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Background: Toxoplasma gondii is a protozoan with a worldwide distribution, in warm-blood animals, including humans. Local conditions and environmental disturbances may influence transmission dynamics of a zoonotic agent. This study evaluates the epidemiology of T. gondii based on toxoplasmosis prevalence in two populations of cats living in distinct urbanization conditions in Rio de Janeiro, Brazil. Methods: Among 372 domestic cats sampled, 265 were from a public shelter located downtown Rio and 107 from a relatively preserved wild environment in a residential area. Sera and eluates from dried blood spots were tested for detection of IgG antibodies against T. gondii by modified agglutination test (MAT). Results: Antibodies to T. gondii were detected in 32/265 (12.08%) animals from the public shelter and in 4/107 (3.74%) cats from the residential area. Identical results were observed for sera and eluates. Conclusions: Filter paper provides a reliable accurate alternative storage option when conditions of sample collection and transportation in the field are unfavorable. The significantly lower prevalence in the residential area is discussed in terms of environmental, biological and behavioral features. [ABSTRACT FROM AUTHOR]

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: 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: 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]

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]

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: 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: 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: 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: 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 Leptospirosis is an important disease caused by various serovars of Leptospira sp. It can affect humans as well as domestic and wild animals; therefore, it has importance for public health, animal production, and wild species. The aim of this paper is to discuss the epidemiology of animal leptospirosis in Rio de Janeiro, Brazil, as a possible model for other tropical regions. In several studies conducted in the last 20 years, a total of 47 rats, 120 dogs, 875 cows, 695 horses, 1,343 goats, 308 sheep and 351 pigs from all regions of the state, in addition to 107 wild mammals and 73 golden-lion tamarins were tested (MAT) for anti- Leptospira antibodies. Results Seroreactivity was frequent in all studied species, confirming that the infection is endemic in Rio de Janeiro. Serogroups Icterohaemorrhagiae and Sejroe were the most prevalent in urban and rural scenarios, respectively. This paper reviews the current knowledge on animal leptospirosis in Rio de Janeiro and describes important differences between urban versus rural cycles of the infection in various species. Conclusion Identification of the prevailing serogroups and their reservoirs is essential for understanding agent-host-environment interactions under tropical conditions. [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: 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]

Brazil currently contributes 42 % of all malaria cases reported in the Latin America and the Caribbean, a region where major progress towards malaria elimination has been achieved in recent years. In 2014, malaria burden in Brazil (143,910 microscopically confirmed cases and 41 malaria-related deaths) has reached its lowest levels in 35 years, Plasmodium falciparum is highly focal, and the geographic boundary of transmission has considerably shrunk. Transmission in Brazil remains entrenched in the Amazon Basin, which accounts for 99.5 % of the country's malaria burden. This paper reviews major lessons learned from past and current malaria control policies in Brazil. A comprehensive discussion of the scientific and logistic challenges that may impact malaria elimination efforts in the country is presented in light of the launching of the Plan for Elimination of Malaria in Brazil in November 2015. Challenges for malaria elimination addressed include the high prevalence of symptomless and submicroscopic infections, emerging anti-malarial drug resistance in P. falciparum and Plasmodium vivax and the lack of safe anti-relapse drugs, the largely neglected burden of malaria in pregnancy, the need for better vector control strategies where Anopheles mosquitoes present a highly variable biting behaviour, human movement, the need for effective surveillance and tools to identify foci of infection in areas with low transmission, and the effects of environmental changes and climatic variability in transmission. Control actions launched in Brazil and results to come are likely to influence control programs in other countries in the Americas. [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: In Brazil, 99.7 % of malaria cases occur in the Amazon region. Although the number of cases is decreasing, the country accounted for almost 60 % of cases in the Americas Region, in 2013. Novel approaches for malaria treatment open the possibility of eliminating the disease, but suboptimal dispensing and lack of adherence influence treatment outcomes. The aim of this paper is to show the results on dispensing practices, non-adherence and determinants of non-adherence to treatment of non-complicated malaria. Methods: The study was conducted in six high-risk municipalities with Plasmodium vivax and Plasmodium falciparum transmission in the Brazilian Amazon and based on the theoretical framework of the Mafalda Project, which included investigation of dispensing and adherence. The World Health Organization Rapid Evaluation Method has been used to estimate sample size. Individuals over 15 years of age with malaria were approached at health facilities and invited to participate through informed consent. Data was collected in chart review forms focusing on diagnosis, Plasmodium type, prescribing, and dispensing (kind, quantity, labelling and procedures). Follow-up household interviews complemented data collection at health facility. Non-adherence was measured during the implementation phase, by self-reports and pill-counts. Analysis was descriptive and statistical tests were carried out. Determinants of non-adherence and quality of dispensing were assessed according to the literature. Results: The study involved 165 patients. Dispensing was done according to the national guidelines. Labelling was adequate for P. vivax but inadequate for P. falciparum medicines. Non-adherent patients were 12.1 % according to selfreports and 21.8 % according to pill-counts. Results point to greater non-adherence among all P. falciparum patients and among malaria non-naîve patients. More patients informed understanding adverse effects than 'how to use' anti-malarials. Conclusions: Non-adherent patients were mostly those with a P. falciparum diagnosis and those in their second or more malaria episode. New taxonomies and concepts on adherence stress the importance of focusing on the individual patient. Interventions targeted to and tailored for malaria patients must be addressed by health policy and implemented by managers and clinicians. [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: Important social and economic changes accompanying the recent fast rate of urbanization have been considered a major factor in triggering and sustaining urban violence in Brazil. The purpose of this paper is to investigate the effects of exposure to direct, indirect, and contextual violence on the risk of psychological distress. Methods: Prospective longitudinal study carried out among 3,058 civil servants working at university campuses in Rio de Janeiro. Psychological distress was measured using the General Health Questionnaire, and exposure to individual violence was assessed as direct (DV), indirect (IV), and both direct and indirect (DIV). Contextual violence was assessed through the geocoding of residential addresses of study participants and the rates of homicides in 2005 at the corresponding weighting area. Multiple logistic regression was used to evaluate individual and contextual correlates of psychological distress. Results: Exposure to DIV increased more than six times (95% CI 2.7-16.0) the odds of psychological distress occurrence at the six-year follow-up. Regarding persistence of psychological distress, the association with violence exposure was 1.6 (95% CI 1.0-2.4) for DV and 2.7 (95% CI 1.3-5.3) for IV. Contextual violence was not associated with psychological distress, and no interaction effect was found between exposure to individual and contextual violence in the occurrence/persistence of psychological distress. Conclusions: Results of this study highlight the importance of assessing multiple forms of violence in research on the social determinants of mental disorders and support the view that individual exposure to different forms of violence increases the risk of psychological distress. [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 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]

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: 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: 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: 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: In Brazil, high contraceptive prevalence rates coexist with high rates of unintended pregnancies. Contraceptive discontinuation may explain this context, but few studies have focused on highly educated young women in countries with low unmet need for modern contraception. This paper explores frequency and associated factors of contraceptive discontinuation among undergraduate students in Brazil within 12-months. Methods: This retrospective cohort study was conducted among a probability sample of 1679 undergraduates of São Paulo University. Data were collected online using a contraceptive calendar. We examined factors related to monthly discontinuation of oral pills and male condoms using Generalized Estimating Equation models. Results: Altogether, 19% of oral pill users and 48% of male condom users discontinued their method for method-related reasons within 12-months, and 18% of oral pill users and 15% of male condom users abandoned/or switched to less effective methods. Women in casual relationships were at increased odds of oral pill (OR = 1.4 [1.1–1.8]) and male condom discontinuation (OR = 1.3 [1.0–1.7]), and at increased odds of switching from oral pill to less effective or no method (OR = 1.4 [1.1–1.7]). Other associated factors were method specific. Women from lower socioeconomic status or who had multiple lifetime partners were more likely to discontinue or abandon the oral pill, while more sexually experienced women were less likely to discontinue the male condom. Conclusion: Frequent method discontinuation in Brazil calls for greater attention to the difficulties women face when using short acting methods. Discontinuation was associated with type of partner and sexual experience highlighting the changing contraceptive needs of women at the early stages of their professional careers. [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]

Background: In Brazil, members of the sand fly species complex Lutzomyia longipalpis transmit Leishmania infantum, a protist parasite that causes visceral leishmaniasis. Male Lu. longipalpis produce a sex pheromone that is attractive to both females and males. During a cluster randomised trial, to determine the combined effect of synthetic sex-aggregation pheromone and insecticide on Le. infantum transmission Lu. longipalpis had been continuously exposed to insecticide for 30 months. The objective of this study was to determine the effect of continuous exposure to the insecticides used in the trial on the susceptibility of Lu. longipalpis population. Methods: During the trial the sand flies had been exposed to either lambda-cyhalothrin [pheromone + residual insecticide spray (PI)], deltamethrin [dog collars (DC)] or no insecticide [control (C)], for 30 months (November 2012 to April 2015). The insecticide treatment regime was kept in place for an additional 12 months (May 2015-April 2016) during this susceptibility study. Sand flies collected from the field were exposed to WHO insecticide-impregnated papers cyhalothrin (0.05%), deltamethrin (0.5%) and control (silicone oil) in a modified WHO insecticide exposure trial to determine their susceptibility. Results: We collected 788 Lu. longipalpis using CDC-light traps in 31 municipalities across the three trial arms. Probit analysis showed that the knockdown times (KDTs) of Lu. longipalpis collected from the lambda-cyhalothrin exposed PI-arm [KDT50: 31.1 min, confidence interval (CI): 29.6–32.6 and KDT90: 44.2 min, CI: 42.1–46.7] were longer than the KDTs from the non-insecticide-treated C-arm (KDT50: 26.3 min, CI: 25.1–27.6 and KDT90: 38.2, CI: 36.5–40.2) (no-overlapping 95% CIs). KDTs of Lu. longipalpis collected from the deltamethrin exposed DC-arm had similar values (KDT50: 13.7 min, CI: 10.1–16.2 and KDT90: 26.7 min, CI: 21.8–30.6) to those for the C-arm (KDT50: 13.5 min; CI: 12.2–14.8 and KDT90: 23.2 min, CI: 21.4–25.4) (overlapping CIs). The wild-caught unexposed Lu. longipalpis (C-arm), took approximately twice as long to knock down as laboratory-colonised specimens for both insecticides. Conclusions: Our study reveals slight changes in KDT, in sand flies after prolonged exposure to lambda-cyhalothrin in the presence of pheromone. These changes are not considered to have reached the reference levels indicative of resistance in sand flies suggesting that pheromone and insecticide treatment at the level indicated in this study do not constitute a significant risk of increased insecticide resistance. Prolonged exposure to deltamethrin in dog collars did not result in changes to KDT. [ABSTRACT FROM AUTHOR]