Comprendre les dynamiques de l’utilisation des contraceptifs oraux au Brésil : facteurs associés avec l’interruption, l’échec et le changement de méthode contraceptive

La prévalence de la contraception est relativement élevée parmi les femmes brésiliennes, la pilule étant la méthode réversible la plus populaire. Cependant, des disparités en matière d’événements reproductifs persistent selon la région de résidence et le groupe social. Cette étude analyse les facteurs associés avec l’interruption, l’échec et le changement de méthode contraceptive au Brésil, dans le but d’améliorer la base factuelle sur les dynamiques de la pratique contraceptive. Des modèles statistiques de mesure de risque concurrent multi-niveaux sont appliqués aux données provenant de l’Enquête démographique et de santé de 1996. Les résultats indiquent que les risques les plus faibles d’échec contraceptif et d’abandon de la contraception – c’est-à-dire le fait de ne plus recourir à aucune méthode –, sont associés à certaines caractéristiques dont on soupçonne fortement qu’elles sont reliées à une plus grande motivation pour la régulation de la fécondité. Ces caractéristiques sont, notamment, l’âge de la femme, son niveau d’études et son exposition aux médias. En outre, la probabilité de passer de la pilule au condom, d’un intérêt particulier dans cette ère du VIH/SIDA, augmente avec la scolarité. Élargir l’accès aux différentes méthodes contraceptives, améliorer la connaissance chez le personnel de la santé des technologies contraceptives et accroître la supervision médicale de la pratique contraceptive pourraient être considérés comme les clés de l’amélioration de la qualité des services de santé reproductive.Contraceptive prevalence is relatively high among Brazilian women, with orals the most popular reversible method. However, important differentials persist across regions and social groups in reproductive outcomes. This study examined the factors associated with discontinuation, failure and switching of orals in Brazil, with the aim of increasing the evidence base on contraceptive use dynamics. Multilevel competing risks hazard models were applied to data from the 1996 Demographic and Health Survey. Results showed lower risks of contraceptive failure and of switching to no method associated with certain characteristics-notably woman’s age, education and media exposure-presumably related to increased motivation for fertility control. The risk of switching from orals to condoms, of particular interest in the era of HIV/AIDS, increased with level of education. Expanding access to a range of contraceptive methods, improving knowledge among health agents of contraceptive technologies and increasing medical supervision of contraceptive practice may be considered key to expanding quality reproductive health care services for all

Fatores associados à incapacidade funcional dos idosos no Brasil: análise multinível

OBJECTIVE: To analyze the influence of demographic, socioeconomic, health, and contextual factors of the Brazilian federation units on the functional disability of the elderly. METHODS: Cross-sectional study based on data from the 2003 PNAD (Brazilian National Household Survey), of IBGE (Brazilian Institute of Geography and Statistics) and Ipea (Institute of Applied Economic Research). The sample was composed of 33,515 individuals aged 60 years and older. The dependent variable was functional disability, measured by difficulty in climbing slopes or stairs. The independent variables were divided into two levels: individual (demographic, socioeconomic and health-related characteristics) and contextual (Gini Index and Gross Domestic Product per capita by Brazilian state in 2000). A multinomial and multilevel logistic regression model was utilized in order to estimate the effect of the independent variables on the functional disability of the elderly. RESULTS: Functional disability was associated with demographic, socioeconomic and health factors. At the individual level, sex, level of schooling, income, occupation, self-perception of health and chronic diseases were the factors that were most strongly related to functional disability. At the contextual level, income inequality proved to exert an important influence. CONCLUSIONS: Self-perception of health is the factor that is most strongly related to the functional disability of the elderly in Brazil, followed by chronic diseases. Sex, occupation, level of schooling and income are also highly associated with it. Actions that approach the main factors associated with functional disability can contribute significantly to the well-being and quality of life of the elderly.OBJETIVO: Analizar la influencia de los factores demográficos, socioeconómicos, de condiciones de salud y del contexto de las unidades de la federación en la incapacidad funcional de los ancianos. MÉTODOS: Estudio transversal que utilizó datos de la Pesquisa Nacional por Muestra de Domicilio (PNAD) de 2003, del Instituto Brasilero de Geografía y Estadística y del Instituto de Pesquisa Económica Aplicada. La muestra fue constituida de 33.515 individuos con 60 años o más de edad. La variable dependiente fue la incapacidad funcional, medida por la dificultad para subir ladera o escalera. Las variables independientes fueron divididas en dos niveles: individual (características demográficas, socioeconómicas y relativas a la salud) y de contexto (Índice de Gini y Producto Interno Bruto per capita por unidad federación en 2000). Un modelo de regresión logística multinomial multinivel fue utilizado para estimar el efecto de las variables independientes en la incapacidad funcional de los ancianos. RESULTADOS: La incapacidad funcional fue asociada con factores demográficos, socioeconómicos y de salud. En nivel individual, el sexo, la educación, la renta, la ocupación la autopercepción de salud y las enfermedades crónicas fueron los factores más fuertemente relacionados. En nivel de contexto, la desigualdad de renta exhibió una importante influencia. CONCLUSIONES: La autopercepción de salud es el factor más fuertemente relacionado con la incapacidad funcional de los ancianos en Brasil, seguido por las enfermedades crónicas. Sexo, ocupación, escolaridad y renta también son altamente asociados. Acciones que abordan los principales factores asociados a la incapacidad funcional pueden contribuir significativamente para el bienestar y calidad de vida de los ancianos.OBJETIVO: Analisar a influência dos fatores demográficos, socioeconômicos, de condições de saúde e do contexto das unidades da federação na incapacidade funcional dos idosos. MÉTODOS: Estudo transversal que utilizou dados da Pesquisa Nacional por Amostra de Domicílio (PNAD) de 2003, do Instituto Brasileiro de Geografia e Estatística (IBGE) e do Instituto de Pesquisa Econômica Aplicada (Ipea). A amostra foi constituída de 33.515 indivíduos com 60 anos ou mais de idade. A variável dependente foi a incapacidade funcional, mensurada pela dificuldade por subir ladeira ou escada. As variáveis independentes foram divididas em dois níveis: individual (características demográficas, socioeconômicas e relativas à saúde) e de contexto (Índice de Gini e Produto Interno Bruto per capita por unidade da federação em 2000). Um modelo de regressão logística multinomial multinível foi utilizado para estimar o efeito das variáveis independentes na incapacidade funcional dos idosos. RESULTADOS: A incapacidade funcional foi associada com fatores demográficos, socioeconômicos e de saúde. Em nível individual, o sexo, a educação, a renda, a ocupação, a autopercepção de saúde e as doenças crônicas foram os fatores mais fortemente relacionados. Em nível de contexto, a desigualdade de renda exibiu uma importante influência. CONCLUSÕES: A autopercepção de saúde é o fator mais fortemente relacionado com a incapacidade funcional dos idosos no Brasil, seguida das doenças crônicas. Sexo, ocupação, escolaridade e renda também são altamente associados. Ações que abordam os principais fatores associados à incapacidade funcional podem contribuir significativamente para o bem-estar e qualidade de vida dos idosos

Readmissão de idosos por fratura proximal do fêmur: uma abordagem multinível

OBJETIVO Identificar as características individuais e hospitalares associadas ao risco de readmissão em idosos internados por fratura proximal do fêmur no período de 90 dias após a alta. MÉTODOS Para a obtenção dos registros de óbitos e das readmissões foi realizado linkage dos bancos de dados do Sistema de Informações Hospitalares do Sistema Único de Saúde e do Sistema de Informações sobre Mortalidade do município do Rio de Janeiro dos anos de 2008 a 2011. A população de 3.405 indivíduos com 60 anos ou mais, com internação não eletiva por fratura proximal do fêmur, foi acompanhada por 90 dias após a alta. Foi utilizado o modelo de Cox multinível para o tempo da alta até a readmissão, sendo as características dos pacientes consideradas no primeiro nível e as características dos hospitais no segundo nível. RESULTADOS O risco de readmissão foi maior para os homens (hazard ratio [HR] = 1,37; IC95% 1,08–1,73), indivíduos com mais de 79 anos (HR = 1,45; IC95% 1,06–1,98), pacientes que permaneceram internados por mais que duas semanas (HR = 1,33; IC95% 1,06-1,67) e para os que foram submetidos à artroplastia durante a internação quando comparados aos submetidos à osteossíntese (HR = 0,57; IC95% 0,41–0,79). Além disso, pacientes internados em hospitais estaduais tiveram menor risco para readmissão quando comparados aos internados nos hospitais municipais (HR = 1,71; IC95% 1,09–2,68) e federais (HR = 1,81; IC95% 1,00–3,27). O efeito aleatório dos hospitais no modelo ajustado manteve-se estatisticamente significativo (p < 0,05). CONCLUSÕES Os hospitais apresentam estruturas complexas que refletem na qualidade da assistência. Assim, propõe-se que futuros estudos possam incluir essas complexidades e a gravidade dos pacientes nas análises dos dados, considerando também a correlação existente entre a readmissão e a mortalidade para reduzir vieses.OBJECTIVE To identify individual and hospital characteristics associated with the risk of readmission in older inpatients for proximal femoral fracture in the period of 90 days after discharge. METHODS Deaths and readmissions were obtained by a linkage of databases of the Hospital Information System of the Unified Health System and the System of Information on Mortality of the city of Rio de Janeiro from 2008 to 2011. The population of 3,405 individuals aged 60 or older, with non-elective hospitalization for proximal femoral fracture was followed for 90 days after discharge. Cox multilevel model was used for discharge time until readmission, and the characteristics of the patients were used on the first level and the characteristics of the hospitals on the second level. RESULTS The risk of readmission was higher for men (hazard ratio [HR] = 1.37; 95%CI 1.08–1.73), individuals more than 79 years old (HR = 1.45; 95%CI 1.06–1.98), patients who were hospitalized for more than two weeks (HR = 1.33; 95%CI 1.06-1.67), and for those who underwent arthroplasty when compared with the ones who underwent osteosynthesis (HR = 0.57; 95%CI 0.41–0.79). Besides, patients admitted to state hospitals had lower risk for readmission when compared with inpatients in municipal (HR = 1.71; 95%CI 1.09–2.68) and federal hospitals (HR = 1.81; 95%CI 1.00–3.27). The random effect of the hospitals in the adjusted model remained statistically significant (p < 0.05). CONCLUSIONS Hospitals have complex structures that reflect in the quality of care. Thus, we propose that future studies may include these complexities and the severity of the patients in the analysis of the data, also considering the correlation between readmission and mortality to reduce biases

Contraceptive dynamics in Northeast Brazil

In a study of contraceptive discontinuation and switching women may contribute more than one spell of use interval to the sample and, therefore, spells of use from the same woman may be correlated. Moreover, it has been largely recognized that two stage sampling such as those used in the DHS are very likely to have hierarchical structures because individuals selected from the same cluster are more likely to have similar behaviour and attitudes in relation to contraceptive use than those selected from different clusters. Therefore, a series of multilevel models was used throughout this thesis, as they have been pointed out to be the most appropriate for data where observations are correlated.Four empirical studies are carried out in this thesis. First, we investigate factors associated with the choice of reversible methods and sterilization in the Northeast region. Second, the determinants of contraceptive discontinuation, including method failures are estimated. Next, a detailed analysis of contraceptive switching is focused. Finally, we undertake an analysis of the demand for contraceptives in the Northeast, in which the proportion of women with an unmet need for limiting or for spacing was estimated.In general, despite the increase in the level of contraceptive methods, the results show considerably high rates of discontinuation in the Northeast Brazil. Method related reasons, particularly side-effects play an important role in the decision to discontinue the use of a method. Method failure is also an important reason. Of particular concern are the higher rates of switching to no method. The findings suggest that the restrictive mix of contraception in the region constitutes a barrier for the efficient use of methods for spacing purposes, which might explain the fact that the need for contraception for limiting purposes has not declined during the period of study. The results also showed that education was the most important socioeconomic factor affecting choice, discontinuation, switching and consequently unmet need.</p