saúde, 2013. Foram adotados três critérios para definição de estado “não saudável”: autoavaliação de saúde ruim, funcionalidade para realização das atividades da vida diária, e presença de doença crônica não transmissível com grau intenso de limitação. O indicador de nível socioeconômico foi construído com base no número de bens no domicílio e grau de escolaridade do responsável. Para analisar as desigualdades geográficas e por nível socioeconômico, foram calculadas medidas de desigualdade, como a razão, a diferença e o coeficiente angular. RESULTADOS A esperança de vida saudável entre os homens variou de 13,8 (Alagoas) a 20,9 (Espírito Santo) para o critério de autoavaliação de saúde ruim. Entre as mulheres, as estimativas correspondentes foram sempre mais altas e variaram de 14,9 (Maranhão) a 22,2 (São Paulo). Quanto à razão de desigualdades por Unidade da Federação, as medianas foram sempre maiores para a esperança de vida saudável do que para a esperança de vida, independentemente da definição adotada para estado saudável. Quanto às diferenças por Unidade da Federação, a esperança de vida saudável chegou a ser sete anos maior em um estado do que em outro. Por nível socioeconômico, foram encontradas diferenças de três e quatro anos, aproximadamente, entre os últimos e primeiro quintos, para homens e mulheres, respectivamente. CONCLUSÕES Além de os indicadores de mortalidade estarem associados às condições de vida, as desigualdades são ainda mais pronunciadas quando o bem-estar e as limitações nas atividades habituais são levados em consideração, mostrando a necessidade de promover ações e programas para diminuir o gradiente socioespacial.OBJECTIVES To estimate the healthy life expectancy at 60 years by sex and Federated States and to investigate geographical inequalities by socioeconomic status. METHODS Healthy life expectancy was estimated by the Sullivan method, based on the information of the National Survey on Health, 2013. Three criteria were adopted for the definition of “unhealthy state”: self-assessment of bad health, functionality for performing the activities of daily living, and the presence of noncommunicable disease with intense degree of limitation. The indicator of socioeconomic status was built based on the number of goods at household and educational level of the head of household. To analyze the geographical inequalities and socioeconomic level, inequality measures were calculated, such as the ratio, the difference, and the angular coefficient. RESULTS Healthy life expectancy among men ranged from 13.8 (Alagoas) to 20.9 (Espírito Santo) for the self-assessment criterion of bad health. Among women, the corresponding estimates were always higher and ranged from 14.9 (Maranhão) to 22.2 (São Paulo). As to the ratio of inequality by Federated State, the medians were always higher for healthy life expectancy than for life expectancy, regardless of the definition adopted for healthy state. Regarding the differences per Federated State, the healthy life expectancy was seven years higher in one state than in another. By socioeconomic status, differences of three and four years were found, approximately, between the last and first fifth, for men and women, respectively. CONCLUSIONS Despite the association of the mortality indicators with living conditions, the inequalities are even more pronounced when the welfare and the limitations in usual activities are considered, showing the necessity to promote actions and programs to reduce the socio-spatial gradient

Autoavaliação de saúde bucal: resultados da Pesquisa Mundial de Saúde - Atenção Básica em quatro municípios do Estado do Rio de Janeiro, Brasil, 2005 Self-rated oral health: results of the World Health Survey - Primary Care in four municipalities in Rio de Janeiro State, Brazil, 2005

A autoavaliação da saúde é um indicador subjetivo que combina componentes físicos, emocionais e do bem-estar individual e vem adquirindo papel importante na área da Saúde Pública, sendo utilizado na avaliação do estado de saúde da população geral. Este trabalho objetivou estudar os cuidados assistenciais e o estado de saúde bucal, incluindo a autoavaliação, utilizando dados de 1.871 indivíduos, com 18 anos ou mais de idade, entrevistados na Pesquisa Mundial de Saúde - Atenção Básica, realizada em quatro municípios do Estado do Rio de Janeiro, Brasil, no ano de 2005. Foram utilizados modelos de regressão logística binária para identificar os determinantes da autoavaliação de saúde bucal "excelente" ou "boa". Para ambos os sexos, as variáveis significativamente associadas à autoavaliação da saúde bucal foram: renda domiciliar per capita, frequência de visita odontológica e perda de dentes e uso de prótese. Os resultados evidenciam um gradiente socioeconômico na percepção subjetiva, uma precária saúde bucal entre os idosos e a importância da visita odontológica regular para manutenção da saúde bucal.<br>Self-rated health is a subjective indicator that combines physical and emotional components and individual well-being. It has gained an important role in Public Health, with increasing use in the evaluation of the general population's health status. This study focuses on dental care and oral health status, including self-rated oral health, using data from 1,871 individuals 18 years or older, interviewed in World Health Survey - Primary Care, conducted in four municipalities in the State of Rio de Janeiro, Brazil. Bivariate logistic regression models were used to identify the determinants of 'excellent' or 'good' self-rated oral health. For both men and women, variables significantly associated with self-rated oral health were: per capita family income, frequency of dental visits, tooth loss, and use of dental prostheses. The results showed a socioeconomic gradient in self-rated oral health, precarious oral health among the elderly, and the importance of regular dental visits for maintaining oral health

Socio-demographic determinants of self-rated health in Brazil Determinantes sócio-demográficos da auto-avaliação da saúde no Brasil

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.<br>A auto-avaliação da saúde vem sendo amplamente utilizada nos estudos epidemiológicos, não só por ser importante por si, mas também pela sua validade, estabelecida por suas relações com as condições clínicas e com o maior risco de morbi-mortalidade subseqüente. Neste trabalho, são analisados os determinantes sócio-demográficos da auto-avaliação de saúde boa, utilizando os dados da Pesquisa Mundial de Saúde, inquérito domiciliar realizado no Brasil, em 2003. Foram utilizados modelos de regressão logística, considerando idade e sexo como co-variáveis, e o grau de instrução, a posse de bens no domicílio e a situação de trabalho como indicadores do nível sócio-econômico. Além das diferenças por sexo e idade, com auto-avaliações consistentemente piores entre as mulheres e entre os mais idosos, os resultados indicaram acentuadas desigualdades sócio-econômicas. Ajustando-se por idade, entre as mulheres, a instrução incompleta e a privação material foram os fatores que mais contribuíram para a pior percepção da saúde; entre os homens, além da privação material, os indicadores relacionados ao trabalho tiveram efeitos importantes. Entre os indivíduos com doença de longa duração ou incapacidade, o gradiente social persistiu, embora em menor magnitude

Implementation of respondent-driven sampling among female sex workers in Brazil, 2009 Implementação do método de amostragem respondent-driven sampling entre mulheres profissionais do sexo no Brasil, 2009

Female sex workers are known in Brazil and elsewhere in the world as one of the most-at-risk populations for risk of HIV infection, due to their social vulnerability and factors related to their work. However, the use of conventional sampling strategies in studies on most-at-risk subgroups for HIV is generally problematic, since such subgroups are small in size and are associated with stigmatized behaviors and/or illegal activities. In 1997, a probabilistic sampling technique was proposed for hard-to-reach populations, called Respondent-Driven Sampling (RDS). The method is considered a variant of chain sampling and allows the statistical estimation of target variables. This article describes some assumptions of RDS and all the implementation stages in a study of 2,523 female sex workers in 10 Brazilian cities. RDS proved appropriate for recruiting sex workers, allowing the selection of a probabilistic sample and the collection of previously missing information on this group in Brazil.<br>O grupo das mulheres profissionais do sexo é reconhecido, nacional e internacionalmente, como uma população de maior risco à infecção pelo HIV pela sua vulnerabilidade social e por fatores relacionados à atividade profissional. Porém, a utilização de estratégias convencionais de amostragem em estudos nos subgrupos de maior risco de contraírem HIV é, em geral, problemática, já que estes têm pequena magnitude em termos populacionais e estão vinculados a comportamentos estigmatizados ou atividades ilegais. Em 1997, foi proposta uma técnica de amostragem probabilística para populações de difícil acesso, o Respondent-Driven Sampling (RDS). O método é considerado como uma variante da amostragem em cadeia e possibilita a estimação estatística dos parâmetros de interesse. Este artigo descreve alguns pressupostos do RDS e todas as etapas de implementação em um estudo com 2.523 profissionais do sexo em dez municípios brasileiros. A utilização do RDS mostrou-se apropriada para recrutamento de profissionais do sexo, possibilitando a seleção de uma amostra probabilística e a coleta de informações inexistentes sobre este grupo no Brasil