Inappropriate use of medicines and associated factors in Brazil : an approach from a national household survey

This article aims to describe the inappropriate use of medicines in the Brazilian urban population and to identify associated factors. We conducted a data analysis of a household survey carried out in Brazil in 2013–14. The sampling plan was done by clusters with representativeness of the urban population and large regions of the country, according to gender and age domains. For this analysis, we considered a sample of adults ( 20 years) who reported having chronic noncommunicable diseases, medical indication for drug treatment and medicine use (n¼12 283). We evaluated the prevalence of inappropriate use in the domains: non-adherence, inappropriate use behaviour and inadequate care with medicines, all verified in the following groups of independent variables: demographic and socio-economic characteristics, health and pharmaceutical care, health status and use of medicines. Crude and adjusted prevalence ratios were obtained using robust Poisson regression. It was found 46.1% of people having at least one behaviour of inappropriate use of medicines. The worst results were found for the domain of inappropriate use behaviour, a situation of 36.6% of the users, which included unauthorized prescriber, inadequate source of information and indication of the medicines by non-authorized prescribers. The best result was found for the lack of medicines care, informed by only 4.6% of users who kept expired drugs at home. The inappropriate use of medicines was associated with gender (female), region of residence (Northeast), not visiting the doctor regularly or visiting more than one doctor, not having free access to medicines and using of five or more medicines. There was a high prevalence of inappropriate use, which was associated with both individual and health system characteristics pointing out the need to set priorities as for health education and public interventions

Performance of primary care and rational use of medicines for hypertension and diabetes patients in the city of Rio de Janeiro

Submitted by Repositório Arca ([email protected]) on 2019-10-26T14:41:24Z No. of bitstreams: 2 license.txt: 1748 bytes, checksum: 8a4605be74aa9ea9d79846c1fba20a33 (MD5) luiz_villarinho_pereira.pdf: 12426206 bytes, checksum: 5cc6bb26e77adbae57bfde1e5b4c7ec3 (MD5)Approved for entry into archive by Erasmo Martins ([email protected]) on 2019-11-18T15:09:46Z (GMT) No. of bitstreams: 2 luiz_villarinho_pereira.pdf: 12426206 bytes, checksum: 5cc6bb26e77adbae57bfde1e5b4c7ec3 (MD5) license.txt: 1748 bytes, checksum: 8a4605be74aa9ea9d79846c1fba20a33 (MD5)Made available in DSpace on 2019-11-18T15:09:46Z (GMT). No. of bitstreams: 2 luiz_villarinho_pereira.pdf: 12426206 bytes, checksum: 5cc6bb26e77adbae57bfde1e5b4c7ec3 (MD5) license.txt: 1748 bytes, checksum: 8a4605be74aa9ea9d79846c1fba20a33 (MD5) Previous issue date: 2013Fundação Oswaldo Cruz. Escola Nacional de Saúde Pública Sergio Arouca. Rio de Janeiro, RJ, Brasil.A Diabetes Mellitus (DM) e Hipertensão Arterial (HA) são doenças crônicas de grande importância epidemiológica, alvo de diversas estratégias da atenção primária em saúde. O uso racional de medicamentos constitui fator importante para a melhoria da qualidade de vida e prevenção de complicações dessas doenças. O objetivo desta dissertação é descrever e analisar o desempenho da atenção primária em sáude (APS) e o uso racional de medicamentos (URM) por pacientes hipertensos e diabéticos no município do Rio de Janeiro no ano de 2009, período prévio à reorganização da APS nesta cidade. Trata-se de estudo transversal e observacional utilizando base de dados secundária. As informações são provenientes de visitas à unidades básicas de saúde (USr) e à domicílios no âmbito do projeto "Avaliação do Programa Remédio em Casa", conduzido no ano de 2009. São investigados aspectos relacionados à adesão medicamentosa, à automedicação e aos cuidados com medicamentos, organizados em seis indicadores utilizados como proxy para medida do uso racional de medicamentos nesta população. Adicionalmente, são apresentados indicadores de desempenho das US considerando em suas dimensões, aspectos da Atenção Primária em Saúde (APS) e dos Serviços Farmacêuticos (SF) a saber: Acesso, vínculo, elenco de serviços, coordenação ou integração dos serviços, formação profissional, uso racional de medicamentos e satisfação. O URM, medido de diferentes formas, foi maior entre hipertensos, indivíduos casados, que trabalham, que referem receber orientações de seu médico sobre dieta e exercício físico e que não faltaram a consultas na US nos 6 meses anteriores a entrevista. De uma forma geral, encontrou-se baixa adesão ao tratamento, especialmente entre os pacientes diabéticos que também apresentaram valores mais baixos para outros indicadores de URM. Os achados apontam o fortalecimento da APS como possível estratégia para a promoção do uso racional de medicamentos, especialmente importante no caso dos pacientes diabéticos. Em uma escala de 0 a 100, o desempenho geral das USr, medido pela média ponderada de todas as dimensões foi de 43,3, relativamente baixo. No entanto, os dados, coletados em 2009, refletem uma realidade anterior à recente reorganização da APS no município do Rio de Janeiro. Nessa perspectiva os dados aqui apresentados podem servir como uma "linha de base" para efeito de comparação com estudos futuros.Diabetes Mellitus (DM) and Hypertension (HA) are chronic diseases of great epidemiological importance, being the target of several primary health care strategies. The rational use of medicines is an important factor for the improvement of the quality of life and the prevention of complications of those diseases. The main purpose of this thesis is to describe and analyze the performance of the primary health care (PHC) and the rational use of medicines (RUM) by hypertensive and diabetic patients in the city of Rio de Janeiro in 2009, a period prior to the reorganization of the PHC in this city. It is based on a cross-sectional observational study using a secondary database. Data was collected during visits to PHC units and to households included in the project "Avaliação do Programa Remédio em Casa " conducted in 2009. The study investigated the aspects related to medication adherence, self-medication and care with drugs, organized into six indicators used as a proxy measure for the rational use of drugs in this population. In addition, the study presents performance indicators of the health care units considering the following aspects of the PHC and the Pharmaceutical Services: access, longitudinality, comprehensiveness, coordination, workforce development, rational use of medicines and satisfaction. The RUM, measured in different ways, was higher among hypertensive individuals who are married, employed, who reported to have received doctor’s advice about diet and who exercise and attended the medical consultations in the healthcare units during the 6 months preceding the interviews. In general, the study found low adherence to treatment, especially among diabetic patients, who also had lower scores for the other indicators of RUM. The findings highlight the strengthening of PHC as a possible strategy to promote the rational use of medicines, especially important in the case of diabetic patients. On a scale of 0 to 100, the overall performance of the primary health care units measured by the weighted average of all the dimensions was 43.3, a relatively low score. Nevertheless, data was collected in 2009, reflecting a reality prior to the recent reorganization of the PHC in the city of Rio de Janeiro. In this perspective the results of this study may serve as a "baseline" for comparison with future studies

The pharmaceuticalization of tuberculosis control in Brazil

Au Brésil, depuis les années 1940, avec la découverte de la streptomycine, les médicaments occupent une place centrale dans les stratégies de lutte contre la tuberculose. En 1964 le pays a standardisé un premier schéma d’antibiotiques distribué gratuitement à la population. Et en 1979 l’État prend entièrement le contrôle du marché des tuberculostatiques. La fourniture de médicaments devient le principal bras armé de l’État dans l’opérationnalisation d’un programme national de lutte contre la tuberculose (PNCT) que devient l’un des foyers d’unification de la politique d’assurance sociale dans le Pays. À défaut d’avoir pu intervenir efficacement sur les déterminants sociaux de la tuberculose, ce qui dépasse largement son domaine d’action, le PNCT brésilien a construit une politique d’exceptionnalisme autour de l’innovation et de la promotion de l’accès aux technologies de dépistage, traitement et prévention par la vaccination. Une communauté de recherche d’excellence, et une politique étatique autonome de fourniture gratuite de médicaments antituberculeux pour un traitement de masse entièrement standardisé et sans participation du secteur privé font partie d’une longue tradition au Brésil, qui démarque sa réponse de celle des autres pays du tiers monde à charge élevée de tuberculose depuis au moins la seconde moitié des années 1960. L’apogée du PNCT brésilien arrive paradoxalement au moment où la tuberculose disparait progressivement des pays développés. Dans les années 1970 la tuberculose était devenue une maladie délaissée par l’industrie pharmaceutique qui, ne dégageant plus suffisamment de bénéfices sur les marchés des pays riches, se refusait à investir dans le développement de nouvelles molécules antituberculeuses. Par le biais de la co-infection avec le VIH/sida, la tuberculose est réapparue parmi les priorités de santé internationale au début des années 1990. « Urgence mondiale », elle pouvait compter désormais sur la stratégie DOTS qui a effectivement contribué en partie à résoudre le problème d’accès aux médicaments anti-tuberculeux dans les pays en développement. Mais au moment même de l’arrivé du DOTS, au début des années 1990 le PNCT fait face à une grave crise provoquée par les réformes économiques de l’État brésilien. Cette crise a eu de profondes conséquences sur la politique d’accès aux médicaments contre la tuberculose au Brésil. Aujourd’hui, au temps de la santé globale, le pays est à nouveau frappé par une grave crise économique et politique aggravé davantage par la pandémie Covid-19. Dans ce contexte particulièrement difficile d’augmentation de la pauvreté et de mesures d’austérité fiscale, le pays s’est engagé auprès de l’Organisation de Nations Unies à enrayer la tuberculose d’ici 2035 en accord avec les objectifs du développement durable (Plan Brésil sans Tuberculose, 2017). Pour ce faire, assurer une politique pérenne d’accès au diagnostic et au traitement antituberculeux de qualité est indispensable. Dans ce contexte, cette thèse porte un regard critique sur les politiques du médicament mobilisées dans la lutte contre la tuberculose au Brésil depuis ses origines jusqu’à nos jours. En s’appuyant sur des entretiens avec des acteurs majeurs dans le champ de la tuberculose au Brésil, ainsi que sur des archives personnelles, de l’Organisation mondiale de la Santé, de l’Union internationale de lutte contre la tuberculose et de la Casa Oswaldo Cruz (COC/Fiocruz), ce travail propose de décrire la trajectoire de la pharmaceuticalisation contre la tuberculose au Brésil, en s’interrogeant sur les rapports de force entre les propositions des principaux acteurs de la scène internationale de la santé et les solutions locales qui ont été pensées, théorisées et concrétisées par des acteurs brésiliens.In Brazil, since the 1940s, with the discovery of the antibiotic streptomycin, the use of medicine has been central to TB control strategies. In 1964 the country standardised a first antibiotic regimen, which was distributed free of charge to the population. And in 1979 the state took full control of the tuberculostatic market. The supply of drugs became the main arm of the state in the operationalisation of a National Tuberculosis Control Programme (NTCP). In other words, despite of being able to intervene effectively on the social determinants of tuberculosis, the Brazilian PNCT has built a strong policy based on innovation and the promotion of access to technologies for detection, treatment and prevention through vaccination. The development of a world-class research community and a state policy of free provision of TB drugs for fully standardised mass treatment without private sector involvement would become part of a long tradition in Brazil, which has distinguished its response from that of other developing countries with a high number of TB cases since at least the second half of the 1960s. The heyday of the Brazilian NTP came paradoxically at a time when TB was gradually disappearing from developed countries. In the 1970s, tuberculosis had become a neglected disease by the pharmaceutical industry, which, no longer making sufficient profits in rich country markets, was unwilling to invest in the development of new anti-tuberculosis molecules. Through co-infection with HIV/AIDS, TB re-emerged as an international health priority in the early 1990s. As a "global emergency", it could now count on the DOTS strategy, which did indeed contribute to solving the problem of access to anti-tuberculosis drugs in developing countries. But at the same time as DOTS arrived, in the early 1990s, the PNCT was facing a serious crisis caused by the Brazilian state's neoliberal economic reforms. This crisis had profound consequences on the policy of free access to TB drugs in Brazil. Today, at a time of global health, the country is once again hit by a serious economic and political crisis, further aggravated by the Covid-19 pandemic. In this particularly difficult context of increasing poverty and fiscal austerity measures, the Brazilian government has made a commitment to the United Nations to eradicate tuberculosis by 2035 in line with the Sustainable Development Goals (Brazil without TB Plan, 2017). To achieve this goal, it is fundamental to ensure a sustainable policy of access to quality TB diagnosis and treatment. With this background, this thesis takes a critical look at the drug policies mobilised in the fight against TB in Brazil from its origins to the present day. Based on interviews with major actors in the field of tuberculosis in Brazil, as well as on personal archives, the World Health Organization, the International Union Against Tuberculosis and the Casa Oswaldo Cruz (COC/Fiocruz), this thesis proposes to describe the trajectory of the pharmaceuticalization of tuberculosis in Brazil, questioning the power relations between the proposals of the main actors of the international health scene and the local solutions that have been thought, theorized and concretized by Brazilian actors

Políticas de Austeridade e seus Impactos na Saúde

Made available in DSpace on 2018-08-20T18:40:38Z (GMT). No. of bitstreams: 2 license.txt: 1748 bytes, checksum: 8a4605be74aa9ea9d79846c1fba20a33 (MD5) Joyce_Mendes_et_al_politicas_de_austeridade.pdf: 19861337 bytes, checksum: 87bc4f56dd781a8d12768b7f0cc6bd69 (MD5) Previous issue date: 201

La evolución de la carga de causas externas en Brasil: una comparación entre los años 1998 y 2008

Submitted by Regiane Silva ([email protected]) on 2018-08-27T18:01:29Z No. of bitstreams: 1 A evolução da carga de causas externas no Brasil.pdf: 291228 bytes, checksum: 5f14005dc0a988010c4d90b1efddecb7 (MD5)Approved for entry into archive by Regiane Silva ([email protected]) on 2018-08-29T14:37:23Z (GMT) No. of bitstreams: 1 A evolução da carga de causas externas no Brasil.pdf: 291228 bytes, checksum: 5f14005dc0a988010c4d90b1efddecb7 (MD5)Made available in DSpace on 2018-08-29T14:37:23Z (GMT). No. of bitstreams: 1 A evolução da carga de causas externas no Brasil.pdf: 291228 bytes, checksum: 5f14005dc0a988010c4d90b1efddecb7 (MD5) Previous issue date: 2015Fundação Oswaldo Cruz. Escola Nacional de Saúde Pública Sergio Arouca. Rio de Janeiro, RJ, Brasil.Fundação Oswaldo Cruz. Escola Nacional de Saúde Pública Sergio Arouca. Rio de Janeiro, RJ, Brasil.Fundação Oswaldo Cruz. Escola Nacional de Saúde Pública Sergio Arouca. Rio de Janeiro, RJ, Brasil.Fundação Oswaldo Cruz. Escola Nacional de Saúde Pública Sergio Arouca. Rio de Janeiro, RJ, Brasil.Fundação Oswaldo Cruz. Escola Nacional de Saúde Pública Sergio Arouca. Rio de Janeiro, RJ, Brasil.Fundação Oswaldo Cruz. Escola Nacional de Saúde Pública Sergio Arouca. Rio de Janeiro, RJ, Brasil.O objetivo foi comparar as estimativas das causas externas provenientes do estudo Carga Global de Doenças, entre os anos 1998 e 2008. A estimação do DALY (disability-adjusted life year) e do YLL (years of life lost) foi baseada em metodologia do estudo Carga Global de Doenças. Para o cálculo do YLD (years lived with disability), foram incluídas informações sobre atendimentos em emergências. Para comparabilidade, fez-se necessária a aplicação da mesma metodologia nos dois momentos analisados, tendo sido a mais recente eleita como padrão de referência. Em ambos os anos as causas externas foram responsáveis por cerca de 10% do total do DALY. Entretanto, sua distribuição interna apresentou marcada diferença entre as regiões do Brasil, com queda no Sudeste e aumento no Norte e Nordeste. Houve aumento das causas intencionais e o DALY se tornou mais letal (maior parcela de YLL). Espera-se que tais resultados balizem a formulação de políticas e/ou o aprimoramento das já existentes com vistas ao efetivo enfrentamento das causas externas.The objective of this study was to compare estimates of external causes based on the Global Burden of Disease in Brazil Study for the years 1998 and 2008. Methods included estimation of DALYs (disability-adjusted life years) and YLL (years of life lost), based on the methodology proposed in the Global Burden of Disease Study. Calculation of YLD (years lived with disability) required applying the same methodology in both years, with the 2008 methodology as the standard. Although external causes accounted for some 10% of total DALYs in both years, their internal distribution showed marked differences between regions of Brazil, with a decrease in the Southeast and increase in the North and Northeast. There was an increase in intentional causes, and YLLs accounted for the largest share of DALYs. The results can support new policies and/or improve existing ones to address external causes.El objetivo fue comparar las estimaciones de las causas externas desde el estudio Carga Global Enfermedades entre los años 1998/2008. La estimación de los DALY (disability-adjusted life year) e YLL (years of life lost) se basó en la metodología del estudio Carga Global de Enfermedades. Para el cálculo de YLD (years lived with disability), era necesario aplicar la misma metodología en ambos períodos, siendo elegido como el último punto de referencia. Pese a que en ambos períodos las causas externas fueron responsables de alrededor del 10% del total de DALY, su distribución interna mostró marcadas diferencias entre las regiones brasileñas con una caída en el Sudeste y un aumento en el Norte y Noreste. Se observó un aumento de causas intencionales y la YLL fue responsable de la mayor proporción de DALY en todos los grupos de causas externas. Se espera que estos resultados balicen la formulación de políticas y/o la mejora de las que ya existen, con el fin de hacer frente eficazmente a las causas externas